It’s You, It’s Not Me: Treatment Resistant Depression and the Psychiatric Breakup

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“Insanity is relative. It depends on who has who locked in what cage.”
—Ray Bradbury

The Break-Up

Justine1 was in her mid-twenties, queer, a good dresser, and a little insecure about her pandemic weight-gain. She recently quit her security job. Justine’s security duties included kicking people out of the doorways and stairwells where they slept or got high. She didn’t like this part of her work—telling homeless people to go be homeless somewhere else.

Justine’s discomfort made her take a gentle approach. Her coworkers typically woke the sleepers and stood over them until they packed up and moved on. Justine crouched down and woke the vagrants in a gentle voice, and offered to call shelters to see if there was a bed. Justine sought naloxone2 training in her own time in case she ever found someone overdosing. These were not requirements of the job.

Despite her goal to be kind and understanding, she got sworn at and threatened. She began to dread working, so she left and took an entry level position at a department store.

Illustration of poison jars labeled with a skull and the words "COGNITIVE DISSONANCE"

Justine and I first met two years earlier. I was a substance use counsellor and she wanted to quit drinking. She did stop drinking, but the issues that made alcohol appealing never entirely went away. She said that she had severe depression, anxiety, and PTSD. She also suspected she had ADHD and autism.

Justine texted to ask for an appointment. She wasn’t having a good time with life, and not just because of her recent career change.

We met in a coffee shop in a suburb of Vancouver, Canada. “How’s it going?” I asked.

“I met with my psychiatrist recently,” she said. “He’s not going to be able to keep working with me.”

“Oh?”

She smiled, but her eyes didn’t match. “He told me that I have treatment resistant depression.”

“What does that mean?” I said. I’d heard the term many times, but I didn’t know what it meant for Justine.

“It means that I’m fucked.”

“Fucked?” I echoed. “What was it like to hear this from the doctor?”

“Pretty debilitating.” Her smile vanished. “Two years of trying to get help.”

Justine explained that the doctor had tried her on three medications: two SSRIs and one SNRI3, all of which failed to make a satisfying dent in her depression. She felt worse now than when treatment began.

Not all psychiatrists are so quick to give up. They have a number of treatments in their medical bag, but this is the state of the mental health care system in Vancouver, which started buckling four years ago under the pressure of the pandemic. The demand is just too high. My clients referring to a psychiatrist in 2019 were typically told it would be a six month wait. By mid-2020 it was two years. Justine’s psychiatrist had done all he could and a lot of other people needed help. It was time for a breakup.

I was angry on Justine’s behalf, though I didn’t say so. It may seem unfair to get mad at the hard-working psychiatrists doing their best in an impossible situation. I would be more sympathetic if it wasn’t them who created this crisis. More on that shortly.

Justine’s diagnosis of treatment resistant depression poked at a question researchers have asked for more than fifty years: Why do many depressed people get better with medication while others don’t?

This question points us in the wrong direction. It has us look at the patient, has us trying to figure out what about them is different. It skips over a more urgent question: who is to blame when the treatment fails?

Justine accepted that the problem was her, or at least it was her depression. She didn’t know it, but her untreatable disorder was the symptom of an illness within psychiatry.

Diagnosing Dissonance

There’s a classic theoretical model that explains what happened with Justine, but it’s not the one we find most often in psychiatric literature. Psychiatry mostly investigates treatment resistance through the lens of biology: what is different about Justine from those who get better on antidepressants, and what else can we offer? That’s not the model we’re going to use.

To understand treatment resistance, we must look beyond the depressed person. We typically look at the patient’s physiology when we also need to look at the doctor’s psychology. Specifically, treatment resistance is best explained not as a medical issue but as a way for psychiatry to resolve cognitive dissonance.

Cognitive dissonance is a famous theory, used in therapy, marketing and by unhappy lovers explaining why they stay with the C- partner instead of searching for an A+. Cognitive dissonance is defined in many ways, but most simply, it is the discomfort you feel when reality and your beliefs about reality are having an argument. If you think you’re an honest person, you may find yourself a little uncomfortable explaining why you took a sick day from work when you were really taking a beach day. Either you must admit that you’re on honest person, weather pending, or you have to be flexible with social constructs like “sick” or “honest.”

April McGrath, of Mount Royal University in Calgary, outlined seven strategies for reducing cognitive dissonance. I’ll mention two. Say I’m on a diet and, when ordering my alfalfa sandwich, the server asks if I want fries. I say yes. How do I reconcile my diet to my fries? The most frequently studied way to resolve this is through attitude change: “How much do I want to be on this diet, anyways? Maybe this is a good weight.” Another way of resolving dissonance is to denial of responsibility: “If the server had said salad first, I would have ordered that, but I didn’t have time to think.”

We know much about the ways people resolve dissonance, but less about how they choose from their menu of options. But we have two clues that influence such a choice: 1) What problem are they trying to solve and 2) How much control do they have over the situation?

