George Washington was killed by his own doctors. This actually was not the outcome they were hoping for. They meant well and wanted to save the life of the first President of the United States. They got to work eagerly to try to help.
But there was a deep problem. Their theory of what caused illness was wrong. They believed in the humoral theory, that sickness was due to an excess of humours, or fluids in the body (bile, phlegm, blood, etc). Therefore, they thought the solution to his throat infection was blood letting, to reduce the excess humours. They removed 40% of his blood in 12 hours, and thereby killed him. Which shows that good intentions and hard work, plus the wrong understanding of what causes illness, leads to disaster.
Deep Flaws in the ‘Chemical Imbalance’ Model
To avoid this type of needless harm and death, we need to be very sure that our theory of what causes illness is correct. In terms of mental illness, the dominant model is the ‘chemical imbalance’ theory, that depression and other disorders are due to low levels of serotonin, or abnormal levels of dopamine, or other imbalances of chemicals in the brain. Yet when we look closely, three problems emerge in this chemical imbalance model. The first flaw is that there simply is no way to measure the levels of neurochemicals in a living brain. Therefore, we cannot know what is a correct balance of neurochemicals or what is an incorrect balance. The assertion that there is an imbalance has no data to support it. The next flaw is that the theory never explains how the chemicals become imbalanced in the first place.1 It claims that depression is due to low levels of serotonin, or that schizophrenia is due to abnormal levels of dopamine. It never explains why the levels of serotonin supposedly dropped in the first place. Is it due to a random fluctuation? Too many X-rays? Not enough Vitamin D? This inability to explain the origin of the drop means that the theory is incomplete. If there is something upstream that causes the levels of serotonin to drop, then that would be the actual cause of depression.
The third flaw is the most serious. When researchers try to measure the levels of serotonin in the brain (blood plasma levels, autopsies, etc) they simply find no evidence of a chemical imbalance.2 None. They do not find that depressed people have lower levels of serotonin in the brain than non-depressed people.3 This conclusion can be hard to acknowledge, since the belief in a chemical imbalance is extremely widespread in our culture, and is repeated on major media nearly every week. Yet in the words of Lacasse and Leo, “there is not a single peer-reviewed article that can be accurately cited to directly support claims of serotonin deficiency in any mental disorder, while there are many articles that present counter-evidence.”4
This has colossal implications for the whole field of mental health. The dominant theory has no direct way of measuring the balance of chemicals in the living brain, it cannot explain how the chemicals apparently become imbalanced, and there is no scientific evidence of a chemical imbalance resulting in any mental disorder. In short, it has no more intellectual credibility than the humoral theory, which held that an excess of yellow bile caused sickness, or which said that bloodletting was the correct treatment for a throat infection.
Why Care About the Cause of Problems?
So how did a theory that has zero scientific support become the dominant model for why people become depressed, anxious, or have problems with their thoughts? The reason is simple. A person’s theory of causality is extremely powerful. Once you have defined what you think is the cause of a problem, then the solution follows right behind. In fact, you have to use the solution. And because doctors in 1799 believed that an excess of humours (certain fluids in the body) caused illness, George Washington was bled four times in the final hours of his life. Cause determines solution, even if the solution is occasionally lethal.
Which is why the drug companies spent billions of dollars promoting the “chemical imbalance” theory of depression, schizophrenia, and other conditions. As soon as someone accepts the concept that their emotional difficulties or experiences are due to a chemical imbalance, then they believe they have to take a pill to correct this imbalance. Nothing else will do. They will have no reason to believe that psychotherapy or other interventions will correct the imbalance, so they must start the pills. And once they do, they have to stay on them. If they stop, then the ‘chemical imbalance’ will reassert itself, causing misery all over again.
