Beyond Therapeutic Nihilism

Norman E. Alessi

How should childhood or adolescent depression be treated? Is there a cure? What is the most effective treatment? Is there a most effective treatment?

Unfortunately, there are no studies that deal with the “total" treatment of depressed children and adolescents. There are drug studies, and there are anecdotal reports of effective psychotherapeutic interventions for both individuals and families. But, there are no studies that clearly demonstrate the efficacy of one therapeutic modality over another for children and adolescents with depressive disorders. Further, there are no studies that have even attempted to look at a multimodal approach. Why?

There are a lot of reasons. One of the foremost is tradition. Until recently, child and adolescent psychiatry, and for that matter psychiatry in general, has not relied on “studies” as a way to determine the efficacy of its interventions. It is only the advent of psychopharmacology that has changed these expectations, and now “studies” are seen as the way to approach and assess therapeutic interventions.

Other reasons include the lower frequency of major depressive disorders in children and adolescents, as compared to adults; the lack of funds; the lack of personnel to carry out such studies; and the lack of coherent treatment models for children and adolescents.

All of these factors elicit various responses; but the most destructive response is “Therapeutic nihilism,” or abandoning faith in one’s therapeutic effectiveness. One’s effectiveness depends a great deal on one’s attitudes, beliefs, and the sustained ability to care. One cannot treat depressed children or adolescents, or for that matter adults, without being affected adversely by their depression. These are not disorders of cognition or behavior, but of emotional states. Their disturbance is one that cannot always be understood fully on an intellectual level. Consequently, to treat depression means that one will be affected.

Principles of treatment
Despite this “lack of information,” there are general principles that can be followed in managing these children and adolescents. These principles are not to be thought of as specific therapeutic interventions, but rather as general parameters to observe during the course of treatment, regardless of the specific therapeutic modality chosen.

Principle #1. Attend to emergencies first.
Obviously, there are a broad range of circumstances that require immediate intervention. Clinicians respond more frequently in these circumstances when encountered in adolescents, but these circumstances are either unnoticed or ignored in younger children. The most frequently ignored symptom in children is the expression of severe aggression as a manifestation of depression. Too often, this is mislabeled as a conduct disorder or, if the child is younger, an oppositional defiant disorder.

Any child or adolescent with a chronic aggressive disturbance characterized by liability of affect, “temper tantrums.” or overt impulsive aggression should be evaluated for a mood disorder. The identification of a depressive disorder in this group could have enormous impact on treatment and, if the patient is hospitalized, could shorten the hospitalization substantially.

Suicide ideation and threats are relatively common in adolescents. It is too easy to dismiss these as “pseudocide” or not real, especially if chronic or in an adolescent with severe character pathology. A clinician must attend to any suicidal ideation or threat a patient may have, whether in a child or adolescent, and whether it has been verbalized before.

Principle #2. Don’t assume that a single treatment modality will suffice.
Often our patients come to the clinic having had either a prolonged course of “psychotherapy,” or having been on several medications, or both. Our clinic most often will begin a therapeutic trial of medications in conjunction with “family therapy”. We have found individual “psychotherapy” to be ineffective if the child is unable to concentrate or feels extremely self-absorbed, guilty, or ashamed.

Those studies that have looked at this question in adults have shown that neither medications nor “psychotherapy" are superior. The best response appears to result from a combination of treatment interventions. While this has not been proven with children and adolescents, it is useful to begin with the assumption that a multimodal approach will be most effective.

Principle #3. Don’t assume that a single therapeutic intervention will not suffice.
There are circumstances where only one therapeutic modality is necessary. Sometimes this is the use of a medication alone, with very little parental, family, or individual work. A child or adolescent may return monthly for medication checkups, with little more needed. This also can apply to a psychotherapeutic intervention being indicated and sufficient. Currently, a singular versus multimodal approach is most often determined by the comfort and experience of the clinician, not any research data.