If I am convinced that I will get better by taking antidepressants but then don’t, this creates dissonance. If I continue to take the pills, I have to explain, at least to myself, why I do so. But the person prescribing them (or manufacturing them) has a different problem to solve: explaining why I should still trust them to guide me to wellness. The patient tends to change their attitude, towards themselves or their psychiatrist. Psychiatry protects itself by blaming the patient.

The Fix is Broken

An article about “Treatment resistant depression,” ought to define treatment resistant depression. This is hard to do; there is no universal understanding of the term. Hundreds of articles are devoted to defining it, observing that it is yet to be defined or saying we should really get on top of defining it. A condition that affects thirty percent of depressed people can’t be pinned down, meaning that it might only affect fifteen percent of depressed people, or fifty, depending on who you ask. When we speak of treatment resistant depression (TRD), we do so in broad parameters.

TRD is mostly understood as depression that doesn’t improve with medication or other medical procedures. Studies disagree on how many medications need to be tried before depression can be called treatment resistant, or what is a reasonable amount of time to try each medication or what is an acceptable improvement. Is a patient treatment resistant after trying one med or eight? For two months or six? Should they be a little better or in remission? And who gets to draw these lines?

We haven’t decided exactly what TRD is, yet there is massive clinical interest. As of May, 2024, a search of TRD on Google Scholar yields 96,300 hits. It showed up in the literature for the first time in 1974, when a small number of psychiatrists published some clinical observations of a “therapy resistant depression.” The therapy to which they referred was entirely pharmaceutical—it was always a failure to improve with medication.

“Treatment resistant” follows a core assumption: that depression is a result of biology, a disease that lives in your body like an invading virus or a failing kidney. This is called the medical model of mental disorder.

Psychiatry’s move to the medical model in the 70s and 80s sparked a debate, still going four decades later, as to how helpful this is for patients. It is undeniable that it has been helpful for the pharmaceutical industry, which continues to grow yearly, and as of 2022, the antidepressant market has reached $17.02 billion worldwide.

The eighties and nineties were a depression-treatment renaissance. The SSRI Prozac was brought to market in 1989, and a year later it was twenty-one percent of antidepressant prescriptions. Medications were improving, we were told, and the medical model seemed to be working. There was just one little problem: half the time, the pills, both the new and the old, didn’t do anything. That’s never how the research framed the problem, though. Instead, research said that a sizeable chunk of depressed people were treatment resistant.

TRD erupted in the research literature. There were a few dozen studies of TRD before 1980. There were hundreds by 1990. Still, it eluded clear definition and the DSM-III’s adoption of the medical model meant that it was almost always defined in terms of the patient’s response to medications. “Treatment” has a singular meaning—the kind of treatments you get filled at the pharmacy.

In 1997, psychiatrists M.E. Thase and A.J. Rush came up with the clearest system of TRD so far. Similar models have developed since then, but Thase’s and Rush’s is still in use. It’s a five-stage program that graduates the resistant patient from the most benign to more aggressive treatments: start with any antidepressant, then a different antidepressant, a tricyclic, an MAOI4, and finally, electroconvulsive therapy. Meds, other meds, tough meds, tougher meds, then shocks. The attempts to standardize medical treatments are so beautifully linear that we can almost forget that in 2024 we are still searching for the proof that depression is a disease.

A medical disorder becomes recognized when a breadth of accumulated evidence points to its existence. This is standard practice—an enterprising doctor can’t just invent a new disease. The APA decided to reverse this process—create the disorder, then find the evidence.

James Davies in his book Cracked: the Unhappy Truth About Psychiatry, along with hundreds of papers over forty years, documented how members of the APA created most disorders with little, and in many cases, no empirically reviewed studies. Mental health disorders were created by committee—if the committee agreed, a disease was real. It was science that skipped some steps.

The use of the disease model was enormously successful for psychiatry. Medicine took thousands of years to refine to the point where we could have confidence in—not always its results, but at least the methods by which if strives for results. Psychiatry got there by riding on medicine’s coattails. It needn’t go through its tedious task of constant refinement; it could just use the language of its older, more established sibling.

The medical model makes an assessment and a promise, that depression is biological and its treatment is chemical. The depression eggs are all in one pharmaceutical basket. Why is psychiatry so reluctant to embrace non-medical approaches to depression? The most obvious answer is that the pharmaceutical industry has a lot to gain from a medication-only approach, and they are allowed to market directly to physicians, who are, in turn, often rewarded with financial incentives and vacations. But this alone doesn’t explain it.

I’ve worked with many psychiatrists. I don’t know any who believe that environment and life factors play no role in depression. Most are kind, want to help and believe that prescriptions will improve patients’ lives. It’s too black and white to say that they’ve all been plugged into the pharmaceutical matrix.

It’s only when we go industry wide that we see patterns. The pattern is to treat depression as biological, to adhere to a medication regime even when that regime is not working, to omit non-medical treatments from the conversation and to describe the treatment’s failure as something to do with the patient.

