by Al Galves, PhD

The recent concern about the overprescribing of psychiatric medication expressed by Secretary of Health and Human Services Robert F. Kennedy Jr. has illuminated the anti-psychiatry movement in an unprecedented way.  The MAHA summit at which the concerns were expressed has been reported widely in the media and was followed by Daniel Bergner’s New York Times Magazine article entitled “The Strange Alliance Trying to Remake American Psychiatry”.  That article triggered numerous responses from psychiatrists and critics and, according to Ellen Barry of the Times, was much talked about at the annual meeting of the American Psychiatric Association.

This is a welcome development.  There has been a robust anti-psychiatry movement at work for the last 50 years.  It is comprised of psychiatric survivors, dissident psychiatrists and psychologists, journalists, writers and lawyers.  It includes MindFreedom International, Mad in America, the International Society for Ethical Psychology and Psychiatry and many ad hoc groups which are critical of mainstream psychiatry.  The movement has been operating under the radar.  Few people know about.  It has not been well-covered by the media.

What do I mean by “anti-psychiatry”?  I mean a skepticism about the belief that mental illnesses[*] are caused by brain disorders, chemical imbalances and genetic anomalies and that psychiatric medication is good treatment.  I mean a concern that the medications are harmful and that people seldom receive complete and accurate information about them when they are prescribed.  I mean a concern that appropriate, understandable, meaningful and potentially useful reactions to life experiences and life situations are being pathologized and considered disorders.  I mean a concern that variations in human behavior have been medicalized and turned into diseases.  I mean a concern that states are making it easier to involuntarily commit people to mental hospitals and force medication on them against their will.  I mean a concern that the payers for mental health treatment have privileged medication as treatment at the expense of more effective and less harmful approaches.

This skepticism and concern is not “pie-in-the-sky”.  There is evidence behind it.

The belief that mental illnesses are caused by physiological dynamics is not supported by sufficient evidence.  Neuroscientists have found associations between certain physiological dynamics and the symptoms of certain mental illnesses.  But they have no evidence that the physiology is primary, causal or important.  Given what we know about the stress response, blushing and voluntary movement it is more likely that the psychology, the mental and emotional dynamics are primary, causal and important.  Despite having spent billions of dollars on the effort, neuroscientists have not found any clear genetic explanations for any mental illness, nor have they found dependable physiological markers for any mental illness.

Psychiatric medication is harmful to people.  Antidepressants cause emotional numbing, sexual dysfunction, akathisia and increased risk of violence and suicide and can throw people into mania.  Antipsychotic medication causes tardive dyskinesia (Parkinson’s disease), brain shrinkage, cognitive impairment, increased risk of diabetes and early death.  Benzodiazepines (Valium, Xanax, Ativan) are addictive and extremely hard to withdraw from.  All psychiatric medications impair emotional processing, take way caring and blunt emotions.

The medicalization and pathologizing  of human experience has led people who used to be considered shy and reserved to be diagnosed with social anxiety disorder, people who used to be considered volatile and unpredictable to be diagnosed with bipolar disorder and people who used to be considered strange and different to be diagnosed on the autism spectrum.

The move by states to make it easier to lock people in mental hospitals and forcibly medicate them flies in the face of evidence that people are at much higher risk of killing themselves after being released from a mental hospital than at any other time.  Skepticism about the effectiveness of forced treatment is a no-brainer.  When treatment is being forced on a person, against their will, it is unlikely to be effective.

The payers for mental health treatment spend billions on medication, much less on psychotherapy and close to nothing on approaches proven to be effective, i.e. Soteria houses, Open Dialogue, supported housing, intensive case management.

For those of us who have been expressing our concern about the practices of mainstream psychiatry for 25 years, this concern about over-medication is the tip of the iceberg.  The much bigger problem is that the standard treatment for mental illness is medication and, in our opinion, medication is not good treatment for mental illness.  To understand why we believe medication is not good treatment for mental illness, consider these questions:

What is going on with people who experience mental illness?

What is mental illness about?

What is the meaning of the symptoms of mental illness?

What is the cause of mental illness?

Let me explain.  The symptoms of mental illness are moods, thoughts, emotions, reactions to emotions, intentions, perceptions and behavior.  There are many explanations for why a person is feeling, thinking, reacting, intending, perceiving or behaving in a way that leads the person to be diagnosed with a mental illness.  Following are some of them:

·       The person is suffering from a brain disorder, chemical imbalance or genetic anomaly.  Some kind of physiological dynamic is causing the problem;

·       The person’s diet is causing the problem;

·       The person has been damaged by some kind of environmental toxin, including prenatal exposure and complications during birth;

·       The person is experiencing a spiritual emergency;

·       The person has experienced a life-threatening trauma – rape, mugging, military combat, emergency surgery, a serious automobile accident

·       The person has suffered a devastating loss;

·       The person is facing an extremely difficult dilemma, a dilemma that has no good answer or solution;

·       The person is experiencing an extreme amount of fear and overwhelm;

·       The person has been so hurt, rejected, dishonored, discounted, made to feel inadequate that, in order to survive in this world with these human beings, a deep part of their psyche has created a fantasy world in which they can survive;

·       The person is suffering from troubling habits, i.e. learned patterns of negative thinking, impulsive reactions to life events, poor coping skills;

·       The person has been hurt by poverty, homelessness, lack of social support, exposure to violence or discrimination;

(The last six of these can be subsumed in this explanation: The person is reacting to their life experience and life situation and to concerns they have about their life and themselves).