And as long as the cause is believed in, alternate approaches are excluded. Even if they are far more effective. For example, Ignaz Semmelweiss found that if physicians washed their hands before they delivered a baby, then the death rate for the mothers due to infection was less than 1%. However, if the physicians did not wash their hands, then the death rate was 10%. This was so well known that women begged to be admitted to the clinic where hands were washed. In fact, it was safer for a woman to give birth in the street than to give birth when a doctor assisted. The maternal death rate was 4% when she birthed her child in the gutter outside the clinic.
But even though Semmelweis produced data (and thankful mothers) showing that washing hands saved many lives, he was ignored because he “could offer no acceptable scientific explanation for his findings.” He had no theory of causality. It was only after his death, when Louis Pasteur confirmed the theory that germs caused disease, that doctors began regular hand-washing. A new cause for illness had been discovered, which was germs. This displaced the old cause, the humoral theory. As a result, bloodletting stopped, hand-washing became widespread, and many lives were saved.
Several key lessons can be drawn so far. It is not enough to say that the current solution is ineffective. Bloodletting was harmful, and it still persisted for two millennia. It is not enough to say that the new treatment is far more effective. Semmelweis cut the death rate by 90% and was still ignored. If you want to change health care practice, you must propose an alternate cause. Only then can the useless or harmful solutions be stopped, and people receive real help.
That is why there is so little change in the landscape of mental health problems. “Chemical imbalances” are seen as the cause by the majority, and alternate solutions are side-lined. It is not enough to say that psychoactive pills are ineffective over the long term. Prescription rates are still climbing. It is not enough to say that psychotherapy has better long-term outcomes and no side effects. It still is side-lined, relative to using pills. It is not enough to say that there is no research that supports the idea that chemical imbalances cause depression or other problems. The pharmacological approach retains tremendous power, and the number of people taking pills rises each and every year, because the causal theory has not been replaced with a new one. There was no research that showed an imbalance of humours caused illness, but that theory lasted for millennia.
There is a New Model of Mental Illness
There is now an alternate model for what causes mental health problems. Unlike the chemical imbalance theory, it has the backing of thousands of research studies. It can also explain some of the vexing contradictions in psychiatric research. It proposes a brand new way of assessing people and their emotional health issues — one that fundamentally replaces the DSM and other symptom-cluster models. More importantly, it leads to safer and more effective interventions for people who are in serious emotional pain. It places their experiences and their choices about treatment front and center. Instead of pigeon-holing them with a diagnosis, and using power to impose an intervention on them that they often do not want or understand.
The new model is the psychological injury (PI) model. It states that the single largest cause of mental health problems is when a person experiences a psychological injury. These occur when the person is subject to marked neglect, abuse, disrespect, or chaos in their social environment. They can also occur when the person experiences a traumatic event. There are at least four groups of psychological injury, the first being trauma in childhood, the second being highly stressful life events, the third is working for an abusive boss, and the final is trauma in adulthood. The PI model acknowledges that mental health problems can occur from other reasons (i.e. hormonal fluctuations leading to postpartum depression) but maintains that the single largest cause is psychological injury. We will briefly look at each of these four types of psychological injury, before discussing assessment, treatment, and how the PI model resolves contradictions in psychiatric research.
Childhood Trauma as Psychological Injury
The groundbreaking research in the area of childhood trauma was carried out by Drs. Fellitti and Anda, of the Centers for Disease Control. They asked 17,000 residents of San Diego whether they had experienced different types of abuse and neglect, as well as five types of dysfunction in the parents. Initially, they did not expect much. Three-quarters of the sample had been to college, and they had good jobs, good healthcare, and lived in one of the most beautiful and affluent cities in the US. But the pain was right below the surface. Two-thirds of the sample had some form of abuse or parental dysfunction. Most had multiple traumas. Kids with alcoholic fathers also experienced emotional abuse, and saw Dad smack Mom around.
The effect of this childhood pain carried on for decades. If a woman was fortunate enough to grow up in an emotionally healthy home, she had an 18% chance of developing depression by middle age. But having just one adverse childhood experience (ACE) boosted her risk by 50%.5 Two ACEs boosted her risk by 84%. And the poor souls who had five or more ACEs had a 340% greater risk of developing depression than someone who grew up in an emotionally healthy environment.