It gets worse. A 2008 paper pulled together 74 studies for the twelve leading antidepressants. Just over half of the studies (38 of 74) showed a positive effect and half showed either no effect for antidepressants or that they performed worse than placebo. Yet, 37 out of the 38 positive studies were published in journals, versus only three of the negative ones, and the ones that were neutral were proclaimed as positive. The same authors updated this study in 2022 where they examined another thirty drug trials. They found that the omissions weren’t as extreme as in 2008, but still found that all the positive results (fifteen of thirty) were published compared to seven the fifteen that found negative or no effect were not published. This creates a distorted view: 75-94% of published studies makes it seem like the meds are effective and we never see most of the papers that say otherwise.

The accumulated weight or research indicates that antidepressants are helpful sixty percent of the time. This might sound impressive, until you realize that placebos alleviate depression fifty percent of the time. This doesn’t make antidepressants objectively useless, but it does give us cause to question why they are the first, and usually only, line of defense, especially with side effects ranging from jitteriness to lowered sex drive to increased risk of suicide. It’s not surprising that the pills won’t work for everyone. It’s harder to grasp why we rely on them.

There are patterns to how the medical and pharmaceutical fields respond to failure, and that pattern is to never admit failure. In the face of poor performance, psychiatry searches for the problem everywhere but in psychiatry.

Psychiatry’s foundation is built on a medical model that has never accumulated the kind of certainty it claims to have, that treats mental illness with drugs that often don’t work, ignores evidence that undermines its role in treatment, and locates the blame for ineffectiveness somewhere in the patient’s biology.

Denial of responsibility. Omitting contrary evidence. Limiting the conversation. This begins to sound a lot like cognitive dissonance.

Cures and Cares

The treatment resistant problem may not entirely be the fault of psychiatry, or even the drug companies. Chemical cures sell so well, in part, because we want them. We are a market ready and willing to throw our money at anything that promises to end our misery without massive personal change or social activism. And, if it sounds like science, if the person talking to me about my depression wears a white coat and can cite studies, then why doubt it? Psychiatry may be quick to hide its shortcomings, but we’re also willing to not dig for them.

There’s a cost to this agreement, though, and most of it is paid by people like Justine. When her psychiatrist says that she is treatment resistant, she is ready to accept this; the problem is her. Psychiatry gets to deny responsibility, meaning Justine has to accept it.

This leaves a conundrum: how do I help Justine?

Justine was unaware that she inherited a legacy of seventy years of marketing that successfully frames her perpetual low mood and sense of failure as a disease of biology, where a field of psychiatry struggles to retain its unstable ground as a scientific discipline, where the poor efficacy of her medications are downplayed and where her hopes for wellness are dependent on circumstances beyond her control. Depression’s history runs unseen in the background, like the coding for an app.

The only way I know how to help Justine is to invite her to explore this story she has inherited. One therapeutic discipline calls this “re-authoring,” meaning that the client is invited to reframe the story. Re-authoring is the well-adjusted stepchild of cognitive dissonance. Instead of creating tension for Justine to resolve, she is asked about details she may never have considered.

I asked her, “What kept you from giving up?”

She seemed to be mildly surprised at this question. She thought he’d made it clear that she had given up.

“Well,” I said, “all that you did to get help, I don’t imagine it was easy.”

“Nope.”

“And now you’re here, talking to me.”

“Yeah.”

“When it was hard and you had constant barriers and doors closed on your face, what kept you going?”

Her response was beautiful. I still tear up when I think of it.

“Because I have to believe that all this suffering counts for something.”

“What do you mean?” I’m sure I cocked my head, my reflexive response when someone evokes my curiosity.

“I mean, if I stop now, all that I’ve done will mean nothing.”

One of the most privileged aspects about a job like mine is I get to see surprises in every person. Justine was full of surprises. “So, it’s possible that all that you’ve been through can mean something.”

“I sure hope so.”

“What do you call that?”

“Call what?”

“What do you call the thing that keeps you believing that this will mean something?”

She was quiet for a moment. “I… guess I’d call it hope.”

She called it hope.

This question, “What kept you going?” is my favourite, because it makes clients acknowledge strengths, often ones they didn’t know they have. Clients frequently think they should tell me about the worst things that have ever happened to them. I am more interested in how they survived the worst things that ever happened to them. The focus on trauma revisits the idea that they are a victim. Stories of survival bring to light so much more.

I asked Justine how she had kept that hope alive. Her answers were too long to record here, but she spoke of her grandfather, who never gave up, and of her wish that her struggles can be an inspiration for others. She’d thought of her life as being ruled by depression; she re-wrote her story as someone who lived through depression by constantly pushing back on it.

I asked Justine what this conversation was like for her. She said that it left her in a different place. She hadn’t realized how much she’d been driven by hope.

Treatment resistant depression is a symptom of psychiatry that has pinned all its hope for credibility onto the medical model, but the medical model is itself a symptom of a greater problem, that there’s no place in our lives for suffering. We’ve come to see the mental health field as a take-out window of pills that will fix our pains the way a burger will fix our hunger. This makes it hard for the people in whom we trust with our wellness to offer some of the things we need to be well—emotional connection, empathy and a sense of control over our lives. It’s not that a psychiatrist can’t offer these things, it’s that it isn’t a necessary part of the interaction. Most psychiatrists I know would have stayed with Justine longer than hers did, but it was psychiatry that supplied her doctor with the reason for the breakup.

