I was recently talking with a young man about his anxiety, which he experiences as extreme. When I asked him what the anxiety was about, he didn’t know. When I suggested that we become curious about it and explore what it might be about, he told me that it was so extreme, it must be “biochemical.” This meant to him that the anxiety could not be understood in a psychological way, but had to be dealt with as part of his “illness.”
I acknowledged to him that anxiety certainly involves biochemistry, but suggested that there are also experiences and interpretations of experience that trigger the biochemistry into action. For example, if he experienced someone pointing a firearm in his direction, he would likely experience an intense biochemical process within his body, but the experience would not be “just biochemical.”
If people are going to understand themselves and work through emotional problems, it is essential that they get curious about their experiences and reflect on what might be triggering them. Sometimes such curiosity or reflection results in getting valuable messages from those experiences, or at other times, it involves identifying a mistake that triggered the emotional experience, which then allows for resolution. To use the simple example of the threat perceived from the firearm, one might either take quick action to avoid being shot, or in another situation perhaps observe more carefully and notice a movie is being filmed and that the firearm being pointed is just a prop.
Of course, experiences like anxiety and depression often have their sources in much more complex experiences, and so more complex reflection is necessary to sort out what actions to take or what interpretations to revise. We live though in a society that does not like complexities or deep reflection, so we already have a bias toward thinking that disturbing emotions that don’t quickly make sense must just be something wrong with us. This bias makes us think we “shouldn’t have” disturbing emotional states, so we tend to push them away or dissociate from them, which just makes it more difficult for us ever to understand their sources and decide what to do about them.
Those who market psychiatric drugs take advantage of this cultural bias to offer a seductive pseudo explanation, which is that unwanted emotional states that aren’t easily resolved must be the result of a “biochemical imbalance” or some other biological problem. Our culture has become heavily influenced by this viewpoint, to the point where it seems the majority believe that seriously disturbing emotional states lacking easy explanations must be caused by a fault in biochemistry, rather than being something that can be potentially understood and resolved.
The sad result of this marketing effort has been to dramatically aggravate a cultural tendency to avoid deeply listening to each other, or even to ourselves. Any mental or emotional problem which does not rapidly resolve must be “biochemical” and not worth even trying to understand; instead we should be trying to drug it away.
While many others have pointed out how this dishonest marketing pushes drugs that often cause damage or make mental health problems worse in the long term, I think it is worth reflecting on how the beliefs promoted by the marketers are themselves damaging to mental health. In particular, I want to emphasize the way these beliefs aggravate splits within a person, typically splits between more conscious aspects of the person and the less conscious parts that are experienced as disturbing emotions and/or voices.
A certain amount of “division of labor” within a person is actually functional: we are complex beings with multiple needs that must be attended to. But when people are traumatized, or when they experience conflicts that exceed their ability to manage them, such divisions often become entrenched and deep and troublesome. One word that has been used to describe such splits is “dissociation.” Such splits can be seen as the basic dynamic behind all the common mental and emotional problems, as described in my (free) recorded webinar on Dissociation as a Common Factor in Many “Mental Disorders” Including Psychosis. (You may also be interested in the paper “Dissociation, trauma, and the role of lived experience: Toward a new conceptualization of voice hearing” for which voice hearer Eleanor Longden was the lead author, and you may be interested in a new “transdiagnostic” approach to therapy which sees conflicting purposes within a person, and not pathological “symptoms” as the basic mental health problem: for a great introductory video, see Introduction Vignette – Method of Levels.)
When dissociation is the problem, there is a need to work toward more understanding and integration. Dialogue (such as in the Open Dialogue method) is needed, both within the person, and between people, to give voice to the various purposes that may need to be integrated. But the effect of beliefs about a “biochemical imbalance” is to instead aggravate the dissociation. Rather than wonder what the anxiety or depression is about, for example, the person convinced it is a biochemical imbalance seeks only to get rid of it, to wall it off even more, without attempting to understand its source within.
When people are convinced their problems are biochemical, they are also less likely to explore the problem with others or with a therapist. And when a therapist is convinced that his or her client’s problem is “biochemical” then that therapist is likely to focus on sending the client in for a “medication check” rather than looking deeper into what may be going on. (“Biochemcal imbalance” theories are also great for explaining away any failures of understanding on the part of therapists!)
