Mental Illness is Not In Your Head
May 19, 2023 4:34 AM   Subscribe

What do we have to show for a century of psychiatric research? In a review of recent books by Anne Harrington and Andrew Scull, the historian of medicine Marco Ramos follows the changing fashions in twentieth and twenty-first century psychiatry--from eugenics to brain dissection to lobotomies to psychoanalysis to DSM to Big Pharma to psychedelics--and offers an unsparing assessment of the field's ethical record, scientific discoveries, and public health achievements.
posted by sy (25 comments total) 29 users marked this as a favorite
"We've Had A Hundred Years of Psychotherapy and The World's Getting Worse" by James hillman and Michael Ventura
posted by DJZouke at 5:09 AM on May 19, 2023 [2 favorites]

take a look at budgets. compare research programs using massive compute to associate genetic markers with mental illnesses with community programs to intervene directly with people's actual problems. the results may not surprise you, but they certainly are depressing.
posted by AlbertCalavicci at 5:27 AM on May 19, 2023 [10 favorites]

I wish I could dig the citation out, but after the destruction of the World Trade Centers an army of grief counsellors descended on the bystanders and families of victims, and the results of all of their efforts were, in the end, no more or less effective than the passage of time.

The 20th century is really going to look like a scientific Dark Age someday, isn't it?
posted by mhoye at 5:50 AM on May 19, 2023 [4 favorites]

I think there were a few other developments during the 20th century besides grief counselors.
posted by star gentle uterus at 6:04 AM on May 19, 2023 [19 favorites]

Sure, but look at the parade of horrors in that article, the mass sterilizations, incarcerations and killings, the (without going into the details, for anyone who doesn't want to read something awful) 1947 Nobel Prize awarded for absolutely nightmarish pseudomedical barbarism.

Elsewhere, consider economics - in particular, that almost magical graph on page 5, "Uses of Quasi-experimental Terms in Top Economics Field Journals", where we learn that the notion of empiricism in economics has not been a feature of prominent econ publications for as long as the Simpsons have been on TV. There are lots of examples of this general shape of problem.

While the details are different, there are a lot of fields of human endeavour that, today, are just barely emerging from this effectively superstitious, pre-scientific condition.

Anyway, I don't want to derail here, though I guess I've done that. I still believe in science, if that's a phrase that means anything, but it is very difficult for any person or institution to convince an established, comfortable status quo to admit that not only does their chosen emperor have no clothes but that he has, in fact, never met a tailor.
posted by mhoye at 6:24 AM on May 19, 2023 [8 favorites]

I am a psychiatrist. This article crystallizes much of my cynicism about the field, but also offers quite a bit of perspective I was not previously aware of. Thank you very much for posting it, sy.

I can’t help but discuss politics when teaching medical learners. Our society (in Canada, could be worse) is structured to give me no shortage of work, and no shortage of misery for most people.

I will continue my work, and I do hope that people with mental illnesses and other mental health concerns can get treatment as needed. Often the most acute problems respond the best to treatment. If you need help, I sincerely hope you can get it, whether that means healthcare or something else.
posted by sillyman at 6:25 AM on May 19, 2023 [22 favorites]

I really didn't like this piece, even though I expected to. This line encapsulated my problem with it: "Genealogies of resistance conceptualize 'health' not in terms of access to individualized treatment provided by academic physicians but rather in terms of collective liberation from the structural conditions that produce the vast extent of psychological suffering and trauma."

In a piece that talks about the repetition of styles and mindsets in psychiatry over the course of its history, it's odd that a sentence like that can just sit there without having its own repetition be interrogated. It's a very mid-20th-century sentence. It is echoing the earlier quote in the piece from the Chicago Gay Liberation Front, with which it shares a sort of frightening optimism. Instead of worrying about your depression, let's just end racism, sexism, heterosexism, capitalism! The work of an afternoon! But if we center our thinking about psychological problems around 'structural conditions' over which the individual has no control, then the patient is always a victim of an external force, and in a piece that is so concerned with the lack of success of psychiatry, it's odd not to see any evidence--at all--that structural-oppression-based mental health techniques have any efficacy. What are those techniques, and are they being studied? We're at the end of the piece; he has lost interest, or run out of words. Maybe next time we'll hear about it.

