I mention this in light of an ongoing debate: what is the best approach to mental illness?  This question has plenty of stock answers – too many, perhaps. When we boil down a complex issue to just two sides, it helps us to digest subsequent arguments. Making a simplified choice at the start of a debate (pro or con?) gives us a footing for grey area. But human beings don’t like grey area right off the bat.

Unfortunately, mental illness is grey area. In its most extreme forms it may not be – everyone agrees that John Hinckley was a sick man – but extreme forms of illness are just that; they’re rare. Most of the time, mental disorder expresses itself within a vast spectrum of behaviors that we can and do normalize. Sadness, emptiness, anxiety, fear, compulsion: these aren’t just symptoms.

The inherent “greyness” of illness makes it a difficult topic. We can reduce it to black and white, but that never does justice to our cause. Take, for example, this recent bit of news:

The level of Americans’ prejudice and discrimination toward people with serious mental illness or substance abuse problems didn’t change over 10 years, a new study has found… [Sociologist Bernice Pescosolido] and her colleagues compared the attitudes of people in 1996 and 2006. During this period, there was a major push to make Americans more aware of the genetic and medical explanations for conditions such as depression, schizophrenia and substance abuse… People who believed that mental illness and substance abuse had neurobiological causes were more likely to be in favor of providing treatment. But these people were no less likely to stigmatize patients with mental illness or substance abuse problems. [my emphasis]

First of all, this is progress. If more people support treatment, that’s a huge plus. Nonetheless, these researchers sound disappointed: “It’s time to stand back and rethink our approach,” said Pescosolido.

Really, guys? Obviously doctors are going to take a medical approach. But I’m a bit astonished that doctors, of all people – the ones who have the most direct experience with illness in all its various forms – think that purely medical explanations are going to satisfy us. Yes, it is absolutely crucial for people to understand illness as a medical problem. As I’ve written in the past, classifying something as a “mental illness” is just a way of acknowledging that treatment exists. But reducing these woes to brain chemistry in order to make illness more approachable?  It’s almost comic. I’m not suggesting that brain chemistry is too complicated for the average person (the fundamentals are easy to grasp, actually). It’s deeper than that. No one wants to think of their emotional life, no matter how unbalanced, as chemical soup.

First of all, this robs us of agency; it suggests a lack of free will. Second of all, it’s an obvious over-simplification. It’s not a distillation of the issue; it’s reductionist. (From a recent post: “It is time… to wonder deeply in and about our gifts, rather than reduce ourselves to primitive urges and selfish genes.”)  Everyone feels in their bones the reach of illness, that illness itself is wrapped up with fundamental things. Even if mental disorder is “just” errant neurons, we know from experience that our psychological development is a feedback loop – that our thoughts, feelings and actions inform our future selves (i.e., our neuronal development). By definition, sufferers can’t control their illness, but invariably they will make decisions that affect its course.

What does this have to do with stigma?  Everything. The premise of my efforts here and elsewhere is that stigma makes illness more difficult to bear – and that whatever exacerbates mental illness is actually part of it. Mental illness is simply too amorphous, too expansive and too rich to reduce to molecular biology alone. People may not articulate this in my way, but this argument is at the heart of a lot blowback against a medicalized view of mental suffering. People do believe, and they want to believe, that when it comes to mental illness, everything matters – not just science.

I’m inclined to agree. Part of my discussion with the students this summer included a brief lesson in neurology, showing them how SSRIs actually work in the brain. This is an essential piece of my attack on stigma, but it’s just a piece. I spent much more time talking about the stigma itself: how it arises, why it’s damaging, and how to combat it. I also talked to them about life in general, and in particular feelings of failure and/or hopelessness: how to recognize them, how to address them, and why they’re okay – why they’re essentially, actually, to a life well-lived. This can be abstract stuff. Brain chemistry is more concrete. But if we don’t acknowledge that our attitudes matter, then why change them?

I pride myself in keeping an open mind about mental illness, but I have to admit that it’s tough to watch this video without feeling a pang of conservative rage. Where are we going with all of this? Are we so desperate and starry-eyed that we’re willing to experiment on our own children?? Don’t they deserve a more cautious approach?!??!?!

I’m not quick to judge any of the parents. My heart goes out to them. I’ve never had a kid, let alone one with mental illness. But I do know something of the helplessness that surrounds families in the midst of these crises. It’s a God-awful experience – and a dangerous one, too. Feelings of abject helplessness lead to extreme vulnerability. And that’s exactly what you see in this video: vulnerable families being pressured into troubling treatment, all at the behest of powerful institutions with their own interests to weigh. I’m not skeptical of doctors or “experts” (that’s a strain of American fundamentalism I could live without), but at the same time we have to recognize our respective roles. A child’s care is the sole responsibility of his or her parents. The educational system and the health care industry, despite what they advertise, were not designed to care for any particular child. Those institutions have competing priorities (the profit initiative, organizational flow, etc.), including millions of other kids. What is good for a school or a doctor’s office might be at odds with what is good for a child. When it comes to medicating our youth, we should be especially vigilant about these conflicts of interest, and wise to how good people’s judgment can go bad.

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[Note the segment tiles above the video display; to watch the whole program, click on each segment.]

In a paper published last month in the journal Nature Reviews Neuroscience, Dr. J. Allan Hobson, a psychiatrist and longtime sleep researcher at Harvard, argues that the main function of rapid-eye-movement sleep, or REM, when most dreaming occurs, is physiological. The brain is warming its circuits, anticipating the sights and sounds and emotions of waking.”

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[Surely dreaming has some sort of physiological purpose. But how does that undercut the power of interpretation? Dreams aren't designed with analysis in mind – that's precisely what makes them so interesting. In a sense, dreams are the purest form of free-association. When we're not awake to censor ourselves, our expressions run rampant. Dreams can be confusing, scary, mystifying and weird, but they cannot be someone else's. They may feel foreign – they often do – and it's always useful to consider why that's so. After all, one thing's for certain: we are their authors, intentionally or not. -Ed.]

(photo: detail from The Nightmare by Henry Fuseli)

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Neuronetics NeuroStar TMS Therapy System

[I'd still use it. -Ed.]

[A] genetic trait tremendously maladaptive in one situation can prove highly adaptive in another. We needn’t look far to see this in human behavior. To survive and evolve, every society needs some individuals who are more aggressive, restless, stubborn, submissive, social, hyperactive, flexible, solitary, anxious, introspective, vigilant—and even more morose, irritable, or outright violent—than the norm. All of this helps answer that fundamental evolutionary question about how risk alleles have endured. We have survived not despite these alleles but because of them. And those alleles haven’t merely managed to slip through the selection process; they have been actively selected for.

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[Fascinating stuff – reminiscent of this post. Also included, this wonderful zinger: "The orchid variant of the DRD4 gene, for instance, increases risk of ADHD (a syndrome best characterized, Cochran and Harpending write, 'by actions that annoy elementary-school teachers')." -Ed.]

“If you just sit on your couch, then steroids aren’t going to be very effective,” he says. “Antidepressants are the same way: if you want the drug to work for you, then you have to work for the drug.”

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