Three Books about the Chemical Imbalance Theory of Mental Illness

I highly recommend the two-part article by Marcia Angell in recent issues of the New York Review of Books.   In June, she wrote a piece entitled ‘The Epidemic of Mental Illness:  Why?’; then in the July issue, she followed up with another piece entitled ‘The Illusions of Psychiatry.’ In these two articles, she discusses several important books that address the “epidemic” of mental illness in this country, including Robert Whitaker’s book
Anatomy of an Epidemic which I reviewed in three separate posts:  one about the theory that mental illness is caused by a chemical imbalance in the brain, another concerning the actual effects of psychiatric medications and the third addressing the entirely false belief that treating psychological disorders with such drugs is like taking insulin for diabetes.  Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and a former Editor in Chief of the New England Journal of Medicine; these lengthy articles are thorough and scholarly.

The other two books under review are The Emperor’s New Drugs:  Exploding the Antidepressant Myth by Irving Kirsch and Unhinged:  The Trouble with Psychiatry — a Doctor’s Revelations About a Profession in Crisis by Daniel Carlat.  I haven’t yet read these two latter books, but here is Marcia Angell’s description of them:

“The authors emphasize different aspects of the epidemic of mental illness. Kirsch is concerned with whether antidepressants work. Whitaker, who has written an angrier book, takes on the entire spectrum of mental illness and asks whether psychoactive drugs create worse problems than they solve. Carlat, who writes more in sorrow than in anger, looks mainly at how his profession has allied itself with, and is manipulated by, the pharmaceutical industry. But despite their differences, all three are in remarkable agreement on some important matters, and they have documented their views well.”

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60 Minutes and Greg Mortenson’s Fraud: The Power of Sentimentality

As you probably know, Greg Mortenson is the best-selling author of two books that detail his efforts to build schools and promote the education of young girls in Afghanistan and Pakistan — Three Cups of Tea and Stones into Schools.  On CBS, 60 Minutes recently aired a segment which revealed convincing evidence that much of Mortenson’s narrative is a fraud:  some of his heart-warming stories are exaggerated or mis-represented, others invented whole cloth.  The segment also highlights financial improprieties at Mortenson’s charity, the Central Asia Institute, which Mortenson has used to pay millions of dollars for his book tours without sharing the proceeds of those books with his charity.  If you haven’t seen the segment, you can view it here.

These books are required reading for U.S. servicemen deployed to Afghanistan.  In the liberal-minded district where my children have gone to school, Three Cups of Tea is assigned almost every academic year:  it exemplifies the values of altruism and social service heavily promoted by its instructors and administration.  According to the teachers who assign it, this book is full of tales that should fire your idealism, inspiring you to emulate Greg Mortenson’s self-sacrifice and dedication to social service; it presents an alternative model to the egoistic, selfish approach to life that seems so prevalent in our society today.  My kids hated it.  My oldest son found it manipulative and preachy.

The 60 Minutes piece on Greg Mortenson’s fraud shows that he used his stories, retailed in two best-selling books and hyped with promotional tours and speaking engagements, to solicit donations to the Central Asia Institute, which he used as his own “personal ATM.”  Despite the way my own children felt about Three Cups of Tea, it apparently does the job Mortenson intended, for his charity has collected millions and millions of dollars in donations.  A look at some of his core stories — his founding myths, so to speak — will show why he has been so effective in bilking the public.

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When Is It Appropriate to Feel Shame?

In many of my earlier posts, I’ve written about the role shame plays in psychological and emotional difficulties.  I’ve discussed the fantasy flight into an idealized self in order to escape an unbearable sense of toxic shame; I’ve also tried to describe typical defenses against shame and frequently connect shame and narcissism, as I did in my post about Charlie Sheen .  In each instance, I’ve been discussing shame when it becomes toxic and thereby linked to different forms of mental illness; but is there a different type of shame, one that is non-toxic and in some sense “normal”?  Isn’t it appropriate, sometimes, to feel shame?

