Particularly in psychiatry, patients often complain that they are immediately handed out a prescription the moment they see their doctor for psychological and emotional issues. Despite the discomfort associated with it, they frequently do not not know what else could have been done and they are not aware of alternatives. They resign themselves to taking the medication because they are in emotional pain and don’t know how to get better. They often end up taking these medications for years to come, because they are told that they have a chemical imbalance like the diabetic has an insulin deficiency requiring medication. They are told the medications are harmless and they might as well take them as a prophylactic measure to prevent a relapse. When they try to get off the medications, they experience a return of symptoms and don’t know any other interpretation than that they are obviously dependent on them for proper functioning. The problem is that medications have side effects, including for some a sense of moving through life like a zombie without much passion or sense of meaning. Medications also sometimes lose their effect over time and they prevent the person from engaging in the necessary brain wiring changes they need to grow into health. The result is nothing short of a social scourge creating a whole generation of people who have lost the capacity to develop resilience. There are undoubtedly people who need medication, sometimes for a short period of time, sometimes for a lifetime, but by far not as many as are actually taking medications. The number of people on unnecessary psychiatric medications is staggering and the symptom of a far deeper problem: namely the fact that as a society we do not foster education in the human mind. We raise our children, educate, teach and live our lives as if we had no minds, and that applies no less to the medical and even psychiatric community.
Living as if you had no mind means to be in the dark about the fact that the brain is not like a camera, providing a faithful reflection of captured reality. Instead, it is a mapping organ that constructs a reality from ‘raw’ data from the senses. However, the senses have an anatomical and physiological architecture that limits the spectrum of information they capture and pass on to the central nervous system. In short, we only see what we construct, and what we don’t construct is experienced through the restricted dimension of neural architecture. For better or for worse, in living life we largely create our own reality, and if we don’t know that, we either feel victimized by what happens to us or miss out on the opportunity to change our lives by changing the way we use our mind.
To give you access to the narrative and imaginative difference between an inquiry that assumes no mind and one that does, let me give you two very different examples of how patients can be approached. This is taken from a patient I have followed for many years. For obvious reasons of confidentiality I changed the name and certain biographical details. I will use the psychiatric assessment as the tool with which to show you this glaring difference and the wide-ranging consequences in treatment that flow from it.
This patient I will call Belinda saw a psychiatrist and a CBT (cognitive-behavioral therapy) therapist starting about two years prior to her coming to see me. CBT is a form of psychotherapy that can be very effective in depression and that focuses on changing destructive and distorted thought patterns. It typically focuses on current thought patterns, issues and even problem-solving strategies, but does not delve into making sense of a patient’s history. She had seen her psychiatrist 1x/month to monitor the medication, which had to be changed or adjusted a few times because of side effects. She had also seen the CBT therapist 1x every other week at first, then 1x/month during the two years before she came to see me for a second opinion. The treatment results were unsatisfactory to her and her family physician thought that coming to see me and be exposed to a different approach might be helpful. In my chart I have a copy of the psychiatric assessment performed by my predecessor, the text of which I will use to compare the two approaches. The way the assessment is written gives clues as to the method and process used to get to know and understand the patient. To make this accessible for a short essay, I will condense the information in both my colleague’s and my assessments. Here is the gist of how my predecessor saw Belinda:
Belinda, 40 years old, has been anxious and depressed for about one year, although these symptoms have existed in a mild form for many years before that. She does not sleep properly – can fall asleep, but wakes up after a few hours and cannot get back to sleep. She ruminates incessantly, worried about the future and feeling guilty about past decisions she made. Her mood is low, she lacks motivation, finds it hard to concentrate, cries sometimes for no reason but mostly feels numb, can barely get out of bed in the morning and even fantasizes about dying. At times she is overtaken by dizziness, light-headedness, racing heart palpitations, a feeling of not getting enough air and fear of fainting. It feels like she is going to have a heart attack. In her family history her father was a depressed, abusive alcoholic and her mother had an anxiety disorder. A paternal grandmother also suffered from depression. Belinda’s marriage is ‘normal’ apart from a few challenges she figures everyone has. She has a good job and the family is financially secure. She cannot find any reason to feel this way. Diagnostically the psychiatrist concludes that she meets the criteria for a major depressive disorder and a panic disorder. She is told that her illness is genetic, given that there is a family history of depression, anxiety and alcoholism, that she has a chemical imbalance, and that the recommended treatment is a combination of an antidepressant with an anti-anxiety medication and a sleeping pill to rebalance the brain chemicals. A course of CBT is also recommended as an adjunct to treatment, so that she can learn to substitute destructive thought patterns with more constructive ones.