The end result is that marketing misinformation may itself be hugely iatrogenic, and be one of the primary causes, along with negative long term effects of drugs, of the worsening of mental health outcomes.
This issue is one I hope to address in a seminar Pam Birrell and I will be teaching called “When Treatment Might Cause Harm: Exploring Ethical Dilemmas related to Diagnosis, Drugs, and other Possibly Iatrogenic Aspects of Mental Health Care.” We will be presenting in Eugene OR and Portland OR in early September, but we hope to present it later in other locations, and also as a webinar, so that mental health professionals can earn their CEUs in ethics while also learning how to minimize iatrogenic harm, including harm that results from the unfortunate effects of believing drug marketing propaganda.
I encourage all of you who might be interested in taking this course at some point, perhaps as a webinar, to get on my email list. Also, I hope some of you consider yourselves teaching a course like this in your own locality: we need to spread the word widely about the importance of these considerations if we are ever going to create that necessary revolution in mental health care! I will be happy to help you do that if I can.
I’m glad that someone finally said this. I don’t recall any other blogger bringing this up yet but it’s a very important part of the issue. Even if we lived in some fairy-tale land where the drugs had no side effects and were 100% effective, we’d still be in danger if the symptoms we were medicating were actually caused by problems in life in the first place.
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Excellent reply. I’ve never seen it written so clearly.
Often I hear people (service providers for example) that drugs can help people deal with real life problems because they help them calm down enough to think about them. I have no evidence of this. It sounds like even more pie in the sky in most, if not all, cases.
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Exactly. I always want to ask anyone who states this just exactly how they think someone is going to think about and process anything when they’ve been chemically lobotomized or heavily tranqualized. You certainly can’t do any deep thinking when you’re suffering from akethesia so badly that all you can think aboutis killing yourself to make it stop. So many “service providers” live in some kind of fantasy land about the “good treatment” they’re providing to people. Torture is actually what they’re carrying out against people.
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I agree that drugs more often interfere with therapy and with recovery than help. But I suspect there are some positive uses of them. Especially for example when lack of sleep is making the mind unable to function: drugs that induce sleep can really help. That’s why the one kind of drug they give right away in Open Dialogue is stuff to help people sleep (but not anti-psychotics – those are reserved for times when nothing else works after a number of weeks.)
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I think there is also a societal cost here, as well as an individual one. The epidemiological evidence is that severe mental distress, the sort that gets people diagnosed with schizophrenia for example, is linked to trauma, often childhood trauma. Child sexual assault, family violence, early loss of a parent, bullying, racism, homophobia and poverty are all linked to later higher rates of diagnosis of serious mental illness than in the general population.
If we want to reduce the level of mental distress then we need to admit this and governments need to develop policies to tackle these problems.
The biochemical explanations allow society and governments to avoid all these problems as well allowing drug companies to make huge profits.
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And then imagine if your childhood trauma were actually caused by psychiatric treatment. Imagine then being screwed up as an adult and having nowhere to turn to but, you guessed it, psychiatry. Or self help.
I remember one of my earliest memories was how confused I was at how the “doctor” (psychiatrist) had said I was sick even though I felt fine and then when I complained about how sick I was from the drug he told my parents I couldn’t come off it because I was doing so much better. This sort of thing went on for years. One adverse reaction to a drug was all it took to guarantee a barrage of more drugs and more problems and once I realized this I actually had begun trying to hide problems caused by the drugs. Could you imagine having a terrible drug induced anxiety (akathisia) and then just trying to hide it on a psych ward because you’re SCARED of more “treatment”? Imagine that at the ages of 7-14. And then when you grow up to be a screwed up adult on SSI, you’ve got nowhere to turn. I’m 29 years old now and still living in my parent’s attic. I haven’t left this house to go anywhere but to get blood work from my GP in YEARS! When my parents die I can see myself getting trapped back in that system (i’ll actually kill myself first) where the explanation for all my problems will be to blame biology and just try to put me back through everything that caused my problems in the first place. That’s the reality of my life.
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There is hope Jeff, beyond the mainstream reaction to existential distress, which is caused by our mind reading diagnosis of our fellow human beings.
