Well, I’d said I was wrapping up my half-year-long series last month unless you, dear readers (not sarcasm, I really do value each of you that engages with my work whether or not you leave a comment or I will ever know about you), had suggestions for me about unhelpful phrases I neglected to cover. Not only did several of you write to me with such suggestions, but the insightful discussions in the comments have sparked some thoughts for me that I’d like to respond to. So the Stop Saying This series is back for a final hoorah as we close out one hell of year, this post fueled entirely by reader suggestions and comments.
Any discussion of “chemical imbalances” or medication
It’s a strange time when even some who consider themselves “mental health advocates” push either directly for the chemical imbalance theory or promulgate it through their comparing “depression” to diabetes, which I’ve discussed before. But “mental health professionals,” with all that training and licensing and certification and whatnot, should know better: the chemical imbalance theory—and the biomedical model it often gets confused with—is a theory, and a pretty terrible one at that.
There are tomes written on why it’s a terrible theory both scientifically and advocacy-wise, so I’ll stick with the if-you’re-a-professional-stop-saying-it angle: aside from being dismissive and lazy, telling a client that you believe their struggles are because their brain randomly got imbalanced one day perpetuates deeply harmful deceptions.
The general public still believes that psychotropic medication is neutral or tolerable when it comes to “side” effects. The general public also believes that you, mental health professional, are an expert and whatever you suggest is at least with your clients’ best interests at the forefront of your mind. So the chances that an average client has done their research on the lasting damage the drugs manufactured under the guise of “correcting a chemical imbalance” can do, and the lifelong trauma that can result from entering the systems that prop up the companies who make these drugs, are quite low.
When you casually discuss chemical imbalances or suggest medication as if it is one option among other equal options, especially without discussing any of the side effects, risks for addiction, and other serious impacts these medications can have, you are at best misleading a client into a belief that medications are neutral, if not beneficial. At worst, you are leading them straight into danger.
What you’re discussing, essentially, is the possibility of giving a blowtorch to a toddler because they told you they were cold. Don’t miss the point of that comparison: I’m not saying clients are stupid children. I’m saying that you’re assuming the toddler is informed about risks they can’t even begin to comprehend.
Also, don’t miss the entirety of that comparison: the damage a toddler can do with a blowtorch is to themselves and to others, it can happen quickly and it can be total.
Antidepressants have been linked to increased risk of suicide and violent behavior in adults. And “all antipsychotic medications are associated with an increased likelihood of sedation, sexual dysfunction, postural hypotension, cardiac arrhythmia, and sudden cardiac death,” write John Muench and Ann Hamer, in the same article in which they brush off “life-shortening” symptoms because of the “trade-off” of “treating” “psychotic symptoms” and urge primary care providers (not, it should be noted, therapists or other mental health professionals), to understand the risk of adverse “side” effects.
This shows, among other things, that true education—the only kind that would allow for true informed consent—is left totally up to the client. The nonchalant way that most therapists discuss chemical imbalances or suggest that one “might try” medication as if it’s a new food contributes to funneling those seeking relief for their mental and emotional stress right into that minefield.
Discussions of “diagnoses” as medical conditions
This one is very tricky. Discussions of “diagnoses” are problematic for similar reasons as I discussed above, but it doesn’t mean they shouldn’t happen. The DSM diagnoses are not based on anything other than the votes of self-appointed experts and do not reflect anything in reality. They can, however, stigmatize people for life, damage their sense of self and agency, and affect how the systems of the world treat, mistreat, use and abuse them. I’ve never heard of or personally experienced a discussion with a therapy about diagnoses that included warnings about any of that or about the internalized stigma that can wreak havoc with one’s ability to live life on their own terms.
But a therapist should not simply be putting down a diagnosis on their insurance billing without talking to their client first. This, in fact, is the main reason therapists “need” to use diagnoses, but they should talk to the client about what diagnostic codes they are using for insurance billing purposes. This is important because you, the therapist, have the power to potentially create a pre-existing condition for your client on paper such that they could lose insurance coverage or access to future coverage in unpredictable ways that they will not be able to reverse.
To be clear, you are not “agreeing” with your client on whether or not they feel like “Generalized Anxiety Disorder” is the “correct “diagnosis; you are asking your client to collaborate with you on how you can paid for your “services” in such a way that does not damage their ability to access health insurance coverage in the future.