My colleague’s assessment note reads pretty much the way this last paragraph sounds, and I am sure that in reading this you probably find the story and the psychiatrist’s view of the patient reasonable – and it is to a limited extent. What is not visible in this assessment is what is left out due to the fact that my colleague’s approach assumes that Belinda’s mind is not shaped by history, experience and relationships, and that therefore Belinda has nothing to do with her illness. Her psychological symptoms are treated like physical symptoms, in that it is assumed they have no psychological meaning, but only a physical reason. Because her mind is assumed to exist independent of her history and relationships, it is also not part of the approach to understand Belinda’s autobiographical narrative. If you cough and have a fever for example, there is no meaning to the symptoms other than to say that they are the effect of a physical dysfunction, the reason for which can be found through medical tests. How you tell your physician that you cough and have fever is of no relevance – the physical findings speak for themselves and upon further investigation they reveal the nature of the illness. When it comes to the psyche and the mind, however, reducing emotional symptoms to physical processes in the brain and the body (chemical imbalance, genes) does not do justice to the fact that the mind functions according to its own laws that are different from the laws of physiology, and that the mind is storied and deeply relational. The mind cannot be reduced to the brain and the body, even though brain and mind interact.
How did the same patient look like through my assessment, which assumes that we all have a storied mind that has been shaped by our history and our relationships? The story Belinda initially tells would sound exactly the same, but the therapist’s assumptions and interventions would be very different and lead not only to a very different assessment process and relationship with the patient, but also to a very different understanding of Belinda’s situation and to different treatment conclusions. I will insert in italics thought processes, assumptions and questions I introduced into the conversation, and which Belinda often felt nobody had ever asked her before. You will see how much longer the story will be than the biologically oriented assessment of my predecessor.
Belinda, 40 years old, has been anxious and depressed for about one year, although these symptoms have existed in a mild form for many years before that. “How long before that?” Belinda adds that she probably has felt sad since at least adolescence. She does not sleep properly – can fall asleep, but wakes up after a few hours and cannot get back to sleep. She ruminates incessantly, worried about the future. Her mood is low, she lacks motivation, finds it hard to concentrate, cries a lot for no reason, can barely get out of bed in the morning and even fantasizes about dying. At times she is overtaken by dizziness, light-headedness, racing heart palpitations, a feeling of not getting enough air and fear of fainting. It feels like she is going to have a heart attack. “Why do you feel so depressed and anxious?” She first says that she feels depressed and anxious because she can’t sleep, her mood is low, she has palpitations etc. Now notice how her mind tricks her into not answering the question – it is as if when asked why the river flows into the ocean you would answer that it is because more and more water keeps flowing into the ocean. She does not notice at first that she is not able to penetrate deeper into the reason for her symptoms. When I point that out to her, she first notices that the previous therapists never asked her that question and at first she says she does not know, and that there is no reason for her to feel that way, given that her life is otherwise pretty normal. Again, what was quite clear to me at this point is that the reasons for her suffering were so deeply repressed by her mind that she had no access to them. She then ended up repeating what her previous therapist told her, that it must be a genetic chemical imbalance.
