I entered graduate school for clinical mental health counseling pretty much on a whim. Since earning my undergraduate degree in the early nineties, I had worked in various positions in higher education. At the end of 1999, I found myself in a job I really disliked and wondering what was next. My co-worker and friend, knowing I was interested in holistic health and deeming me “a good listener,” thought I should consider the counseling field. She even had a school in mind with a holistic concentration.
While I had spent many hours researching the purchase of my current car, no research whatsoever went into my decision to apply to grad school and to enter the mental health field. In fact, I knew very little about the field and, frankly, had never given it much thought. Sure I knew that people could be depressed and anxious, but I had never viewed those as illnesses. I just figured life happens, and for some it does in very bad ways. Of course, there were those eccentric folks who could be seen walking the streets of my hometown exhibiting bizarre behaviors, and who “probably” had what I and many others thought to be the brain disease of schizophrenia. But beyond that, the idea that many suffered from a variety of mental illnesses had never crossed my mind. Despite all of this, my friend’s idea caught my interest.
In the early nineties I had been introduced to the concept of the mind-body connection through my participation in a twelve-week pain management program. I had been enthralled by all I learned and at the end had inquired about how I might go about becoming a facilitator for such a program.
The response was that I would need to attend graduate school. This was not an appealing thought at the time, given that I had just finished my bachelor’s degree a year or two prior. I did not enter into formal study at that time, but throughout the following years I did continue to educate myself about what it meant to be healthy in mind, body, and spirit. Thus, a counseling program with a holistic specialization was very appealing and I thought it would provide me with the education and the degree needed to help people as I had been helped years ago.
In the spring of 2000, I attended the open house, completed my application, and waited to hear if I had been accepted. I had applied to no other schools, nor did I have a Plan B. I also did not do any research into the field while I waited. The acceptance letter arrived and I entered my weekend intensive orientation to the program in August of 2000.
I felt at home upon walking through the doors that first day, and confident in what now seems to have been a somewhat impulsive decision. I have also never regretted making it. I loved and excelled in my classes. My professors took a client-centered approach to counseling and the focus was on empowerment rather than disease. In my psychopathology class I was taught to diagnose mental disorders using the DSM-IV and discussions often centered on the difficulty of having to label people and how to best treat them.
Cognitive behavioral therapy (CBT) is listed throughout my notes from that class as being an effective treatment, as is recognizing a client’s strengths and resources. In none of my notes is there a mention of a biological basis for these disorders or the need for medication to cure them. In fact, according to my class notes, I was informed that the DSM is “a theoretical document” and “that we should keep asking the question, ‘What’s the norm for whom?’” Additionally, my professor said that it is “a document based on what happens outside the people and that there is no language to address the subjective experience and no place for thinking about the person themselves.”
The questions begin.
In reviewing other classes I took, nowhere was I taught that mental disorders are an illness arising from a chemical imbalance which needs to be treated with medication. If my university professors did not teach it, then where did I learn it? The answer lies in working in the field itself and hearing it from supervisors and other colleagues. But where did they learn it? Was it from their professors and their training? Or have we all been so well “educated” by those ubiquitous television ads which show us how our brain does not “work” when our neurotransmitters are not “balanced” that we have come to accept this as truth? Have the medication providers with whom we work also promoted this myth because they too are prescribing based on the false education received by the pharmaceutical companies? Even insurance companies suggest that we speak with clients about taking medication to improve their symptoms. Why do we to continue to blindly go along without questioning whether or not any of this makes sense or is helpful?
About a year and a half ago I had stumbled upon a documentary about the history of psychiatry which led me to begin further questioning the disease model of mental health and the use of psychiatric drugs. I soon found myself listening to podcasts and watching videos with interviews of Peter Breggin, MD, the Harvard-trained psychiatrist who has written extensively about the dangers of psychiatric drugs, and who has been an expert witness in FDA hearings and trials against the makers of those drugs. The interviews of others included Mad in America’s Robert Whitaker and Britain’s Joanna Moncrieff, MD, author of The Myth of the Chemical Cure. I also began reading their books.