It seems that every culture (including less developed and non-Western cultures) includes ideas and codes of behavior related to shame.  According to Rochelle Gurstein in her book The Repeal of Reticence (1996), shame is always connected to physical exposure and vulnerability; it also “threatens to engulf us at moments when our biological reality — our ‘animal’ nature, as it is commonly called — overwhelms our ‘civilized’ self; that is, when we are too directly confronted with the body in its most physical aspects.”  She quotes Norbert Elias (1939), who held that “people, in the course of the civilizing process, seek to suppress in themselves every characteristic that they feel to be ‘animal.'”  The origins of the word shame — not only in English but French and German as well — are linked to the idea of covering up.  You may recall that, in the Bible, shame was born when Adam and Eve ate from the Tree of Knowledge, realized that they were naked and covered themselves to hide their nakedness.

So (putting it baldly) if a stranger were to walk in while you were on the toilet or having intercourse, you’d want to cover up; the feeling that motivates you is shame.  (This does not imply that we feel those activities are “dirty” or “bad” — a religious overlay — but that they should not be witnessed by other people; they are private.)  Apparently this sort of feeling in connection with the activities of our “animal nature” is to be found in virtually all civilized cultures, even primitive ones.  As they become “civilized”, human beings everywhere want to distinguish themselves from other animals on the planet, to believe we are on a different plane; when we have an experience that confronts us with the fact that we are not so different — that we, too, are animals despite all the trappings of civilization — we experience shame.

On the other hand — and I may be anthropomorphizing here — it seems to me that our dog Maddy on occasion feels shame, too.  Usually, she sleeps through the night without waking us and waits to relieve herself until morning.  But on several occasions when she was suffering some kind of digestive problem and couldn’t wake us up to let us know, she peed on the floor.  In the morning when we awoke and saw what had happened, she hung her head and slunk off to the closet — to me, the very picture of someone filled with shame.  This occurred without our saying a word to her, or attempting to humiliate her for losing control.  I’ve seen this with other dogs and heard similar stories from other dog-owners.  My theory is that Maddy feels shamed not of her animal nature but when she is unable to control her bodily functions.  Most human beings would also feel shame under those conditions.  Can you imagine how you’d feel if you lost control of your bowels in a public place?  This doesn’t mean that you should feel ashamed but that you inevitably would.

As Gurstein notes in her book, ours has become a society where this type of shame scarcely exists any longer.  If you suggest that some behaviors actually are shameful (that is, should be kept private), you will be called “uptight” or labeled a “prude”.  During graduate school, Gurstein studied with the historian Christopher Lasch, who famously wrote about The Culture of Narcissism (1979) and how individuals in modern American society, with a fragile sense of self, become obsessed with fame and celebrity.  Her own book shows how the “repeal” of social standards that used to preserve a realm of privacy around the transactions of our animal nature, particularly sex, has led to a debased public realm in which virtually nothing is held to be sacred and private.  She does not link the two themes — shame and narcissism — but I will do so now, expanding one of my central themes into the social realm.

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Do You Want to Be a ‘Good’ Person?

Many years ago, I was discussing religious beliefs with my friend Phil, a thoughtful man who believes in the God of his faith (Judaism).  When I told him that I was agnostic, that I didn’t really know what to believe about the existence of a supreme being, he asked how I could be a moral person.  I insisted that my lack of belief in the Judeo-Christian God didn’t mean I had no moral values, but he continued to wonder what force those morals could have without religion to back them up.

It’s an interesting question.  Phil’s position implies that morality has to come from the outside, from a greater authority or system of values to which we submit; without such a source of authority, he believes we would behave in an amoral fashion.  And yet I don’t behave that way.  By most people’s standards, I am a “good” person:  I’m a law-abiding citizen, an involved father, considerate friend and a psychotherapist who has helped many people in his career; I care about the welfare of my friends and family and do what I can to help them; I remember birthdays and write thank you notes.  In my financial dealings, I never take advantage of people.  If no God or religion is urging me to behave in these ways, then why do I do so?