Principle #4. Recognize and use countertransference.
Countertransference is the feeling state elicited within the therapist in response to a patient. Emotional disorders are contagious, and those clinicians who say that they are not responding to these patients are either not relating to them or are denying their own feelings of countertransference.
There are a number of responses that clinicians may have in response to countertransference. The most prevalent is to distance oneself from the patient. Clinicians may see certain patients less frequently in an attempt to guard against their own feelings of inadequacy or other narcissistic states, or the amount of time clinicians spend with these patients may become negligible, perhaps restricted to just the administration of a medication without any attempt to deal with the patient. The clinicians may even label the patient as resistant to help, personality disordered; or conduct disordered, any label to rationalize the need for distance and to maintain narcissistic boundaries.

Recognizing the countertransference will help the clinician to understand the full impact of the depressive disorder on the child or adolescent and the world around them. If the child's feeling states create a sense of hopelessness or numbness within the clinician, assume that the same will happen to others with whom the child comes into contact. It will help to discuss this with family and, if possible, the youth, to gain a sense of the illness and its impact. Further, recognizing the countertransference may help the clinician to have sustained empathy with the child, thereby providing an avenue of relatedness that may not be available otherwise.

Questions you may want to ask yourself to determine if you are having a countertransference towards a child:

Do you feel uncomfortable with the patient when you are with him or her?
If you feel uncomfortable, what feelings do you have? Anger, depression, somatic feelings? Are you feeling slowed down, finding it difficult to concentrate, etc.?
Do you feel better after the patient leaves your office? Sometimes the countertransference response, if it is more somatic in nature, will not be identifiable at the time you are with the patient, as it may come on extremely slowly. Therefore, it is important to note what you feel after the patient leaves the office.
Do you avoid seeing the patient? Do you minimize the time seen directly with the patient, spending time primarily with the parents? Do you speak tersely with the child or adolescent, or do you leave them in the waiting room, never seeing them?
Are you thinking about transferring this patient because “you can’t help them very much”? Is this a realistic assessment, or one motivated by countertransference?
Do you have a tendency, with this patient, to feel that “they are not trying in treatment”? Have you started labeling this “not trying” as being character pathology, saying that they have “an anal retentive personality" or they are “passive aggressive" or “passive dependent”?
Do you have feelings of inadequacy when you are with the patient? Do you feel that it is your fault that you are unable to reach or bond with them?
Do you feel a sense of anger? Do you feel that this patient deserves to get inadequate treatment or no treatment because of their “attitude”?
Have you found that you would rather see other patients than this patient? Do you feel there is absolutely no sense of gratification derived from this patient? Do you want more gratification from this patient than they can realistically provide?

Principle #5. Identify parental depressive disorders and seek treatment.
When a child or adolescent is seen for the assessment, assume until proven otherwise that one of the parents is or has been depressed, as well. Numerous studies have demonstrated that the frequency of depression among the offspring of depressed mothers is quite high. Further, the age of onset for the child or adolescent is dependent on the age at which their parent had the onset of their depression.

Ask the parents about the age at which they began becoming depressed. A lot of parents have never been asked these questions, and therefore have never thought about them. It is helpful to explain why you are talking with them about their depression. If a parent had an early onset during their own childhood or adolescence, the nature of the child's depression might be better understood. And, the potential of it becoming a lifelong illness might be mirrored in the parent’s own experience.

Parents can be referred for a clinical evaluation and assessment. This can be done within your own clinic or in a clinic outside of your care. Depending on your own expertise and comfort, you could do the evaluation yourself. The advantage of evaluating and treating a parent’s depression in your own clinic is that you have direct experience of the depression and you can observe the interplay with the child's depression. This also helps in integration of care in the family treatment.

Principle #6. Make certain that you know the family history for the presence of depression and its many forms and for successful therapeutic interventions.
Often there is an extensive history for depression in these families. There may have been suicide attempts or successful suicides. There also may be histories of alcoholism, sociopathy, and low-level depressions expressed through aggression, irritability, etc. It is important to get a full history of what the literature refers to as “depressive spectrum disorders.” These disorders, identified by George Winokur at the University of Iowa, have been demonstrated to be higher in families with depressive disorders. In families with these kinds of disturbances, it is extremely important to understand if therapeutic interventions had been sought. Often, medications working with one family member can predict that medication's usefulness in a related child or adolescent. This has been demonstrated with the use of lithium carbonate in families with manic-depressive illnesses; and we have found this to be true in families with histories of depression where not only has a child been treated, but a mother, a sibling, an uncle, or a cousin of the primary patient has received treatment as well.