In any other industry, the word for using a name for something that does not actually exist in order to get reimbursed by insurance would be fraud, right? This is why it is important to talk to your client about the diagnostic codes you are using on your insurance submissions and simultaneously why these conversations are difficult to navigate. As the therapist, you essentially have to say, “So, um, I need to label you with this thing that isn’t actually real in order to make the insurance company believe I’m treating you for said unreal thing in order to get paid. I was thinking of using the code for the label Generalized Anxiety Disorder. Does that fit?”
If you’re paying attention at all to the world, the “generalized anxiety” part probably would fit, but it’s the world that’s disordered, not the person struggling to survive in it. More and more therapists are starting to acknowledge this, but that’s all the more reason why, rather than having discussions about which diagnostic names to use to get therapists paid, the entire diagnostic system should be put near that toddler with the blowtorch.
Until then, “mental health professionals” should stop talking about diagnoses as real things—depression is not like diabetes, and a diagnosis of depression is not like a diagnosis of diabetes, either—and more as the codespeak for insurance-approved “services” that they actually are.
“Calm down, don’t worry”
This is straight-up gaslighting for a therapist or anyone else to say. Not only does it not work to tell someone to calm down or not worry (as if such things have never occurred to the upset person), it’s tone policing, which only happens when someone is uncomfortable with your emotions (which is their problem, not yours) or as a deflection from the real issue that they don’t want to deal with.
While it can be easier to talk through an interpersonal conflict when you’re calm, our culture seems to have made a rule that you’re only allowed to talk about difficult things when you’re calm, which really means when you’re able to not display any emotion at all. So, to resolve things, we have to be sociopaths, basically. That is obviously dysfunctional.
Also, I don’t always find it easier to truly resolve things when I’m calm. I have, in the past, tried taking a break from talking through interpersonal conflict and, the majority of the time, one of two things happens. I will be able to regulate my nervous system and downshift into a lower state of physiological arousal during the break but will become reactivated and upset again the moment conversation resumes. Or I will be able to remain calm only be repressing how I really feel about things and thus create a false sense of resolution. This resolution will be false because it will either meet the needs of the other person at the expense of myself or it doesn’t take into account my truth and what I need, because I cut myself off from what I was really feeling in order to accommodate the inappropriate discomfort our emotionally abusive society has with emotions.
Most importantly, though, as I mentioned above, the current state of the world is, and has for a long time been, providing an unrelenting supply of things to genuinely be anxious and angry about. It doesn’t matter what your political beliefs are, it seems like the one thing we, the little people who do not have power or obscene resources or way more than any human could ever need, can all probably agree on is that things are an absolute mess.
It is, as Krishnamurti put it, “no measure of health to be well-adjusted to a sick society.” There are myriad things to be validly anxious about. Anger is so often these days an appropriate response. I find it dismissive, illogical, and a bit self-righteous when friends tell me to calm down, except in very specific cases where they have some control over the outcome of a particular situation I’m worried about. Given how appropriate anger and/or fear can be, it is self-serving and dehumanizing to tell someone to calm down or not worry, especially if no other solution, course of action, resource or connection follows.
For a therapist or other figure our society currently elevates as someone who is supposed to help people feel better, it is a deep, deep betrayal to tell people not to worry or to calm down in a world that stokes and provokes anxiety and worry without end.
I would now like to address a few delicious topics that came up in the comments of my post last month.
The “observer” and quantum theory
I discussed the dubious notion of “the observer” in my last article; how it was questionable whether such a construct could be neutral and, even if it could be, if neutrality is truly the most helpful approach (which is partly related to what I said above about how “calming down” has actually hindered me more often than not in my pursuit of true resolution in interpersonal conflict). What I neglected to mention, and what was brought up in the comments section, was the role of quantum mechanics in observation in general. I am far from an expert in quantum theory but, from what I know, one of its main principles is that the very act of observing something changes it. It doesn’t change the observer’s perception of the observed; it actually somehow changes the observed.
Again, I am neither a quantum physicist nor an expert in how to handle emotions, so this is a purely theoretical exploration sparked by a comment on a previous post that caused me to think I’m seeing a connection. I could be wrong, but I’m interested in respectful discussion about it.
The implications for this in relation to psychotherapy are too vast to explore fully here, but one thing this does mean is that neutrality actually is not possible even (or especially?) in the observer role. It could also mean that stepping into “the observer role” is both easier and more effective for positive change than I’d originally thought; perhaps “all” you have to do is simply look at/consider/call to mind something that you’d like to change.