Suicide attempts follow closely behind cases of severe depression. If someone had no childhood traumas, they had a 1% chance of attempting suicide.6 But their risk increased with each additional trauma, until the people who had seven or more traumas were 36 times more likely to attempt suicide than those who had none. Crunching the numbers showed that 2/3 of all suicide attempts were due to trauma in childhood.
These results have been replicated over and over. Canadian researchers accessed an even larger sample, where every person in the country had an equal chance of being studied. They asked 24,300 people about three childhood traumas (physical and sexual abuse, domestic violence).7 If people grew up with all three of these traumas, they were 26 times more likely to attempt suicide as those who suffered none. That is almost a photocopy of the results from Drs. Felitti and Anda. The Canadian study went beyond replicating the results from San Diego. It assessed nearly all major mental disorders, both through self-report and structured interview. Summing across mental disorders, the risk was 2.5 times greater if the person had one trauma, 4 times greater if they had two, and 8 times greater if they had all three traumas.
This is the pattern for bipolar disorder. People were 8 times more likely to develop bipolar disorder if they had all three traumas. Although it is widely conceived of as a chemical imbalance, the research paints a completely different picture of the primary cause. It is significant emotional dysregulation as a result of childhood trauma. Same thing with schizophrenia. A summary of the research found that people with childhood trauma were 3 times more likely to develop schizophrenia than those who had none.8 Major studies in the US and Britain found that having five traumas increased the risk of having symptoms of schizophrenia between 53 and 160 times.9
These numbers are so staggering that it is worth stepping back to recognize what they mean. They show that schizophrenia is not fundamentally a brain disease. Nor is it a chemical imbalance, either. No. What we call schizophrenia in most cases is actually people with trauma who have significant difficulty with regulating emotion, organizing their thoughts, and connecting with reality.
At this point, some will vigorously protest. They will point out that people who report hearing voices or have odd experiences have problems in brain structure and functioning. They will mention the damage to the hippocampus in the brain, cerebral atrophy, and other structural problems. They will say that the HPA axis (hippocampal-pituitary-adrenal) is overactive in the brain, and that there are abnormalities in certain systems of neurotransmitters. That is true. However, as Dr. John Read has pointed out, those are exactly the same changes as occur in the brains of children who have been traumatized.10 11 When a 7-year-old boy is terrified and ashamed as his mother slaps his face and screams at him that he is as much of a failure as his father is, his brain is flooded. The amygdala is sparking off with the fight-flight-freeze response. Fear is making adrenaline and cortisol gush into his bloodstream. If this happens day after day, month after month, then his brain will surely change. And if the child has five or more different traumas, then the child’s risk of having difficulty regulating their emotions, organizing their thoughts, and connecting to reality goes up anywhere from 53 to 160 fold in adulthood. It is the variety and frequency of traumas that alters the brain, and enormously increases the risk of problems later in life.
Stressful Life Events as Psychological Injury
These highly stressful events can occur in adulthood as well. One study followed 2000 twins for over a year.12 This enabled the researchers to separate genetic factors from environmental ones. When life was calm, those people at highest genetic risk were twice as likely to develop depression as the lowest risk group. But when life became highly stressful, such as being abruptly fired, or a teenage son starting to use drugs heavily, then they were 14 times more likely to develop depression. Although genetics may have played a role in the onset of depression, psychological injuries were a far more powerful factor in pushing someone into depression. This sparked a flurry of research. The summary of all these papers was that the serotonin transporter gene had no influence on whether someone became depressed or not.13 14 It was stressful life events such as finding that your spouse cheated on you, or a major conflict with your mother, that predicted depression. Even when people were followed for up to 12 years, 88% of episodes of depression were triggered by stressful life events.15 This finding contradicts the chemical imbalance theory, which would assume that depression occurs on a random basis, unrelated to events in a person’s life. But when 88% of depressions can be traced to a stressful life event, then the psychological injury model has robust support.