Principle #7. Don’t assume that you can cure the child or adolescent.
There is a significant difference between healing and curing. Healing is the attempt to help reduce the severity of symptomatology and assist a person to come to grips with their illness. My purpose as a clinician is to heal these children, their parents, and families. I do not hold out the idea that a cure will be forthcoming. By not having a cure as my goal, I am much more realistic in my expectations; and ultimately, this reduces the likelihood of my being overly frustrated. Posing this as a lifelong problem, where there will be implications throughout an individual’s life in many developmental stages, has made it much easier for me to help parents and children deal with this illness. Ultimately, it has also helped them.

Principle #8. Not everyone will be helped.
There are a number of children and adolescents who will not be helped if treated. In the adult literature, there is a phenomenon referred to as refractory depressive disorders, meaning depressive disorders which do not respond to medications, psychotherapy, or any therapeutic interventions. To date, there has been only one paper written about this topic as it applies to children and adolescents. This paper highlights the therapeutic response of children to a fairly broad number of pharmacological interventions. It also clearly states that we do not know at this time how many children will or will not respond to multimodality therapies, or for that matter, even extensive pharmacological interventions.

When a person enters into a treatment with one of these children and their families, parents must be told that even though we know the nature of the problem, we may not be able to help the child remediate all of his or her problems. Elements of the depression may respond to medication, and other facets may respond to parental and family interventions, but there still may be communication or interpersonal skills that will be lost for life.

Treatment may involve helping these people only to develop adequate coping skills and an understanding of these limitations.

Principle #9. The purpose of treatment is to help the patient, not prove a point.
I say this because, unfortunately, there have been lines drawn between people with different professional orientations. There are the psychopharmacologists. There are the psychotherapists. There are the family therapists. In the midst of all of this, there is a patient who has needs that always should be regarded as primary. Patients should not be labeled or made to feel the brunt of their illness because they are sick and do not respond to a particular treatment. This would be like labeling someone with cancer and saying if one particular therapeutic intervention did not work, we would let them die. It is that level of severity that I am speaking to.

Principle #10. Never give up hope.
These are patients who are extremely difficult to treat. In addition to keeping an open mind regarding the multitude of therapeutic interventions, you have to maintain a sense of hopefulness. Among these patients, other caregivers, and family members, it is easy to get swept away in a sense of hopelessness. We must maintain a sense of hope if we at all want to help these individuals.

There is a way of rising above therapeutic nihilism in treating these patients. To do so, we must keep open minds. We should look to other professionals who might be able to help us. We should not come to rapid conclusions about these individuals, or about the fate of these children or adolescents and their families. It is only with hope and openness to a broad range of therapeutic interventions that these individuals can be helped.

References

Alessi, N.E. (1991). Refactory childhood depressive disorders from a pharmacotherapeutic perspective. Advances in neuropsychiatry and psychopharmacology, Volume 2:Refactory depression, New York: Raven Press, pp. 53-63.

McKnew, D.H., Cytryn, L., Efron, EM. et al. (1979). Offspring of patients with affective disorders. British J Psych, 134, 148-152.

Ryan , ND., Puig-Antich, J., Ambrosini P. et al. (1987). The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 44(10), 854-861.

Shafii. M. & Shaffi, S.L. (1992). Dynamic psychotherapy of depression, in Clinical guide to depression in children and adolescents. Washington, D.C.: American Psychiatric Press, pp. 157-175.

Shafii, M. & Shaffi, S.L. (1992). Inpatient treatment of depression, in Clinical guide to depression in children and adolescents. Washington, D.C.: American Psychiatric Press, pp. 233-248.

Weissman, M.M., Gammon, D., John, K. et al. (1987). Children of depressed parents. Archives of General Psychiatry, 44. 847-853.

Weissman, M.M., Paykel. ES., & Klerman, G. L. (1972). The depressed woman as a mother. Social Psychiatry, 7, 98-10.

This feature: Alessi, N. E. (1993). Hope for the helpers: Beyond Therapeutic Nihilism. Reclaiming Children and Youth. Vol.2. No.2 pp.39-41