I don’t know enough about quantum theory to speak about how much the intention of the observer plays a role in the outcome of the change that the mere act of observation has on the observed; is it possible that, if one holds a positive intention in one’s conscious awareness as one turns to observe whatever they would like to change, that they could affect change in the way they intend? I truly have no idea.
And I want to be careful here; I do not want to claim that people who are suffering injustice, abuse, or oppression can just think or “observe” their way out of their circumstances. Blaming the victim is the absolute last thing I want to do; there are always other people’s free will and massive, unaccountable systems involved in suffering.
Telling someone to just have better thoughts so they don’t keep creating shitty situations for themselves is a message therapists often send, not something that I actually believe is true. I’m simply trying to approach the role of the observer with a bit more nuance and uncertainty than I did in my previous post, due to the connection a commenter made between observation and quantum mechanics that I had not previously considered.
Therapists covering up abuse versus not knowing how to recognize it
Finally, more than one comment pointed out that, rather than covering abuse up, therapists often cover for it. This, too, gave me something to think about that I had not considered in my previous post. While I think many therapists do fail to recognize signs of abuse, I am now considering that this might be because the entire system built to train and license them doesn’t train them to do so intentionally. If that is the case, perhaps it is because the system itself is abusive so it would be against its self-interest to train people to recognize the signs of abuse.
One basic way the system is abusive is that it construes the very human need for connection and support into a profit node. This not only stratifies access to “help” based on financial resources, inevitably putting it out of reach for people who need support (which is not synonymous with any service the mental-health field proffers) the most. It further also demoralizes the person seeking help by pinning him on the bottom of a false power structure, then elevates the human with a license from the state to “help” above anyone needing help. This reinforces the stigma our individualistic culture has against asking for help.
Another way is it gaslights those seeking connection with others is that, while “the skills of a superb psychotherapist are mainly common-sense human skills—warmth, empathy, reliability, a lack of pretentiousness or defensiveness, an alertness to human subtlety, an ability to draw people out—the necessary qualities very similar to those one looks for in a good friend” (Martin and Deidre Bobgan in Psychoheresy: The Psychological Seduction of Christianity, p. 229), therapists are very clear that they are not their clients’ friends. In fact, it is against the code of ethics for therapists to be friends with their clients. And it would actually violate the standards of true friendship for therapists to be their clients’ friends, too, since friendship is free; the moment money is exchanged, we instinctively know that is no longer a friendship. Yet, the therapist needs to act in ways very similar to a good friend if they are to be a “superb” therapist, whatever that means.
The idea that therapists would purposefully cover up abuse, as opposed to simply not knowing how to recognize it, also helps me to understand what the hell my former marriage counselor might have been doing. She would tone police me, attempt to “manage” my emotional “outbursts” and stop the therapy session until I…wait for it…calmed down.
When I asked her why she never challenged my ex-husband on the damaging behaviors and verbal abuse I reported to her in session, she claimed she was “confronting” him. I asked her when she ever did that and she said, “Oh, when I ask him how he feels about that hurtful thing he said to you last week, when I ask him how his relationships with his brothers are, when I ask him about how he feels about his father.”
I felt dissatisfied, angry and completely confused about how what looked to me like coddling and permitting could be “confronting” and “challenging” to the therapist. It was baffling to me how she didn’t recognize my ex smashing glass near me multiple times, saying “I felt no love for you on our wedding day,” staying at work well into the evening even on nights it was his turn to cook, not telling his family about my food allergies when we went to visit them out of state (as in, I had no way of providing my own food without doing something painfully awkward like asking adults I’d met three times in my life to borrow their car), as abusive and neglectful (so, abusive).
I can’t know for sure that my former couple’s therapist saw the abuse I was experiencing and decided to say nothing (and thus enable it to continue) or if she truly missed it, but the former is a possibility I had not considered before and it makes more sense to me than her blindness to what was so obvious to the friends I told.
I don’t pretend to address all of these things, or even this topic (the list of things helpers and friends should not say to people in distress is likely endless) adequately or exhaustively. But thank you, readers and commenters and those who emailed me, for engaging with this series so thoroughly, for your suggestions and for your deep thinking that has helped my own, as well as to facilitate my healing and recovery from the abuse I have suffered at the hands of those professing (and getting paid, sometimes quite well) to help.
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.