The psychiatrist failed because he tried to treat a disease when he just needed to take some time to see Justine. Her depression was treatment resistant but it wasn’t Justine resistant.

Sources:

Davies, James. Cracked: The Unhappy Truth About Psychiatry. (2013)

Greenberg, Gary. Manufacturing Depression: The Secret History of a Modern Disorder. (2010).

Hickie, Ian, Cuijpers, Pim, Scott, Elizabeth, Iorfino, Frank. Is it time to abandon the concept of treatment-resistant depression? (2024)

Mrazek, David A., Hornberger, John, Altar, C. Anthony, Degtiar, Irina, A Review of the Clinical, Economic, and Societal Burden of TreatmentResistant Depression: 1996–2013. (2014)

Pandarakalam, James Paul. Challenges of Treatment Resistant Depression. (2018)

Paykel, Eugene. Basic concepts of depression. (2008)

Rush, John, Thase, Michael. Strategies and Tactics in the Treatment of Chronic Depression. (1997)

Schroder, Hans, Patterson, Elissa, Hirshbein, Laura. Treatment-resistant depression reconsidered. (2022).

Souery, Daniel, Papakostas, George, Trivedi, Madhukar, Treatment-Resistant Depression (2006).

Turner, Erick, et al. Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. (2008)

Turner, Erick, et al. Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy:Updated Comparisons and Meta-analyses of Newer Versus Older Trials.(2022).

Voineskos, Daphne, Daskalakis, Zafiris, Blumberger, Daniel. Management of Treatment-Resistant Depression:Challenges and Strategies. (2020).

Show 4 footnotes

  1. “Justine” is a real person, but I have changed the name and certain details that would make it possible to identify her.
  2. Commonly known as Narcan, the drug that reverses opiate overdoses.
  3. Selective serotonin reuptake inhibitor and serotonin and norepinephrine reuptake inhibitor, two common classes of antidepressants.
  4. Monoamine oxidase inhibitor

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83 COMMENTS

  1. This sorry soul-dead culture is M O N O culture. ONE WAY. It’s way are DRUGS, and ECT mostly because we are seen to be electro-chemical machines. Get it?? That is the bottom line of it! ALONG with this convenient myth/story/narrative/tale is the M O N E Y this story brings the main players pushing it….I was quick to suss all this out, especially after being attracted to the cover of a book many years ago in a bookshop, it was titled The Myth of Mental Illness. As a result I avoided shrinks AND psychologists like the plague even though I have been through some extreme life crises.

    They are NOT interested in the complexities of life, and the problems of living, when they can take in money pushing anti this anti that drugs pretending they know what they are doing….In reality how we feel is important. ——our innate intelligence is showing us that we are not happy with things, and like said this can be complex. But the way the system is set up we are supposed to be ‘productive’ and not seen to be ‘mentally ill’, and so people depend on the doc. AFTER this last few totally insane years, I think we should look for other ways! UGENTLY!

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    • Agree 100%. It’s good you included psychologists as most are trained in psychiatry’s diagnostic bullshit. The only difference is psychologists and similar therapists peddle “therapy” instead of drugs which can be just as habit-forming.

      Which is the reason whenever one of them says, “I do this because I want to be helpful,” I say to myself, “No you don’t. You do this because you want to be powerful,” which is something too few of them are even aware of.

      IMHO.

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      • You words resonate with me, Juliano. Most of my clients show up with their depression and other issues already medicalized. I can’t blame them. I used to do this, too, both to them and to myself. It’s what we were taught to do, explicitly in school and implicitly through media and our interactions with others. Life can beat us up at times, but if we feel beaten up, this is somehow sickness.

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      • Birdsong, one of the parts of the article I cut because my original draft was far too long, was my own cognitive dissonance that comes with working in a profession that is supposed to be helping. Therapy has its own share of abuse and horror stories, of blaming clients for not getting better, for exerting too much social control—I could go on. Even in writing this article, I’ve had to answer for myself why what I do is different. I think this is a good thing, because, as you say, the person “helping,” more often than not, does so from a position of power.

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        • “Even in writing this article, I’ve had to answer for myself why what I do is different. I think this is a good thing, because, as you say, the person “helping”, more often than not, does so from a position of power.”

          Having to ask oneself this question imo is precisely why the uneven power dynamic in “therapy” needs to go. After all, doesn’t the term “thera-PIST” implicitly mean power???

          Moreover, I think that (most) psychologists – by virtue of the power they hold – are fooling themselves if they think simply asking themselves this question means their incapable of misusing it.

          But what else can you expect from a culture historically built not only on hero-worship, but on hero-wannabe’s….

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          • Spot on as usual Birdsong! (I love your comments!) But I (also) think the therapist presumption of expertise is as big an issue as the power issues? In fact, it seems to me this particular presumption is a big part of the (unconscious) power imbalance. Perhaps I’m parsing this too finely? But it seems to me that the presumptive “professional expertise” (at multiple levels and with multiple objectives) is rife with all kinds of constitutive holes, not least of which is that some patients/clients are actually healthier and smarter than their therapist. The holes in “expertise” hardly end here!