Sadly this need to diagnose others begins in the family and results in the classic early adulthood crisis of self-doubt, about how to cope with life and its stress challenges? Example:
“The Family Projection Process:
The family projection process describes the primary way parents transmit their emotional problems to a child. The projection process can impair the functioning of one or more children and increase their vulnerability to clinical symptoms. Children inherit many types of problems (as well as strengths) through the relationships with their parents, but the problems they inherit that most affect their lives are relationship sensitivities such as heightened needs for attention and approval, difficulty dealing with expectations, the tendency to blame oneself or others, feeling responsible for the happiness of others or that others are responsible for one’s own happiness, and acting impulsively to relieve the anxiety of the moment rather than tolerating anxiety and acting thoughtfully.
If the projection process is fairly intense, the child develops stronger relationship sensitivities than his parents. The sensitivities increase a person’s vulnerability to symptoms by fostering behaviors that escalate chronic anxiety in a relationship system.
The projection process follows three steps:
(1) the parent focuses on a child out of fear that something is wrong with the child;
(2) the parent interprets the child’s behavior as confirming the fear; and
(3) the parent treats the child as if something is really wrong with the child.
These steps of scanning, diagnosing, and treating begin early in the child’s life and continue. The parents’ fears and perceptions so shape the child’s development and behavior that he grows to embody their fears and perceptions. One reason the projection process is a self-fulfilling prophecy is that parents try to “fix” the problem they have diagnosed in the child; for example, parents perceive their child to have low self-esteem, they repeatedly try to affirm the child, and the child’s self-esteem grows dependent on their affirmation.
Society at large works in the same way, with people improving their sense-of-self, by projecting their need to feel like a high-functioning adult, onto “pitiful” others whom they can diagnose as “lesser than?”
Consider approaches and programs for emerging adults like the Yellow Brick foundation, for example?
“Yellowbrick is a private, physician-owned and -operated psychiatric healthcare organization whose mission is to provide a full-spectrum, specialized approach to the emotional, psychological and developmental challenges of emerging adults.
Yellowbrick operates from a research-based care model that combines the most current contributions of neuroscience, innovative psychotherapies, strength-based rehabilitation strategies and wellness medicine. Guided by skilled, experienced and compassionate professionals who are dedicated to accountability and outcome, Yellowbrick offers programming to address the unique developmental needs of these emerging adults.” http://www.yellowbrickprogram.com/index.html
Consider this non-invasive treatment approach?
“Transcranial Magnetic Stimulation (TMS)
Responding to the need for a noninvasive, non-convulsive, non-medication theory, Transcranial Magnetic Stimulation (TMS) has been advanced as a promising new approach for use with difficult to treat patients. The use of TMS for the treatment of depression represents a long sought after paradigm shift in psychiatry.
TMS is the first noninvasive and nonconvulsive procedure that relies on the stimulation of
neurophysiological circuits known to be necessary in maintaining mood. It is FDA-approved for the treatment of patients who have not responded
to at least one trial of medications, and might cautiously be considered as a front line therapy in those patients who are unable to tolerate a full
trial of an antidepressant medication.
TMS is particularly promising for work with emerging adults. It is a 37-minute outpatient procedure requiring no anesthesia or sedation, therefore allowing patients to attend to tasks of daily living with relatively little interruption. In the case of emerging adults, learning tasks of daily living, going to school, planning careers, and establishing intimate relationships all benefit from maintaining focus.
Second, the treatment is time-limited, lasting 4 to 6 weeks, which means that this treatment can be delivered during non-pregnancy periods.
TMS was first developed in 1985 as a non-invasive method of mapping the brain, in particular
the motor cortex (Barker, 1985). Barker et al employed a principle first understood in the 19th
century: transcranial magnetic induction. First discovered by Michael Faraday in 1831,
electromagnetic induction describes the production of voltage – or the flow of electron current –
caused by a change in a magnetic field. Rapidly alternating the flow of electrical current within a
coil of wire produces a magnetic field, which in turn allows for the production of precise electric
current within large neurons perpendicular to the coil.
By inducing an electric current in a particular part of the brain through the use of TMS, the function of that part of the brain is revealed without damaging the brain tissue. The result was a simulated map of neurons, called a neural network, that synthetically modeled specific brain functions.
