The Elephant in the Room


A man I’ll call Paul* is a divorced father of three teen-aged children. He has taken a leave of absence from a routine retail position due to depression and anxiety which has also severely impaired his cognitive attention and concentration capacities. Given to crying spells, suicidal thoughts, though no history of suicidal attempts or plans, his employer provides one of the more liberal employee assistance plans EAPs through which he was referred to a psychologist. However, his family doctor informed Paul that his problems could only be resolved with medication, that the insurance company which pays his salary during a medically approved leave of absence, would only do so if he complied with treatment by taking medication.

Although Paul stated emphatically that he did not want to take psychotropic meds the physician referred him to a psychiatrist for an obligatory ten sessions. He also indicated on Paul’s insurance form that he was not complying with treatment. Paul felt confused and resentful that he was not in control of his treatment and of his life, since he had also not been reimbursed for lost wages due to mental illness for three months.

In his psychotherapy Paul began to effectively address his depression by recognizing it as self-directed anger, to develop awareness of underlying feelings and to learn constructive, assertive strategies for expressing them instead of directing them against himself. In doing so the aura of pessimism and hopelessness with which he had surrounded himself also began to dissolve.

He quickly came to recognize the deleterious effect his cold, unloving and depressed mother had exerted on his self-image and self-esteem in spite of the presence of a consistently loving and supportive father. A mother who stubbornly refused her husband’s repeated efforts to provide treatment. In his prior state of poor self-esteem and lack of assertiveness Paul had contracted a marriage to a manipulative, probably personality disordered woman, an issue he had only begun to address in therapy. The prognosis for Paul, an articulate, severely depressed and therefore motivated client, is quite positive in psychotherapy.

Yet a medically controlled health system in collaboration with the insurance industry would direct Paul’s treatment in opposition to Paul’s expressed wishes into a Procrustean bed. To do as he is told when the evidence basis for his treatment by psychotropic medication is at best highly questionable.

There you have it, a single instance of a dance which repeats itself over and over, again. Dare we, the psychologists, the social workers and other mental health professionals extensively trained and available to address the many problems which are generally and inappropriately presented to busy, less psychologically trained physicians, dare we not speak out for fear of the elephant in the room?

* Identifying details have been changed

Albert Silver is a privately practicing psychologist with more than 35 years experience in treating individuals, couples and families. He has had a long-standing involvement in seeking to provide mental health services to the underserved poor, children, adolescents, seniors, minorities and rural dwellers. Currently, he heads the task force on mental health accessibility of the Ontario Psychological Association.







Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. Thank you Albert! It is great to hear a fellow therapist share about how we help people change by addressing the real life causes of their emotional suffering, vs. the one size fits all, meds only machine that is designed to minimize employer and insurance cost while maximizing psychiatrist and drug company profit.

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  2. I find this somewhat offensive:

    In his prior state of poor self-esteem and lack of assertiveness Paul had contracted a marriage to a manipulative, probably personality disordered woman, an issue he had only begun to address in therapy.

    This statement seems to stigmatize Personality Disorders and to so flippantly apply that label to a person is harmful.

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  3. I would like to point out that in the rush to rightfully condemn the over-medicalization of human suffering that has heaped too many drugs on people, psychologists like the author of this op-ed piece are now running head-on into another problem – pointing the finger of blame at family members. Blaming the family is the reason NAMI got going in the first place. Family members, rightly or wrongly, were sick of being demonized. Instead, NAMI found it preferable to see mental illness as a biochemical imbalance. See, nobody to blame except fault biochemistry. The rest is history. Let’s not have history repeat itself. While I do think parents surely had something to do with a child’s “mental illness” diagnosis, I have worked hard to find out what it is that I may have done wrong, and how can I work to make it right, I can see a huge problem brewing with psychologists who seem to miss the basic concept that you don’t elevate one group by demonizing another. This is dangerous territory and will only lead to yet another backlash. Who will continue to suffer? Those already suffering, of course.

    I would have been much more impressed with this op-ed piece if the author stuck with what he personally observed and stopped after this paragraph: “In his psychotherapy Paul began to effectively address his depression by recognizing it as self-directed anger, to develop awareness of underlying feelings and to learn constructive, assertive strategies for expressing them instead of directing them against himself. In doing so the aura of pessimism and hopelessness with which he had surrounded himself also began to dissolve.