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          • Thank you, Kevin! 🙂

            I agree 100% that the therapist’s presumptive expertise is as big an issue as the power imbalance. I think one leads to the other and back again and that both are impediments to true healing.

            It’s wonderful knowing I’m not the only one who sees therapy as one holy mess!

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          • …and it’s also my personal belief that most if not all patients/clients are healthier and smarter than their therapists – the dead give-away being that only one of them has, had, or will have the audacity to call themselves a “therapist”, the invisible disguise —

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          • A therapist’s inability to perceive the difference between insight and judgment imo exacerbates the problems endemic to therapy, i.e. power and presumption of expertise, two things that not only feed on each other, but imo inevitably lead many if not most therapists to be more judgmental than empathic.

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    • CLARIFICATION: “As a result I avoided shrinks AND psychologists like the plague…”

      Good thing you avoided psychologists too because “therapy” can be just as habit-forming, which I believe is intentional on some level.

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  2. I had to break up with my psychiatrist, after I’d read some of his medical records, and realized he’d declared my entire life to be – in his words – “a credible fictional story.” But since I had good insurance, psychiatry had a very difficult time accepting the break up.

    Another psychiatrist, who was the psychiatric “snowing” partner-in-crime, for a now FBI convicted doctor, wouldn’t stop illegally and fraudulently listing me as her “out-patient,” until I moved out of state … if she even has.

    And I was attacked again in my new state – by a computer hacking, take a percentage of gross/conservatorship contract, disingenuously dressed up as an “art manager” contract – wielding, seemingly “doubting Thomas,” psychologist.

    Hopefully, after nine years, I’ve gotten him out of my computer and phone … but when did hacking into a person’s computer and phone, abusively reading another person’s private journals et al, trying to gaslight someone, trying to set up a website fraudulently utilizing that person’s name and email (according to Google) …. When did such crimes, and attempted crimes, become “mental health care”?

    Honestly, I now think the ELCA psychological and psychiatric “professionals” will stop at nothing … when it comes to covering up the abuse of a lady’s children … 14 different, egregious, anticholinergic toxidrome poisoning attempted murders, etc ….

    God help me, and us all, since we’re all living in an upside down and backwards America, as I painted in 2005.

    The piece I’m working on now is a very imperfectly drawn painting (inspired by a Chagall piece), commemorating my 2009 awakening / should have been properly diagnosed as a “drug withdrawal induced manic psychosis,” but was somewhat accurately diagnosed as an “adjustment disorder.”

    Where I was supposedly informed, by the kind souls of Chicago, that the “tailor who sings with the Lord, is just an American girl.” (The Lord and Taylor store, that used to be next to the Marshall Fields that I worked at, had become an American Girl store.)

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    • Everyone needs to go through a 12 step program. Best thing in the world. At least twice in their lifetime. While surrounded by a community of supportive friends. Other cultures that aren’t run by churches and corporates don’t have depressive disorders. Everyone feels valued and knows where they fit in.

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      • I do understand what you mean, Gervaise. I have a now decades-long recovery from alcoholism & prescription drug addiction. A.A. & the 12 Steps saved me….
        But I don’t think that “…go through a 12 step program.”…, as you put it, is really the best way to express it. “Work the 12 Steps” is much better, IMHO.
        Working the 12 Steps without going to meetings will almost always yield better results than going to meetings without working the steps. See what I mean?….
        THANK-YOU for your comment!
        “When anyone, anywhere, reaches out for help, I want the hand of A.A. to always be there, and for that, I AM RESPONSIBLE….

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    • This made me laugh, albeit in a cynical way. I read Manufacturing Depression in preparing for this article. The author, Gary Greenberg, described a client who stayed with a partner who was controlling and overbearing when she got on antidepressants. I don’t have the exact quote in front of me, so I’ll paraphrase how she explained this. “When you’re convinced you’re mentally ill, your dissatisfaction with a relationship can seem like part of the illness.” Perhaps it’s not always great to be content with your lot in life.

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  3. Consider this analogy:
    If an entire tree is burning and Emergency response is inadvertently focused on just extinguishing the event at the branches (while unintentionally leaving the flames at the stem to reignite the branches), the Emergency response people could incorrectly declare the branches “…Extinguisher resistant…”
    What if the basis of the depression is not structural (the connections in neural pathways), and instead functional (a subtle and consistent aspect of the patient’s physical or social environment); this would act contrary to the treatment. The patient and the medic could then term the condition as ‘Treatment Resistant’. The patient could be completely well adjusted but subtle adversities in their environment then reverse the gains made by both the patient and the doctors

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  4. Josh:
    This article is beautiful. As a therapist myself, I’ve worked with many patients who are “treatment resistant” in terms of their response (or, more accurately, non-response) to medication. I’ve actually used the term myself in clinical documentation, but only to justify alternative treatments—providing medical authorization requires a lot of paperwork.