Toxic Boss as Psychological Injury
The third group of psychological injuries (after childhood traumas and highly stressful life events in adulthood) is not in our personal life, but our work life. Every single week in my private practice as a psychologist, a brand new client comes in. They say they are so depressed that they want to die, or that they wake at three in the morning quivering with fear. And when I ask why they are in so much pain, they say, “I think it is my boss.” They describe managers who tell them that their work is a 2 out of 10, but give no feedback on how to improve it. They talk about bosses who claim that their co-worker Kelly dislikes them, but when the person checks in with Kelly, he honestly says that everything is fine. As they tell me these stories of abuse and manipulation, they start sobbing in my office. One person, who had been selected employee of the year for a multi-billion dollar company, came back from vacation and was assigned to a bully of boss. Within weeks of reporting to the toxic manager, he told me he was going into the woods with a weapon and not coming out.
If toxic managers can shift people from employee of the year to being suicidal in just three months, it shows how deep the psychological injury cuts. We spend the majority of our waking hours at work, reporting to a manager who has the power to promote or fire us. People are also quite psychologically invested in their work, as we evaluate status in our society by the prestige of our occupation. At social gatherings, people will announce that they are “just a housewife,” indicating they are near the bottom of the ladder of status. If someone else says they are a neurosurgeon, they automatically receive high status. And not only do our managers influence our status, but getting fired by them can financially ruin people. It also sends a message that the person is a bad employee, and should be avoided by future employers.
This is not just clinical observation. A study of 4234 employees in Denmark asked them how much they trusted their manager, and how fair the policies were in their workplace.16 They also assessed the employees on 13 other variables, ranging from personality variables to smoking history and more. The researchers followed the people for two years. Even after controlling for the 13 other variables, they found that people who had low levels of trust in their boss, or felt the workplace policies were quite unfair, had three times the risk of developing depression compared to people with good managers and fair employers. This shows that toxic bosses cause depression, in the same way that smoking causes lung cancer.
Trauma in Adulthood as Psychological Injury
The final group of psychological injuries in adulthood is traumatic events. Being involved in a car crash, a natural disaster, or combat can result in post-traumatic stress disorder and/or depression. The cumulative stress can be unbearable for many people. In fact, the psychological injuries are more dangerous than criminals or terrorists. Although it is the job of police to grab criminals (many who are high on drugs and/or armed) and shove them in the back of police cars to take them to jail, that is the safest part of their work. The most dangerous part is when they go home, and have to deal with the pain and PTSD of what they see each shift. Three times as many police officers committed suicide in 2017 as were shot in the line of duty. Exactly the same results were found in military veterans, with three times as many Canadian soldiers dying of suicide as died in service in Afghanistan. When it is safer to have the Taliban throw grenades at you than to deal with the flashbacks of combat, the gravity of psychological injuries is clear.
These four groups of psychological injuries show up in my office every day. People with trauma in childhood, highly stressful life events, toxic managers, or trauma in adulthood sit on my couch. I have done 24,000 hours of therapy in my private practice, and there is only a tiny percentage of people who do not have one of these psychological injuries causing their negative mood. They exist, but multiple lines of research, and tens of thousands of hours of clinical experience affirm that the single largest cause of emotional health problems are from psychological injuries.
A New Model Needs a New Measure
Now that we see the role of psychological injuries, the next step is assessment, in order to understand the scope of mental health issues. Unfortunately, the most widely used approach to assessment misses the point. The Diagnostic and Statistical Manual does not ask about psychological injuries in a systematic fashion. The DSM fusses about which symptom fits into which cluster. It does not start by asking, “What is your life story? What are the psychological injuries from the past that result in such pain and confusion for you today?” Instead, it is set up to say, “You have had this cluster of symptoms for the last month. Therefore you have this diagnosis.” It then is easy to say “therefore take this pill to numb those symptoms.”