Several researchers employing TMS as a tool for brain mapping noted incidentally that some of
their research subjects reported improvement in mood after undergoing TMS (Bickford, 1987). As
brain-mapping research progressed, prefrontal depolarization of large neurons in the left
prefrontal cortex was found to reliably produce improvement in mood. Daily left prefrontal TMS
over several weeks was first proposed as a treatment for major depressive disorder in 1993. Since
the early 1990s, TMS has been extensively studied for the treatment of major depressive disorder,
typically using a left prefrontal cortex placement. Of the studies that have been published, several
concomitant meta-analyses of them have concluded that left prefrontal TMS provided statistical
superiority over sham treatment for patients with major depressive disorder (George, 2010). A
number of clinical features have been demonstrated to be associated with greater response; these
include younger age, diminished resistance to antidepressants, and an absence of psychotic
features.
Psychiatrists experience some version of the “difficult to treat” patient everyday when presented with the need to treat depression. An added layer of complexity arises when working with emerging adults (ages 18 to 29) who present with age- and stage-specific conditions and issues.
For example, there is the twenty-four year-old patient who refuses to try SSRI antidepressants after reading the black box warning that tells him
the medication may cause him to experience suicidal thoughts. There is the twenty-three year old woman on a staggering list of medications for various medical comorbidities; this makes the provider cringe at all of the possible drug interactions.
Still there is the nineteen-year-old young woman who wants to know if this antidepressant is going to interfere with her birth control pills, and, if she does conceive, is the antidepressant going to hurt the fetus? And there are those patients for whom treatments have been ineffective, such as the twenty-five year old young man who has“tried everything;” his frustration and agitation is accelerated by ineffective treatments.
Complicated cases of medicating young patients suffering from major depressive disorder require psychiatrists to deviate from standard protocol.
This is a particularly frustrating concern when the psychiatrist acknowledges that emerging adults are, for the first time, learning to be responsible for their own mental health care. The impetus to find a curative therapy in the emerging adult patient is magnified by recognition of the amountof life yet to live.
Despite the complexity of these cases and the current lack of a literature guiding their treatment, psychiatrists see opportunity for successful treatment given the exceedingly high neuroplasticity normative to this age period. Brain tissue has an unparalleled opportunity to organize and reorganize its function on the basis of stimuli and functional demands. In no developmental epoch beyond emerging adulthood will the brain be able to change on the basis of its environment.”
Transcranial Magnetic Stimulation for Depression in
Emerging Adults, _David V. Hamilton, MD.
I realize this response is off the thrust of Ron’s essay, but found it hard not to address a young person’s deep existential concern.
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Hi Jeffrey,
I can imagine how horrible it must be to feel drug induced problems that you then have to hide to avoid more drugs! That in itself is a great argument for why we have to teach mental health professionals to actually listen to people and hear what their choices are, rather than just impose “solutions.”
I hope though that you start seeing options in life other than hiding in your parent’s attic! You write well, and I’m sure you have other strengths also. If you work at getting back into life, then when your parents die you will be competent to handle things and to stay out of the mental health system.
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Great comments, John & Jeffrey.
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The revolution can not happen.
You are advocating power to the patient, this is the opposite of what those in authority want.
They want the out of control forcibly controlled. Drugs (called medications) stop the out of control person.
The patient might fear their feelings of fear and anger(psychotic) so willingly take the drugs to be good.
What is the patients motivation to be curious about “his anxiety”? He has an unlimited legal drug supply from a doctor.
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A very inspiring post. The beliefs, expectations and theories we have about our mind are very powerful placebos or nocebos (i.e. cures or poisons) for mental issues, whether we take a pill or not. I don’t remember seeing that fundamental principle expressed as well and as convincingly, with all the cultural implications, than in your various posts. I look forward for your webinar.
The expectations and explanations we have about ourselves are shaped by our culture and the expectations and explanations (whether optimist or pessimist) that significant people have for us. Not just our parents, but also very importantly members of the mental health professions (whether through therapy, or mainstream books, or journal columns).
Mental health professionals are quick to recognize the major influence of parents on mental struggles (unfortunately maybe too systematically), but they rarely take responsibility in any outcome for their own influence, even if the struggles appeared in adulthood long after parents have stopped being the most significant influence, and even for people that have considered for years the mental health profession as the most significant source of authority for life issues.
I consider any mental health professional or organization that gives a “lifelong” mental illness prognosis as dangerous and partly responsible for that outcome if it becomes true.