    But I always share with the client that pills alone are not the answer, and that we as a country have been sold a bill of goods by the pharmaceutical companies who have convinced virtually everyone that they can have a better life through chemistry. Not every condition can be cured by medication. I myself have a physical condition that cannot be remedied by either medication or surgery. In my experience, the vast majority of mental health conditions fall into this same category. People with such conditions respond better to a supportive and empathetic therapeutic approach by a humanistic clinician (not one who is a disguised pusher with a PhD or PsyD), lifestyle changes, and—sometimes—advocacy to reverse injustices caused by institutional and structural problems in our society. Of the many people with serious mental illness with whom I’ve worked, only two did not respond to empathetic clinical counseling.

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    • I am working on getting my LPC and was in education for 27 years before this. I also had treatment resistant depression until I found a new antidepressant, Auvelity, that works for me. It works on the glutamate receptor -not just serotonin and neuroepinephrine. I cannot believe no one has mentioned genetic testing for psychotropic drugs in this discussion -it truly works and is targeted. I agree with you that therapy very much helps people with depression but for many, I believe, it has to do with biochemistry and drugs, vitamins, exercise, meditation can all help optimize that.

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      • I may sound like I’m discounting what you say, though I’d like to add another perspective on the self-help approach. In counselling sessions, my stance on medications is clear: I don’t have one. I never suggest that a client should take meds or stop taking them. So many of the people I see come to view themselves as passengers in their life (a sentiment I relate to, because I’ve felt this way myself so often). I may not be fully convinced that the chemical nature of any of their meds help, but I have often found that the choice to take them helps. A number of clients have said that they have “gotten better” because of the meds, not because of anything that they have done or that has changed in their lives. I’ll ask, “who chose to take them?” Or, “was it an option to not take them? If so, what were you choosing for yourself in taking them?” The idea is that the more they see their med-taking as a choice to confront their depression, the more they realize how active they are in their own well being. Exercise, vitamins, medication and meditation may help, but so does the conscious choice to do any of these things.

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    • Advocacy is extremely important. It’s something I never had, not even when I was very obviously experiencing medical/institutional abuse from an ivy league teaching hospital (teaching the next generation of clueless “helpers”). Not one therapist, not one psychiatrist, not one social worker or caseworker or general practitioner would advocate for me.

      So I thought, okay. I’m smart. I understand what’s happening. I’ll advocate for myself. Oh, what a mistake. From a borderline diagnosis 20 years ago, immediately following ECT, to just this month being ripped off my disability pension by the same people who caused so much damage. Why? Because I don’t have a doctor who will write down what my current diagnoses are, how far I can walk/crawl, how long I can stand, how much I can lift, and whether I am malingering, exaggerating, on drugs or just plain out of touch with reality. I told them I don’t have a doctor. I told them I stopped going to doctors a long time ago when I realized the abuse would never end. I told them they can keep their money. They’ve done enough damage. I’d rather live in a tent than play their stupid game any longer.

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        • Jim, you needn’t explain the world to me. I have eyes and ears and a brain. You clearly have no understanding of me or my situation if you think I would ever submit to a so-called “doctor’s treatment”. I’m surprised your comment made it past the moderators. I find it extremely intrusive and demeaning. I consider it a personal attack. Yes, everyone knows what you mean, Jim, by suggesting I need a “doctor” to “heal” after I EXPLICITLY state that I experienced long term criminal harm from doctors. Go gaslight someone else.

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          • I’m sick of the gaslighting too (meant as a truthful joke), KateL, and I totally understand your well founded desire to stay away from doctors.

            But I do agree with Jim that there are some good (non-“mental health”) doctors out there. Albeit, the medical community – as a whole – did make a mistake by partnering with the scientific fraud based psychiatrists, and non-medically trained psychologists.

            Especially since every doctor was taught about anticholinergic toxidrome in med school … so the medical profession, as a collective, did enter into a faustian deal with the psychiatric industry.

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        • Jim, after reading this article, what makes you think that finding a mental health professional is the answer for Kate or anyone else? That MIA has existed for over a decade I think proves that going that route has caused more than a few people to experience an intolerable sense of, can you believe it, COGNITIVE DISSONANCE!!!

          Furthermore, the fact that Kate reads MIA (I think) demonstrates she IS on a healing path of her own making and therefore needs a mental health professional as much as she needs a hole in the head.

          FYI: the word “doctor” is NOT synonymous with healing in so-called “mental health”.

          IMHO.

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        • And Jim, you don’t seem to realize that the most important ingredient for restoring one’s peace of mind, or “mental health” is the ability to see reality clearly, an attribute not overly plentiful in the field of so-called “mental health”.

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      • Kate, your story is a tough one and I appreciate that you are willing to write it out.It’s a challenge of our times that when we are hurting, we often have to go it alone and the people with the most power to help us take too much convincing. Too many of my clients would relate to what you have said. It is unfair that the options you are offered are: do it their way or do it on your own. I don’t have answers for you and I don’t think you were asking for any. Just know that I am grateful that you are still speaking when you could have stayed silent.