“What were your parents and your relationship to them like?” She now starts crying and describes not only an abusive father, but also a short-tempered, constantly stressed, overly critical mother who never had time for the children and was emotionally quite cold and angry. In her family history her father was a depressed, abusive alcoholic and her mother had an anxiety disorder. A paternal grandmother also suffered from depression. “It must have been very painful to have been raised in those kinds of family circumstances!” She agrees. “And how do you think that affected you growing up?” Now she remembers having been a bed wetter for many years and having had trouble concentrating at school because she was so preoccupied with what was going on at home. She therefore failed high school and had to finish it through correspondence classes later on while working for money. She felt so lonely and unhappy at home with her parents that she married her husband to escape her family of origin. “So what is your marriage like?” Although her husband has a good job, he is like her mother, emotionally absent, critical and putting her down a lot, but she has gotten used to it and finds that ‘normal’ like other of her friends’ marriages. This is what she meant before when she said that her marriage is ‘normal’ apart from a few challenges she figures everyone has. In short, her marriage is a major source of sadness, depletion and stress. Thanks to her intelligence she has a good job, and the family is financially secure, but the family atmosphere is everything but secure.
She now admitted that there are likely many reasons for her to feel this way. Although she diagnostically meets the criteria for a major depressive disorder and a panic disorder, it has now become clear that in the course of her childhood the dysfunctional family atmosphere wired her brain to develop a dysfunctional mind that causes a lot of suffering. As an adult she perpetuates the mind habits that cause her to be depressed and anxious without knowing that she is creating her own suffering.
The genetic theory is very much in question, first because there are no genes that without fail cause these dysfunctions. A lot hinges on gene expression, which is dependent on environmental influences. Humans not only evolve through gene mutations that propel natural evolution, but also through the way we pass on our minds (emotional and thought patterns) to our offspring through cultural evolution. Generally speaking, natural evolution moves at a snail’s pace as genes mutate very slowly over thousands of years, which is why our brains (hardware) are likely very much the same as the brains of our ancestors living 30,000 years ago. On the contrary, cultural evolution is fast and the dominant factor in human evolution, which is why compared to our ancestors our brains are wired differently (different software). When it comes to psychiatry, I have come to understand that the same applies; I am rarely impressed by genes in understanding my patients’ suffering, but over and over again do I see how generations after generations pass on dysfunctional mind habits to their offspring, thus perpetuating suffering against their often good intentions to make it better for their children. It is crucial to reiterate that because our mind is embodied, when we use our mind in unhealthy ways, we miswire our brain and the brain of those we interact with, and end up developing ‘chemical imbalances’ in ourselves and our loved ones. Fortunately, this cycle of suffering can be stopped. I see it all the time in people who have gone through the process of learning to use their minds to rewire their brains, allowing them to stop passing on their parents’ sufferings and miseries to their own children. They have learned to use their minds to correct chemical imbalances in themselves.
In Belinda’s case there is certainly enough evidence of disturbances in her parental attunements to explain why her brain was shaped by these psychological influences to provide her with a deeply conflicted mind. She clearly has a chemical imbalance, but in this view it is due to the way she has learned to perpetuate faulty thought and feeling patterns and behaviors to cause her own suffering. Given her capacity for insight, her motivation to look at herself, the fact that she was able to cope and the human mind’s embodiment, the recommended treatment was primarily a combination of psychological tools to help her get to know and use her mind to rewire the brain. Medication was very much optional and in the long run not needed. As she engaged in a longterm (3-5 years) combination of psychotherapy and mindfulness training, she ended up divorcing her husband who categorically refused to see his part in the marital misery and therefore refused help. She eventually worked through all the issues from her childhood and found a new partner, with whom she was able to engage in a healthy marriage. She now lives happily, her ‘chemical imbalance’ rebalanced through the healthy use of her mind. Her symptoms have disappeared and she has no need for medication.
Continuing to do what we did in the past and hope for different results in the future is one of the definitions of insanity. For all those patients who unnecessarily take medication (and there are far too many of them), the corollary is that ignoring the mind and taking medication instead allows them to maintain insanity and feel better. This is how people for example stay in unhealthy marriages despite their toxicity, masking the pain these relationships create with medication that allows them to function and keep the status quo. Learning to use the mind to rewire the brain is not for the faint-hearted and implies being prepared to make profound life changes, some of which can be very difficult to implement. The advantage of this path lies in the solidity of the result and the frequent liberation from medication dependence.
Copyright © 2017 by Dr. Stéphane Treyvaud. All rights reserved.