The research backing up the assertions made by Breggin, Whitaker, Moncrieff, and others validated much of what I had originally thought about so-called mood and anxiety disorders. For whatever reasons, I failed to further question the status quo until recently.
Having worked in the field for over ten years, I have come full circle. Looking back, I see clearly that for many of the clients with whom I have worked, particularly at a community agency in an impoverished city, the pills actually made things worse. I remember the clients who gained weight and developed diabetes because of the antipsychotics they had been taking. In my mind, I can see a man whose hands shook so badly he could barely hold onto anything. This side effect was thanks to the tardive dyskinisia which we knew to have been caused by an antipsychotic prescribed to help him sleep. I also remember a couple of clients who, after I had diagnosed them with major depressive disorder and referred them for medications, developed bipolar disorder. The explanation was that the bipolar disorder had been underlying the depression all along. All of these clients and others were on disability for their so-called psychiatric illnesses. It now seems obvious that the drugs were not improving their quality of life.
Many times during my years at the agency I found myself “educating” clients about the “chemical imbalances” from which they suffered, and informed them that they needed to take their medication as they would need to take a drug for any lifelong illness, such as diabetes. I said the words because I had been trained to do so, but saying them never made sense to me. The one exception to this was those symptoms related to psychotic episodes, which at the time I viewed as a true mental illness. However, my clients for the most part were people who came from—and continued to live in—poverty. They had been horribly and traumatically abused in a variety of ways, and/or were dealing with various multiple losses. These were disempowered folks with few healthy coping skills, in some cases with little-to-no familial or social supports, and limited resources. No amount of pills was going to make their lives alright.
Since leaving the agency and working in private practice, I have been slower than most to refer clients for medication, but have done so. I have made a conscious effort to talk with clients about depression and anxiety without using the terms of a chemical imbalance. However, in having to diagnose them with depression or anxiety, I feel I am placing upon them a label that need not be there. In previously telling people that they have a lifelong “disease” for which they will need to take medication, I have at the very least contributed to and in other cases outright caused more harm than good. While it was sincerely not my intention to do so, that is nonetheless the reality. Thus is my confession.
Here now is my dilemma.
While I have and will always support a client’s right to choose medication, I am now, with perhaps the rarest exception, extremely reluctant to agree with that decision. I feel that there should be fully-informed consent, with the client made aware of the actual risks of these drugs; something which is often missing or minimized by prescribers. Now, when the topic of medication does arise, I spend a good amount of time talking with clients about the real risks involved so that they are able to make the best decision for themselves. I talk with them about the myth of the chemical imbalance and continue to validate their life experiences which have led to them feeling depressed, anxious, or generally moody. Most seem to appreciate these conversations, which often resonate with their own views. Others are understandably skeptical, since I am providing information which often conflicts the views of their doctors and society at large.
I have clients who are on medication and would like to stop, but may not have a prescriber who is supportive of that decision. I know of no one to whom I can refer them. The best I can do at this time is to encourage them to assert themselves with their current prescriber and let them know that I am also willing to speak on their behalf. This lack of a network of prescribers who are fully aware of the risks, and who are willing to discontinue or minimize the use of these drugs, also means that I have no one to whom to refer clients who are on medication which is most likely worsening their symptoms.
The removal of the disease-model lens, and the desire to best help my clients without having the appropriate resources, has left me feeling professionally isolated. I know of no colleagues who have accessed similar information and have drawn the same conclusion. There is no one with whom to discuss the concerns and questions I have. A year ago, in conversation with a colleague when I merely raised the possibility that we were perhaps wrong in our approach of a disease model which required medication I was told that I was “starting to sound like Tom Cruise.” Most others with whom I have had talked have been dismissive or, understandably, skeptical. Some are interested, but seemingly not enough to do their own research. This, too, I understand as people are overwhelmed and busy. But we need to do better.
As a profession, it is time to return to a client-centered approach, rather than a disease-centered one. We need to empower clients to know that they do have some control and can make positive changes in their lives, despite how horrible their experiences. We need to let them know that they are not sick, but instead remind them that they are human and that being human, while emotionally messy at times, is not a disease state or something to fear. I cannot do this alone, but I also know that I am not the only one who feels this way. Will you join me?
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.