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        • Thank you for your reply, Josh. I have to admit that I wasn’t in a good place when I tried to read the article (twice), and I identified so much with Justine’s experience with the psychiatrist that I was unable to finish it. I’ll try again when I’m in a better place.

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    • Thanks for your kind and thoughtful words. I don’t know if you have found this, but loneliness is a recurring theme. I agree that support and empathy are among the greatest things we offer clients. I also see it as a symptom of our times that these things are relegated to the domain of a specialist. My clients rarely get me for more than an hour a week, and, even if I do everything perfectly (which is more rare than I’d like to admit), I always find myself wishing that they had more people who could just listen.

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      • FYI: I don’t think it’ll take very long before MOST PEOPLE know how to listen. That’s what the internet is teaching EVERYONE how to do! And when that happens, I predict the majority of so-called “specialists” will find themselves having to look for a new line of work —

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    • It doesn’t quite work like that, James. If I take it off my chest it’s still in all of my medical records. The damage of the ECT and decades of neurotoxins doesn’t just disappear.

      Not all of us are as fortunate as Arthur Schlesinger Jr.

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      • I share the concern of “medical records are forever”.
        I have stayed hidden for many-many years. I am going to face them. I need a Thyroid script or I will sleep for 14 hours a day.
        This is what I found out (I’m a retired software engineer – aerospace) …

        There are 2 major health systems (in my locale) my records are splattered across. Unbelievably – after all these years (more than 5) – I can login to both of them (where are the cyber security people?). I have only investigated one of them (that’s who my appointment is with). Their system is being migrated and has dropped off records, apparently older than 10 years (2011 is not carried forward). But sure enough – there’s 2015 – 2017, as if that matters.

        I’m not a doctor, but I don’t think their electronic records tell anybody anything (useful). It’s only half a story and it’s mostly opinion (there is no science). Yes – the Thyroid script is in there, but also a script for a psycho active drug (I asked to remove that drug – adverse effects … I do have ongoing concerns about permanent cognitive damage, but I’m pretty sure – there is just not enough known about this, to make any positive difference in my life).

        It’s a 20 minute appointment. I don’t care about opinion (slander) from that long ago and I doubt seriously, this PCP does. As I understand it – they are way too busy. If that doc does – it says more about this individual (or their employer) than it does about me. My plan is to go get that script. If there is any extra time – I would like to talk about mobility issues. Yes – I managed to get “that old”.

        I am not pleased about all the reliving of trauma, this is putting me through … but I am going to go through with it, anyway. It is long past the time when this garbage needs to be put to rest.

        I’m not judging anyone. I have been able to get emergency care in my home country (U.S.A.) and in other states, I have been able to get this script. If I have too – that’s what I’ll do. I will go to another state.

        Just info – if it helps anyone.

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  5. My psychiatrist broke up with me in 2019. I had a love-hate relationship with her. The breakup was unexpected. In my second to last session, she mentioned when she’s in her new practice in a different province…WHAT??? Did you just say you’re leaving me? I quickly said, I hope you have room in your car!!! She apparently forgot to tell me when it would have been appropriate to ease me into the change. As it is now, she never referred me too another psychiatrist before she left me. My depression/ANXIETY/PTSD/ADHD has been a life long struggle of ups and downs. I’m turning 64 this week and I’m still looking for a supportive therapist since Dr. Howell, left me. It has been an extraordinary journey. I’m proof that medication will do what a bandage does but unless you have a good support system, none of it will do a thing. The only thing that has been consistent with medication is that the full out, I’m losing my mind panic attacks have all but disappeared. Those started when I was 17 and finally was diagnosed when I was 31, after my 2nd son was born. For that reason alone, I will stay on the meds. I desperately need a supportive therapist as I’m now pretty well isolating completely. Its a lonely life but i still have this pull to be happy and thriving. Humour and the desire for a better life, keep me going. In my experience, you can’t have one without the other!!!

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      • Josh – I love that quote! Humor is my best weapon against despair. In fact, the only way I can stand to absorb the “news” of the day is to listen to the late-night comedy hosts, like Stephen Colbert. The tragedies currently happening on a global scale make me feel like I’m wearing my insides on the outside, and my “mental illness” feels like wellness compared to the insanity of the most powerful people in the world. THEY are the real lunatics.

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  6. It is entirely possible there was a larger problem that prompted Justine’s psychiatrist to terminate the relationship after just three medications. The professional may have decided to frame the termination as “treatment resistant depression” to the insurance for privacy reasons. Whether the psychiatrist discussed the real problem in detail with Justine, we will never know.

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    • I appreciate your thoughts on this, Helena. I’m probably going to sound contentious in my response but that’s not my goal. Your comment points to a question that my article didn’t answer (and couldn’t, due to space).

      You’re right in that I only have Justine’s story as she presented it. That’s all I ever have with any client. Justine didn’t give me a transcript of her interactions. The psychiatrist, if I were talking with him, would have his own narrative. My job is to understand not the literal rendering of events but the impact those events had on her, and that impact was devastating. And it’s easy to trace the history of TRD and how it functions within the realm of psychiatry. Justine and her psychiatrist inherited a cultural history, and that history is to locate the problem within the patient. Justine believed the problem was her, and she believed, accurately or not, that the psychiatrist thought so as well.