I don't think we will. It's a well-meaning outlook but it doesn't explain anything. "You're depressed because your life is depressing." I mean...yeah! I'm anxious because there are scary things out there! So what? The question is still what to do with the sadness or fear or hallucinations. How to see them, how to fix them if they're problems, how to live around them if they're permanent. I love complaining about psychiatry--it's one of my favorite things, I think it is a corrupt and malign institution--but sweeping it aside and calling for "collective liberation" doesn't explain anything any better than psychiatry. It offers a just-so story where the amounts of serotonin in your brain are now ignored in favor of the amounts of -isms you're up against. Neither is a sufficient explanation.
posted by mittens at 6:36 AM on May 19, 2023 [42 favorites]

"We've Had A Hundred Years of Psychotherapy and The World's Getting Worse" by James hillman and Michael Ventura

Here's a link to Amazon reviews.
posted by Brian B. at 6:56 AM on May 19, 2023 [1 favorite]

"You're depressed because your life is depressing." I mean...yeah! I'm anxious because there are scary things out there! So what?

mittens - I'm going to leap-frog off of this in an "yes, and..." Me and my entire family have struggled with different flavors of "mental illness" throughout our lives. For myself, I've come to see my responses as "this is how my particular brain responds to these particular sets of experiences when I am also cut off from the types of activities that allow me to regulate." So - for example - when I was doing physical labor, I was much, much better at being able to shake off shit, or not reach levels of days-long disequilibrium, because strenuous physical activity is a primary re-set button for me. Working at a desk job again, I linger in those spaces a lot longer.

Similarly, I see family members who work really, really well at a particular type of task, but that task does not afford them a living wage, so to make ends meet, they do something that has a lot more baked-in unpredictability and uncertainty, and their day-job now fuels their anxiety.

What I'm getting at (poorly) is that mental un-health seems to be a systems problem. There is interesting and encouraging research on the intersection of gut biome and mental health. Similarly, there are encouraging studies on the intersection of mental wellness and human interaction or "purpose". There is interesting work being done on genetics/epigenetics and mental health.

I think mental/emotional wellness is a 'complex systems' problem -- 'how one particular brain responds to a series of experiences combined with access to person-specific self-regulating options.' And our science, or societies, do not do exceptionally well with systems-thinking (to wit: climate crisis).

A lot of these think-pieces of mental health are problematic for me because they seem to do a lot of finger-pointing at once piece of the system, without really addressing the absolute complexity of the whole, in the same way that the idea that "everybody should just stop driving cars" is a naïve response to a multi-factor problem.

The article brought in some of the layers of complexity, but I don't feel like to helped point toward much of a path forward.
posted by Silvery Fish at 6:58 AM on May 19, 2023 [10 favorites]

I agree with all the critique in the article, but schizophrenia runs in my family (grandparent, sibling) with varying degrees of severity (sibling has not been able to live independently for the past 30 years), and it is hard for me to believe that my sibling's persistent, destructive, and sometimes violent psychosis is not in their head. It also seems unlikely that brains only malfunction in response to external trauma, considering that all other organs can malfunction for genetic or developmental randomness reasons.
posted by Rhedyn at 7:18 AM on May 19, 2023 [21 favorites]

Mental illnesses very much are related to stuff in the brain. Some of them are quite heritable. Biological treatments do work, for the most part. The details for all of those broad statements are still murky, though.

I don’t recommend that people with, for example, psychosis go off medication and live separate from medical treatment. Psychological trauma is most definitely not the primary cause of schizophrenia and similar illnesses.

I like to think that questioning the nature and purpose of what I do can help me be a better doctor. I mean, to a point, lest I become too jaded to function.

I agree with mittens, I think, that this article in a way is arguing for a different fad, without admitting it. I guess what resonated with me is the partialist nature of each phase described, and the consequent neglect of the humanity and/or biology of the people being treated, and those around them.
posted by sillyman at 8:05 AM on May 19, 2023 [12 favorites]

From the article...
While many therapists adopt an eclectic approach that borrows insights from CBT and various strands of psychoanalysis in practice, the kind of long-term, open-ended therapy that traditional psychoanalysis represented is extremely difficult to access now. Insurance refuses to cover it, and patients who want psychoanalysis are often forced to pay high fees out-of-pocket.

This, right here, is where I’m stuck when it comes to therapy. Unless you’re able/willing to shell-out three-figure fees per session, you’re pretty-much limited to settling for a handful of sessions with an overworked MSW reciting a CBT script. I’ve been down that road too many times, and have never accomplished anything other than adding to my frustrations.