    Instead, the author goes on to discuss hear-say evidence, painting the father of the man as a saint, and the women in Paul’s life as deranged. In my experience, most men and women are extremely hostile to their ex and many people will dismiss Paul’s personal experience as just another spouse blaming his ex. Isn’t Paul just playing the blame game as well? I also agree with Jen’s comment that labeling Paul’s ex (a woman who presumably the author has never met). Why not instead say simply “ Paul was only beginning to address in therapy his unhappy marriage.”

    If the author subscribes to the blame game, he should do it in the privacy of the therapy session. It may be helpful there. There are diplomatic and helpful ways in a public forum to focus attention on how families can help their relatives get better. If this is not handled sensitively, beware the backlash.

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  4. I’m probably the last person on earth to say that what gets labelled “mental illness” is caused by anything else than trauma, in most cases in the shape of dysfunctional relationships. However, I must say I find it disturbing, to say the least, that this post asks us to look at Paul’s problems as understandable reactions to dysfunctional relationships, while it, at the same time, also asks us to completely ignore that both Paul’s mother’s and his wife’s behaviour is an understandable response to trauma. Where is the understanding for and empathy with Paul’s mother and wife in this post? Aren’t they human beings too? IMO, if we are to see them as cold, unloving, and depressed, respectively personality disordered, monsters, then why should we see Paul himself as anything else than a depressed, anxious failure, who just needs to pull his act together, or be put on drugs?

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  5. great comments and observations from marian and rossa. yet i think paul’s therapist should be concerned with paul’s well-being. people suffering from trauma need some validation – the victim needs to be heard and acknowledged. acceptance of the client’s experience is, of course, paramount. then maybe paul can move past the blame and work on his part.

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    • AnaLi, I agree. Validation of one’s experiences is indeed paramount. Nobody is helped if the message is that, no matter what happened to you, you may not feel angry, sad, confused, etc., or we’ll label you “mentally ill” and shut you up with pills. People need to be heard, and they need a space where they may experience and express their emotions, and have them validated. Nothing is more counterproductive than asking somebody who’s traumatised to forgive and let go of their past without first having looked at this past, witnessed it, and said “yes” to it. When my own therapist early in therapy said that “under these circumstances” she didn’t expect me to ever be willing nor able to forgive, it was the validation of my own experience I’d never received before, it put my emotions in a meaningful context with my life story, and it made “madness” unnecessary. But there’s a huge, and IMO very important, difference between believing that someone hurt you because they are/were cold, unloving bastards, personality disordered, and plain evil, only and solely out to hurt you, and knowing that people very easily can mess up and hurt you, because they simply don’t know how to not mess up. Because, sadly, the only way they know how to do things, the only way they’ve learned through their own life experience how to do things, is by messing up. The former usually has people get stuck with their anger, and I see many of these people end up in bitterness, continuously at war, looking for revenge, and unable to ever be anything but the victim. The latter opens up for understanding and empathy, while it, and this is important, doesn’t excuse those who hurt you. On the contrary, it opens up for holding accountable as opposed to pointing fingers, blaming and demonising. Bitterness doesn’t lead to insight and healing. But, that’s true, false forgiveness, i.e. forgiveness without previous validation, doesn’t either.

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  6. I agree with Marian, why is Paul and his father allowed to have suffered trauma, but his mother not. What happened in the therapy room is one thing, but what is described here is totally different. They are labelled as personality disorded, as though trauma had no role at all in what they were doing. How does one develop a personality disorder???

    I would also love to think that psychologists are like this across the board. I personally am not aware of any who will treat someone who is not on medication and all of them see it as there role to educate people about there defective brains and the medications that treat these conditions. What amazed me the most about this was that there is actually a psychologist out there who questions the medical model. The ONLY therapy I am aware of any psychologists offering these days is CBT from manuals which tells peopel that everything is simply an irrational belief and all they need to do is to think properly. Personally for me, psychologists have done as much if not more harm than psychiatrists. Psychiatrists at least numbed me to oblivion, psychologists told me that living a pedophile ring was simply an irrational belief and all I had to do was think positively and all my problems would be solved. I have seen in excess of 50 different psychologits, and another 20 or so social workers. These were not isolated incidents. If they said they didn’t know how to help me I would have accepted it eventually. Instead everything was blamed on my defective thinking or my defective brain. Personally I believe that psychology has bought into this medical model as much as if not more than psychiatry.

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  7. I disagree strongly with an insurance company trying to force drugs on someone. But am also troubled by the Freudian dogma in this post. Yes a bad childhood can effect someone. But we need a sane middle ground. One that acknowledges the role of genetics and biology, yet doesn’t naively fall for pharma marketing campaigns.

    Therapists must acknowledge that we are not all identical blank slates.

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