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  7. We live in a culture that exalts therapists to the degree that it causes people to develop an unhealthy dependence on them, which is precisely why I think ‘therapy’ does more harm than good in the long run, which happens in any relationship based on unhealthy dynamics.

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      • Thank you, James! 🙂

        It’s good knowing I’m not the only one who sees ‘therapy’ for what it actually is: a legal way to financially exploit people’s emotional vulnerability… which makes a certain kind of ‘professional’ a certain kind of biohazard all its own.

        IMHO.

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        • That dependence is part of the shitty inheritance we got from therapy’s weird beginnings. Freud and a number of his spiritual descendants thought that therapy should involve a power dynamic- one person in control, closed off and aloof and one person vulnerable and open. On the psychiatric side, it was believed that doctors shouldn’t listen to patients because they are crazy. I’ve found the only way to go against this hierarchical approach is to remember that the client is the only true expert on their life, and they will always have more to teach me than I have to teach them.

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          • The traditional Freudian “therapy” dynamic in my opinion is, for lack of a better word, a form of narcissism.

            Which is interesting when you consider the fact that Freud himself was responsible for coining the term “narcissism”.

            But even if he hadn’t come up with that term, I still think the son of a bitch qualifies as one of history’s biggest narcissists.

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          • In my 30- something years of psychiatrists and therapists in various parts of the country, I have never had any mental health professional show me the kindness and empathy that you have shown in your article and your comments here. I no longer work with any therapist because of the pain I have experienced with them. It’s good to know there’s at least one. Thank you for taking the time to show us that not all of them are power-hungry vultures, though far too many are.

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  8. In my case I have come to realize that my TRD, anxiety and PTSD are caused by both genetics and life experiences. Thirty years ago, when I was turning 40, my depression and anxiety presented first with physical pain and behaviors like hair-pulling and digging into my scalp. It felt like there was a constant itch under the skin that I could only “scratch” by pulling out the hair by the roots and then digging….sometimes with something sharp, like sewing pins. The more anxious I was, the more intense the itch. Then the muscle pain and spasms began. Then nerve pain. Finally I reached feelings of despair and frustration at my sudden loss of my ability to do all the things that were important to me. I thought suicide was a reasonable option, despite the fact that I had already lost my mother and a brother by that time.
    Anxious to help me, my father pulled some strings and got a prominent psychiatrist — the director of depression research at Mass. General and Harvard professor — to take me as a patient. We tried multiple different medications, some from Canada, and finally two separate rounds of ECT. I got worse.
    After telling me there was no cure for my type of depression and that I would be battling it for the rest of my life, he said there was nothing more he could do for me and he didn’t have time to continue treatment. Goodbye.
    I’m still getting treatment from a psychiatrist because when I stop, I end up either hurting myself badly or attempting suicide. I finally got a decent PC doctor who was willing to prescribe pain medication for the severe pain, so I’m not presently suicidal. I take my psych meds even though they don’t help with depression, because they seem to help a little with my insomnia and nightmares. My PTSD is better than it was, though I’m still unable to venture outside. I don’t have much hope left, but I keep an eye out, reading publications like this one.
    Thank you for the help and information. I will keep checking back and maybe one day I will find something that helps. The comments from the other readers here, especially when you share what has helped you, are probably my best sources for finding out what works…or doesn’t. Please keep sharing! I appreciate you.

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    • Melpomene, thanks so much for saying all this. As much as you get help from hearing others share, we get help from you sharing. I am embarrassed to think that I used to think I knew the steps to guide people through depression (even though it didn’t work for myself). I made myself shut up, and my clients became my teachers. Justine was one of many who showed how everyone who is still going has found some way to keep going. People like yourself are inspiring.

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      • Thank you for your thoughtful response. You may be interested to hear that the psychiatrist who caused me so much damage is still working on treatment resistant depression research. He’s currently looking for people to participate in a trial using xenon gas. Xenon has been used as an anesthetic in Europe and to aid in taking X-rays of the brain…
        Dr. Frankenstein is still creating monsters.

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  9. “Capital is an abstract parasite, an insatiable vampire and zombie maker; but the living flesh it converts into dead labor is ours, and the zombies it makes are us.”
    ― Mark Fisher, Capitalist Realism: Is There No Alternative?

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  10. Mr Josh Hines,
    THANK YOU! I’ve felt validated, triggered, outraged, moved, and touched by several articles in MIA. Your piece is the best one on all of those fronts! Well done! You nailed it.

    If the true story of psychiatry survives and I hope it does, humans will learn so much about how not to behave like blinded fools.
    Psychoactive drugs might very well lead to our species’ extinction, though.
    I can’t say I don’t think we ALL deserve it. But I do still root for us that we will figure out we all are born knowing who we are and then are blinded by religion/science. Unless we do figure that out, we are not going to make it …
    I feel so lucky I personally got to “see” my true self again. I could easily have lived & died before I did.
    Sounds like you’re lucky too, Josh Hines.

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