Visitors to this site who have been attracted by a series of recent posts may be wondering: what’s the connection between the Buddhism/meditation stuff and all this interest in psychopharmacology? Fair question; or two questions, actually. First question: What’s the relationship between the meditative practices that have developed in the Buddhist tradition, and the use of psychotropic medications to alter consciousness, alleviate suffering and enhance human wellbeing? Are they compatible? Is there an implicit contradiction, either in the theoretical commitments or the evaluative judgments involved in the two practices? The second question is: what’s the relationship between the theories which best explain how those medications work, and the body of philosophical doctrine that is the Buddhist dharma. (And the dharma is, among other things, a body of doctrine, despite what some people will try to tell you.)
I intend to address the first question here, and save the second for a later post.
I want to approach the issue by discussing an article by Richard S. Schwartz entitled “Mood Brighteners, Affect Tolerance, and the Blues,” which was published in Psychiatry in 1991. The article is mentioned in Peter Kramer’s Listening to Prozac, and in a sense can be said to have kicked off the “Prozac debate” I’ve referred to before.
The genesis of Schwartz’s paper was a question from a colleague. Dr. Robert Aranow asked him one day
to think seriously about a hypothetical medication — a “mood brightener” . . . [that would] brighten the episodically “down” moods of those who are not clinically depressed, without causing euphoria or the side effects that have accompanied the mood elevators of abuse. Fluoxetine [Prozac] is a significant step in that direction, he argued.
Schwartz adds a couple of relevant remarks.
(A):
Fluoxetine, while probably not a true mood brightener, is at present a potent stimulus of a certain type of inquiry.
(B):
The distinction between depression and unhappiness, clear at the extremes, remains murky at the border and I suspect always will be. I learned long ago that I cannot accurately predict which patients with chronic dysphoria will respond to antidepressants.
If I read this correctly, there’s a bit of confusion here. Schwartz has said:
- Some patients with chronic dysphoria respond to antidepressants.
- Some patients with chronic dysphoria do not respond to antidepressants.
- Those patients who respond to antidepressants are clinically depressed
- Some patients with chronic dysphoria do not respond to antidepressants.
- Those patients who do not respond to antidepressants are not clinically depressed, but simply unhappy.
(I believe Schwartz intends for 3 and 4 to follow from 1 and 2, because that is the sense of passage (B) quoted above: if the second sentence of that passage is intended as an explication of the first sentence, then the implication must follow.)
But now, recall that the definition of a “mood brightener” is a substance that can improve the emotional state of those who are not clinically depressed. Clearly, there is an internal relation between the depression/unhappiness distinction and the antidepressant/mood brightener distinction, such that any attempt to define one in terms of the other winds up in a vicious circle. One way out of the circle would be if there were some clear-cut chemical distinction between the two classes of medication. But given the variety of different compounds that are used as antidepressants (MAOIs, tricyclics, etc.), I can’t see how the distinction can be made based on molecular structure.
Perhaps there is another way out. In my own experience, fluoxetine acts as a mood enhancer in the following ways: it somewhat lessens negative affect (but does not eliminate it entirely.) It also enables the possibility of experiencing positive affect in response to external stimuli. It does not bring about spontaneous experience of joy that have no causes in the experiencer’s environment. If the latter is a description of what a true mood brightener would do, then fluoxetine is not a true mood brightener.
Schwartz distinguishes between the way that mood brighteners [would] work and the way that psychotherapy works using the concept of “affect tolerance”:
I believe that central to any truth therapy would be some version of the concept of affect tolerance. Simply put, affect tolerance means that you can stand to feel what you feel. It is the opposite of a mood brightener, whether of the chemical or psychological variety. The more affect you can bear, the more you can look reality in the eye without either comforting distortions (i.e., mood brighteners) or a collapse into a nonfunctional state of depression or disorganization. The greater your capacity to be aware of reality and to bear the feelings stirred up by that awareness, the greater the range of adaptive responses that you can consider.
To address the central issue I promised to address in this post: In my experience, antidepressant medications act as mood brighteners in the way (and only in the way) I described above. They do nothing to increase affect tolerance. Vipassana meditation is a sustained exercise in the development of affect tolerance. (For a hint as to how this is so, read this.)
Schwartz’s preferred method for developing affect tolerance is talk therapy:
Many clinicians believe that affect increases during the successful psychotherapy in part because the patient identifies with the therapist — that is, identifies with his ability to bear the patient’s feelings, as well as his own. The process usually begins with the patient internalizing the therapist’s voice or comforting presence but one hopes that it proceeds to the point where the patient experiences his new capacity to bear feeling states not as a foreign presence within him but as an integrated part of his own identity.
Obviously, I can’t say that this never happens. But I will say that I believe that meditation is far, far more effective. The “identification” that Schwartz talks about works about as well, and lasts about as long, as singing along at the top of your lungs to a sentimental ballad. (Schwartz, btw, does have some perceptive things to say about music.)
As I said, I’ll address the relationship between biological psychiatry and Buddhist doctrine in a later post. If anyone wants to read ahead, though, I’m thinking about the issues in terms of some things that are said in an article in Buddhazine entitled Still Crazy after all these Years: Why Meditation isn’t Psychotherapy.
meditation and medication
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