The Psychological Injury Index takes the opposite approach. It asks about the varieties of psychological injuries that the person has lived through. When those are mapped out, then others can start a dialogue with the person about how they coped with those injuries. They can discuss how the injuries relate to the emotional distress and odd thoughts that they have now. The trajectory of the person’s life is now front and center. The focus is not on which cluster of symptoms they have had for the last 30 days. It is about the path of their life. And when people can talk about what caused them pain, how they coped with it, how those methods are working (or not), and what they want to change in their life to achieve greater wellness, then they are far more likely to grow.
If You Want Therapy, Why do you get Pills?
Then they can choose what their healing looks like. And overwhelmingly, they want to talk to someone. Three times as many people want therapy as pills, across different countries, age groups, and types of problem.17 Even when psychiatrists are asked to treat themselves, three times as many would chose therapy for themselves as would recommend it for their patients.18 It does not matter who you are, you want to talk to someone about your life and your hurt.
But what people want is not what they get. They want therapy, but they get pills. Psychiatrists would send only 1% of their patients to therapy first. They would start the other 99% on pills, and refer 1/3 of those to therapy in combo with pills. The reflex to give people pills is so strong that in Canada, a country of 35 million people, there were 50 million prescriptions for antidepressants filled in 2015. That is enough for every man, woman, and child in the country. And enough left over for every dog, cat, and horse.
And these pills are not particularly safe. If people do take them for a while, they have high relapse rates back into depression.19 Antidepressants, and especially antipsychotics, can cause major weight gain. This increases the risk of diabetes from 30% to 258%, respectively.20 21 The pills can trigger suicidal thinking in young people. Antidepressants increase the risk of sudden cardiac death by 33%, while antipsychotics send it up by 226%.22 23 No wonder people are reluctant to take these pills.
This tendency to give people interventions they do not want has huge implications. When people are referred to a treatment they do not want, a significant number do not even show up for the first session, whereas everyone shows up for the treatment they want.24 Once they start, people who get a treatment they do not want are up to 7 times more likely to drop out early.25 If they do complete treatment, they are less likely to improve if they do not receive the treatment they want. One study found that only 8% of the people who preferred therapy but got pills improved. 50% of the people who preferred therapy and got therapy improved.26
Stepping back a moment, we can see why giving people pills, when they really want therapy, leads to high drop-out and poor outcomes. Because imposing something that is unwanted often echoes the psychological injury that caused the depression in the first place. The perverted swimming coach, the bullying boss, they imposed their will on the person in the past. The client did not want what they did, but was powerless to resist. And when a similar dynamic happens in the present (take this pill first even though you want therapy), then the client either never shows up for treatment, or drops out early, or makes less progress. But if you ask people what treatment they want, that is a cooperative approach. They have a say. They are not pushed into something, they are choosing. And three times as often, they want therapy.
What Heals Psychological Injuries?
This strong preference for therapy is because at a deep level, we know the most powerful method of healing psychological injuries. It is this. People heal people. This resonates right at our core. People heal people. The statement hums and sings with truth. We think of the times when another person’s caring words soothed our pain, and we want that when pain comes again. True, some people hurt people, and this is the cause of most psychological injuries, but the real change and healing comes when someone listens deeply and respectfully. The best way to heal a psychological injury is with psychotherapy.
And when the therapist walks with them, using an approach that makes sense for them, the trust builds again. When the client sees that the therapist is focused on helping them achieve their goals, and not manipulating them for their own ends, then healing continues. Most psychological injuries are inflicted by a perpetrator who did not care about the victim’s feelings, who cared only for their own agenda, regardless of what the victim thought or wanted. But when the therapist does the opposite, listening respectfully, helping the client with their goals, working with the client, then one person heals another.
And the healing genuinely lasts. Multiple studies have looked at people who take pills or therapy for depression and then stop all treatment. After a year or two of follow-up, people who received therapy are 260% more likely to be well, compared to those who took pills.27 People heal people indeed. Swallowing the pills may numb the pain for a while. But when the person stops the pills, it will likely return full force. Only therapy can heal the psychological injury. That is why it is 260% more effective over the long haul.