I’ve been dealing with severe clinical depression all my life, and the only sort of therapy that has ever helped is long-term talk therapy with someone who has the tools and skill to guide and probe and illuminate. It’s what I respond best to, and it’s what I cannot get anymore. So, I go without.
posted by Thorzdad at 9:20 AM on May 19, 2023 [18 favorites]

Thanks for linking to this article. Deeply interesting and I think truthful.

I am bothered by one, maybe small, thing. A quote: "Scull [the author of one of the books under review] laments the loss of connection that psychoanalysis represented for some (mostly privileged) American patients at mid-century...." This review doesn't need to be longer than it is, but I think given the other mental illnesses discussed that it's worth mentioning that psychoanalysis never claimed to be effective with the seriously mentally ill. A person with hallucinations or in a profound depression is no candidate for the civilized exchanges and personal insight of psychoanalysis.

Not as important but the headline is click-bait and doesn't represent the article very well. Shame on the Boston Review.
posted by tmdonahue at 9:22 AM on May 19, 2023 [5 favorites]

In addition to the excellent critique by mittens above, the author writes:
In other words, the collection of symptoms that defined each condition in the DSM have still—after billions of dollars of investment—not been correlated with robust changes in our brains, blood, or genes.
I understand the problem highlighted in the article with the current total dominance of the biological approach to the exclusion of all others, but isn't this conclusion in itself very valuable? The hypothesis that mental disorders have biological causes isn't prima facie unreasonable, so evidence showing that biological factors are less relevant or more complex than hypothesized seems very useful in trying to determine what the causes of mental illness actually are.

In addition, the article itself contradicts this statement and notes that certain biological factor/process correlations have been verified (e.g., some drugs do seem to work even though we may not understand the mechanism, some schizophrenia is explainable via genetics, etc.). So while biology isn't everything, it does seem to play some meaningful role.
posted by star gentle uterus at 9:43 AM on May 19, 2023 [6 favorites]

One of the most personally disturbing dating experiences I've ever had was with a psychiatrist. I still shudder to think of what his patients experience. It totally changed my own approach to mental health. Just a few dates and I realized that true evil existed in ways I'd never imagined.
posted by lextex at 9:48 AM on May 19, 2023

Oh, also, one of the darker ChatGPT things I've seen is a self-styled "Prompt Engineer" tweeting about some bullshit prompt they've come up with that's "just like a psychiatrist so everyone can get free mental health advice". I sincerely hope it doesn't end up harming someone desperate.
posted by star gentle uterus at 9:52 AM on May 19, 2023 [1 favorite]

I want to recommend the book, Patient H.M.: A Story of Memory, Madness, and Family Secrets, by Luke Dittrich. Henry Molaison's significant memory issues were caused by an experimental bilateral medial temporal lobectomy to control seizures by William Scoville. One of the things I find really disturbing about the case is that Henry was studied for decades and he was a great subject because he forgot everything that happened to him in the very recent past, so he was a fresh canvas every day. The scientists that studied him were careful to note that Henry consented to their studies, but is it really consent if you can't remember that you have been studied every day for most of your life?

The book goes into the history of brain surgeries, back to ancient Egypt and goes into the ethics of experimental treatments like lobotomies. It is a fascinating book about a very dark subject.
posted by ceejaytee at 10:19 AM on May 19, 2023 [3 favorites]

I want to recommend the book, Patient H.M.: A Story of Memory, Madness, and Family Secrets, by Luke Dittrich.

Thanks, ceejaytee. If anybody wants to discuss Rachel Aviv's Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, I posted about it on FanFare.
posted by MonkeyToes at 10:35 AM on May 19, 2023 [2 favorites]

The parents of one of my oldest friends were a psychiatrist and a psychologist, and got *damn* is my friend still a hot fucking mess even at age 51. I know, post hoc ergo propter, but boy oh boy does there ever sure seem to be causality there.
posted by outgrown_hobnail at 10:37 AM on May 19, 2023 [1 favorite]

I had a nasty neurosis that made me seek help in 2013. In the erstwhile capitol of NY State, Albany, the options for one on one therapy were very limited and still are. I was lucky to find a therapist on my own. I had remembered that he curated the Lake George Jazz Festival for many years and practiced therapy too. From 2013-15 we met once a week via Skype. During those two years I lost my sense of taste and smell. Almost two years to the day I was able, with the help of an exceptionally gifted therapist, to regain those precious senses. He expressed the fact that my repression was causing my loss of smell and taste. He was right. I can not begin to describe the elation and feelings of rebirth. That lasted until late 2019 when an ear-sinus infection once again took away my sense of smell and taste. Unfortunately my therapist died of cancer in 2017. I have found another therapist but the spark of transference isn't there.
posted by DJZouke at 10:39 AM on May 19, 2023 [2 favorites]

There's been a lot of solid research into the environmental causes of mental illness, though, and it's becoming pretty clear that what you breathe and and ambient heat levels have a major effect on our psyches.