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Very well-said, Stanley.
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I know from personal experience how devastating this can be. And it’s not only because society goes on as if there’s some dangerous chemical imbalance going on; it leaves a person in a state of utter despair to even have the association that there’s something irreparably wrong with their mind. As if it’s doing something wrong, as if there’s something innately wrong with it.
And then in reality, the mind was just letting go of fear, of discarding what was getting in it’s way rather than having something wrong with it. Someone who goes dancing in the rain fearlessly to remember what it is to be human (and have skin) is supposed to have something wrong with them because this breaks obscenity laws. Someone who just can’t maintain their grip on statistically accepted norms of definitions of things and fear based controls on behavior, and starts moving into an awareness that actually witnesses what’s truly going on, has a vibrant symbolical significance in it’s conceptual imaginative responses: and might actually sink in and be understandable; this person is supposed to have something wrong with them. Someone who can’t conform to the fascist situation at work and gets “depressed” about this is supposed to have something wrong with them. A child that isn’t comfortable sitting still for 8 hours behind a desk at school; isn’t allowed to go to the bathroom without raising their hand; isn’t allowed to talk to the person next to him; has to listen to stuff it’s not particularly interested in and then go home and do more work: this child is supposed to have something wrong with them, when they are so uncomfortable with this that they respond in a normal fashion. This is the kind of fear that society instills in people in order to create harmony. From here we go into all the rest of the areas that would be called more disturbing, thanks to how disturbing the basic tenets of fear based controls are.
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The basic premise of the chemical imbalance is as damaging to society as eugenics theories, or the belief that the group with the greatest ability to destroy and intimidate is the most just..
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The idea that mental problems are biochemical in nature robs us of any sense of personal agency, the idea that we have some level of control over how we feel, what we think, and what we do in the world. It is very interesting that in the 2008 study on schizophrenia that Bob quotes, the author finds that one of the key factors in common with people who recovered from schizophrenia in his study was, in fact, a sense of agency, of control over his/her world and in the possibility of self-generated improvement in his/her condition.
This is the one inadmissible point in the bio-psychiatric paradigm of care, and is interestingly the one most likely to lead to recovery. My experience in providing crisis counseling and brief therapy is completely consistent with this. The thing that helped most was 1) identifying what was troubling the person, 2) NORMALIZING the emotional reaction (letting them know that it was COMPLETELY UNDERSTANDABLE that they’d experience fear, anxiety, depression, anger, or whatever as a result of their experience), and 3) helping them find at least one small thing they could do that could make the situation even slightly better.
The biological paradigm does the opposite: 1) ignore any potential outside causes and focus only on the symptoms, 2) make sure the patient knows that the “symptoms” are both inexplicable and abnormal, and 3) inform the patient that there is not the least thing they could do to improve their situation, that they will be condemned for life to a broken brain, and only the magic pills of psychiatry can give them any hope of relief.
This is not just “another good point” – this is the CENTRAL PROBLEM with the biological paradigm. It’s not just that it’s subjective or untrue or leads to unnecessary drugging and danger (all of which are true); it’s because the biological explanation does EXACTLY THE OPPOSITE of what would be helpful. It undermines any thought or belief in the patients’ ability to regain control of their lives, which is the core of recovery.
Ron, you hit the nail on the head with this one.
—- Steve
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Thanks Steve, I appreciate your positive feedback and that of others who have written here!
In cognitive therapy for psychosis, a key method is called “normalizing.” That’s where you try to help the person understand what they are going through as just a possibly extreme example of stuff everyone goes through, you look at how it makes sense given what happened to them, etc.
In my classes on cognitive therapy for psychosis, I explain that what happens in the mental health system is often the opposite, which we could call “abnormalization.” Experiences the “patient” has are seen as very different than those of “normal” people, are given different words and completely different explanations, so much so that it is hard to see any connection. This is not too helpful in working toward healing and understanding……
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I agree that it’s harmful for people to reduce their problems to biochemical imbalances, I’m not sure that was happening with that young man. He might have been someone trying to acquire a drug for anxiety that was real or made up. Typically someone can go to a psychiatrist, complain about biochemical anxiety and then score a drug. Not only that he’ll get written up as insightful by drug dispensing quack. I’d immediately suspect he had experience scoring drugs from psychiatrists.
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