The importance of the human connection explains one of the great conundrums of psychiatry. A fact that is quite uncomfortable for biological psychiatrists to admit or discuss. For the reality is that who prescribes the pill is more important than what they prescribe. In a very sophisticated study on depression by NIMH, they asked patients how they felt about their psychiatrist.28 If patients thought the psychiatrist was cold or arrogant, their improvement was small when they got an active pill from him. But if the patient perceived their psychiatrist as caring and helpful, they had more recovery. Even if they got a placebo from her! This shows again that people heal people. An empathic psychiatrist who gives a useless placebo to their patients gets better results than a cold one who hands out active pills. It is the caring that heals, not the chemicals. This core truth, that people heal people, cracks the intellectual foundation of psychopharmacology. Psychopharmacology tries to find the right chemical to treat specific emotional problems. But it is more important to find the right person.
Because it is the interaction between one person and another that ultimately matters. That is why the Psychological Injury model will ultimately triumph. Not because there are literally thousands of studies that show how either childhood trauma, stressful life events, toxic bosses, or adult trauma result in mental health problems. Not because there is no research at all supporting the myth put out by the drug companies that chemical imbalances cause mental health issues. In 50 years, we will look back and marvel that a notion with no scientific support gained such wide endorsement, just by spending advertising dollars and paying many psychiatrists large consulting fees. The Psychological Injury model will triumph because at our core, we know it is true. Every guy who was molested by his hockey coach knows at his core that he is so depressed and angry because of that psychic wound. And when we ask “What happened to you?” and inquire about each type of psychological injury, then he can tell his story. And feel heard. And then choose the healing he wants. Instead of being given pamphlets written by drug salesmen, and confused with myths, his choice will be respected. And because people heal people, he can get well, and stay well for life.
- Hasler G. (2010) Pathophysiology of depression: do we have any solid evidence of interest to clinicians? World Psychiatry. Oct;9(3):155-61. ↩
- Belmaker RH, Agam G. (2008) Major depressive disorder. N Engl J Med. Jan 3;358(1):55-68 ↩
- Valenstein E (1998) Blaming the Brain: The Real Truth About Drugs and Mental Health. Simon & Schuster ↩
- Lacasse JR, Leo J. (2005) Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med. Dec;2(12):e392. Epub 2005 Nov 8. ↩
- Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. (2004) Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord. Oct 15;82(2):217-25. ↩
- Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH (2001) Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. Dec 26;286(24):3089-96. ↩
- Afifi TO, MacMillan HL, Boyle M, Taillieu T, Cheung K, Sareen J. (2014) Child abuse and mental disorders in Canada. CMAJ. Jun 10;186(9):E324-32. ↩
- Varese, F. Smeets, F. Drukker, M. Lieverse, R. Lataster T. Viechtbauer W. Read J. van Os J. & Bentall R. (2012) Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, Volume 38, Issue 4, Pages 661–671. ↩
- Shevlin, M., Houston, JE. Dorahy, MJ., & Adamson, G. (2008) Cumulative Traumas and Psychosis: an Analysis of the National Comorbidity Survey and the British Psychiatric Morbidity Survey Schizophrenia Bulletin vol. 34 no. 1 pp. 193–199. ↩
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- Risch N, Herrell R, Lehner T, Liang KY, Eaves L, Hoh J, Griem A, Kovacs M, Ott J, Merikangas KR.(2009). Interaction between the serotonin transporter gene (5-HTTLPR), stressful life events, and risk of depression: a meta-analysis. JAMA. Jun 17;301(23):2462-71 ↩
- Keller MC, Neale MC, Kendler KS. (2007) Association of different adverse life events with distinct patterns of depressive symptoms. Am J Psychiatry. Oct;164(10):1521-9. ↩
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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.