Ozone linked to depression in adolescents: Even “fairly low exposure” could raise risk of mental health issues, according to new research.

Genes and Air Pollution Multiply Healthy People’s Risk of Depression
“The bottom line of this study is that air pollution doesn’t only impact climate change, it’s affecting how your brain works,“ said Daniel R. Weinberger, M.D., Chief Executive Officer and Director of the Lieber Institute and a co-author of the study.
Small increases in air pollution linked to rise in depression, finds study

Depression and suicide linked to air pollution in new global study

Growing up in dirty air 'quadruples chances of developing depression'

Air pollution linked to more severe mental illness – study: research finds small rise in exposure to air pollution leads to higher risk of needing treatment

Air pollution linked to ‘extremely high mortality’ in people with mental disorders

Heat exposure associated with mental illness: older people in rural areas especially vulnerable

Almost 8,000 US shootings attributed to unseasonable heat – study

Air pollution linked to increased mental illness in children

Long-term exposure to ambient air pollutants and mental health status: A nationwide population-based cross-sectional study

Nearly all of us are breathing poor quality air, World Health Organization says

It turns out our big, incredibly complex brains are pretty particular about what we breathe.
posted by MrVisible at 11:18 AM on May 19, 2023 [10 favorites]

however living with air pollution doesn't guarantee that you will get depression. having a particular set of genes doesn't doom you to schizophrenia. living in a suburban hellscape doesn't automatically lead to bipolar disorder. as Silvery Fish noted above, complex interacting systems are complex; trying to pin down mental illness to a single underlying cause is probably fruitless, but so is excluding possible factors because they don't explain 'enough' of the variance.

guy in TFA is right that it's not all biology but is wrong to give the impression that biology doesn't matter and that anyone who says biology does matter is a fool or a charlatan
posted by logicpunk at 12:04 PM on May 19, 2023 [8 favorites]

Something that doesn't get enough attention at the pop-science level of psychology is that correlation doesn't equal causation. Does pollution cause depression, or is it a predictable correlation with something else that causes depression (like poverty or living in a noisy environment)? If it's poverty as the underlying causation, then we're back to structural reasons.

I'm not having a dig at any of this. It's just that we still have so much to learn, we've barely begun.
posted by harriet vane at 1:29 AM on May 20, 2023 [4 favorites]

I'm a highly anxious person. For whatever reason, anxiety doesn't get media coverage the way depression does. Just saying it, not saying one is worse than the other.

Anyway, extreme anxiety runs in my family. My mom has had terrible, extreme anxiety—untreated—her whole life. She's 82 and her anxiety as my mother affected me and my siblings a large amount during our formative years and even today. She won't take her prescribed medication except very rarely. She has a scrip for some xanax-type thing, a very low dose and she'll only take half a pill maybe once every three months if I gently convince her that she's having a bad episode and it's not too early in the day.

I'm not blaming anyone for my condition, but I think in my case I think it's a combo of genetics and growing up with a mentally ill parent. Bipolar disorder also runs in my family. Neither of my folks had it, but my older sibling has it pretty bad. But they are treated medically and it keeps them living a pretty "normal" life punctuated with bouts of depression. I'm on a good drug combo right now, but it leaves me uninterested in sex. Not great, but better than without the drugs.

I don't think this stuff will ever be completely understood. I firmly believe that. We might get better at treating symptoms, but brains and lifestyle and upbringing and trauma are too complex to ever be fully understood in individuals.
posted by SoberHighland at 7:12 AM on May 20, 2023 [3 favorites]

Then again we live in the age of anxiety. Our scientific materialism and literalism have desacralized nature and the gods have taken root within our bodies as symptoms.
posted by DJZouke at 9:00 AM on May 20, 2023 [3 favorites]

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