You could argue that I’m nonetheless subject to authority in the form of values internalized from my parents and society at large.  This has to be true to a large degree.  It’s part of what Freud meant when he developed his theory of the superego.  That internal agency embodies attitudes and values we absorb from our parents, teachers and the people we’ve chosen as role models.  The superego is a kind of internal God, enforcing standards and punishing us with guilt when we fail to meet expectations.  Fear of internal punishment and guilt may, in part, keep me in line.

Beyond that, I believe two other factors lead to “moral” behavior:  empathy and enlightened self-interest.  First of all, I believe that the capacity to feel what others are feeling, to put yourself in their shoes and emotionally identify with them, is the basis of much behavior sanctioned by moral codes.  For me, and I suspect for a great many people, it’s more than a capacity; it’s an inclination, something that happens automatically, whether or not I intend to empathize.   Since humans are a social species and function best in groups rather than in isolation, it makes sense that we can empathize:  it improves communication and promotes social cohesion.  To be “moral” in this light is to behave in ways that benefit the family/group/tribe/species as a whole, rather than simply gratifying individual desires without regard to the feelings or needs of anyone else.

I confess that I feel a great deal of empathy only for those who are close to me and the strength of my empathic response diminishes with distance.  When I’m listening to a client in my office, sobbing over a major loss, my body will literally ache in sympathy.   When I see videos of the current suffering in Japan, I feel something, but it’s faint compared to what I feel for the suffering of my loved ones.  In other words, empathy (for me) has its limits for promoting moral behavior.   That’s where enlightened self-interest comes in.

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“Psychiatric Medications Have Led to Dramatic Improvements in Mental Health Outcomes” (Big Lie No. 2)

In continuing my discussion of Robert Whitaker’s Anatomy of an Epidemic from my last post, I begin with the results of a study on the use of anti-psychotic medication for treating schizophrenia; it is one of many such studies discussed by Whitaker which report very similar outcomes.  This study was funded by the National Institute of Mental Health (NIMH) and conducted at NIMH’s clinical research facility in Bethesda, Maryland.  According to Whitaker:

“[T]hose treated without drugs were discharged sooner that the drug-treated patients, and only 35 percent of the non-medicated group relapsed within a year after discharge, compared to 45 percent of the medicated group.  The off-drug patients also suffered less from depression, blunted emotions, and retarded movements.”  The investigators reported that, over the long term, the medicated patients were “less able to cope with subsequent life stresses.”

Study after study shows that, in the short term, anti-psychotics do reduce unrealistic thinking, anxiety, suspiciousness and auditory hallucinations, but in the long-term, they make those continuing on medication much more prone to relapse and re-hospitalization than non-medicated patients or patients given a placebo.   “Schizophrenic patients discharged on medications were returning to psychiatric emergency rooms in such droves that hospital staff dubbed it the ‘revolving door syndrome.’  Even when patients reliably took their medications, relapse was common, and researchers observed that ‘relapse is greater in severity during drug administration than when no drugs were given.'”

In other words, schizophrenic patients who received no medication had much better long-term results than those treated with anti-psychotic drugs.  This jibes with both (1) a historical comparison between long-term outcomes for schizophrenic patients prior and subsequent to the introduction of anti-psychotics; and (2) a comparison between long-term outcomes for schizophrenics treated with anti-psychotics in the developed world versus those in poor countries treated without them (much better).  Study after study bears this out.

In short-term usage, psychiatric medications for psychotic disorders have value in stabilizing patients and reducing the severity of their symptoms, but long-term usage makes those people more prone to relapse and “may prolong the social dependency of many discharged patients.”   And here is the tricky part:  If patients are withdrawn from their medications, they do poorly, then do better once they have been put back on those drugs.  For this reason, it appears to be proof that the drugs “work”; but do they only “work” in the sense that they ameliorate a problem created by placing the patient on those very drugs in the first place?  In study after study, it is patients given no medication whatsoever who have the best outcomes.

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