How people understand the symptoms of mental illness, how they interpret them, how they make sense of them determines what they do about them and how they understand themselves.  Some examples:

·       If they understand them as physiological (brain disorders, chemical imbalances, genetic anomalies) they are likely to seek treatment in the form of medication and not likely to wonder much about the symptoms or use them to learn about themselves;

·       If they understand them as a result of poor nutrition, they are likely to change their diet;

·       If they understand them as some form of spiritual visitation, they are likely to turn to some kind of spiritual guru or practice;

·       If they understand them as a reaction to a life experience, life situation or concerns about themselves and their life, they are likely to seek help in the form of some kind of psychotherapy.

 So how people understand the symptoms determines the path they take.  This can make a big difference in their lives.  This is no small matter.  This is potentially life-changing.  How people understand the moods, emotions, thoughts and behaviors associated with diagnoses of mental illnesses is going to have a big impact on their lives.  It is going to determine how they understand themselves, how they manage themselves, the kind of treatment they seek.  And the kind of treatment they seek and receive is going to determine the degree to which they recover and go on to live healthy, productive and satisfying lives.

Americans are confused about this.  They are confused in their understanding of what the symptoms of mental illness are about, what they mean, what they are in essence.  Here are three pieces of evidence.  The first is the case of Simon Biles.  Biles won the Olympic gold medal in female gymnastics at the 2018 winter games.  She was the best gymnast in the world.  At the 2022 winter games she was a member of the United States Olympic team.  She told her teammates that there was so much pressure on her that she was not going to be able to perform well and, therefore, was not going to perform.  In the aftermath of that decision, the word went out that she was suffering from a mental illness and everyone seemed to accept that.  But wait.  Why add the idea or belief that this is a mental illness?  What she did was perfectly understandable and “normal” without adding the trope of “mental illness” to it.  She was under a lot of stress, so much that it was going to affect her ability to perform.  What is the purpose of adding the idea of mental illness?  Does it take away some of her agency?  She couldn’t help it.  She was under the influence of a mental illness.  Does it absolve her of responsibility for her decision?  When the idea of “mental illness” is added to it, it takes on the patina of something other than a reasonable decision by a woman who is under a lot of pressure and believes it will affect her ability to perform well.

The second piece of evidence is a series of interviews I did.  This wasn’t a scientific sample.  I sat in the back of a coffee shop and offered to interview patrons about mental illness.  Some of the ten interviewees were friends.  I asked them what they thought caused mental illness.  All of them gave me some kind of physiological answer.  It was a brain disorder, a chemical imbalance, a genetic anomaly.  I then asked them what they thought had triggered the change in the brain, the chemistry, the genetics.  They hadn’t been mentally ill and then they were.  What had happened?  They all said something happened to the person.  But, I said, you just told me mental illness was caused by some physiological dynamic and now you’re telling me it is caused by something happening to the person.  What is it?  They were all perplexed, taken aback, chastened.  So I asked them the third question.  Do you think there is a difference between how a person is reacting to a life situation and to concerns she has about her life, on the one hand, and a diagnosable mental illness, on the other?  They all said “Yes”.  But they had just told me that mental illness was caused by something happening to the person, a life experience.  They were confused.

The third piece of evidence comes from an article I read and a recent interview with a psychologist. Both reported that when college students begin to feel down, depressed, agitated, manic, panicky, anxious, they ask themselves: is this a response to my life situation, to what is going on in my life and my concern about that or is this a mental illness?  They think there is a difference between how they are reacting to what is going on in their life and to concerns they have about their life and themselves, on the one hand, and mental illness, on the other.  I believe that is a false dichotomy.  There is no difference between those two things.  Mental illnesses are how people are reacting to their life experiences and life situations and to concerns they have about themselves and their lives.

It is not surprising that the general public is confused about the nature of mental illness and, therefore, what is good treatment.  For 30 years they have seen television ads that tell them mental illnesses are caused by brain disorders and chemical imbalances and that taking a pill is good treatment.  If they have gone to psychiatrists, they have been told the same and been prescribed medication and nothing else.  But, somehow, deep down, they know this doesn’t make sense.  They know that the experiences associated with diagnoses of mental illness have something to do with people’s lives and their concerns about their lives.

In my opinion, the best way to understand the symptoms of mental illness is as a reaction to life experiences, life situations and concerns that people have about themselves and their lives.  Here is why.  If people understand the symptoms in that way, they have the power to do something about them.  They have agency.  They can explore the symptoms and use them to get to know themselves, to begin the lifelong task of developing a good relationship with themselves.  Through psychotherapy, they can develop some compassion for themselves and learn to use their thoughts, emotions, intentions, perceptions and behavior to live more the way they want to live.  (Full disclosure: I am a psychotherapist).  Let me say more about this.

In order to be mentally healthy, people have to be able to love the way they want to love, express themselves the way they want to express themselves and enjoy life the way they want to enjoy life.  When they can’t do that, haven’t been able to do that for a long time and are afraid they’ll never be able to do that, when they believe they just don’t have what it takes to do that, they become agitated, manic, angry, panicked, obsessive, depressed, anxious and psychotic.  They become mentally ill.  There is nothing mysterious or alien about it.  It makes sense that when people are afraid they will never be able to live the way they want to live, afraid they are fundamentally flawed, inadequate, not smart, personable, strategic, connected enough to make it in this life they would become depressed, anxious, panicky, manic, obsessive, unable to sleep, dissociated, even psychotic.  Of course, every human being is a unique individual so how a person reacts to her life situation and to concerns she has about herself and her life will be unique.  But following are some general ideas about how life experiences and concerns can be associated with mental illnesses.

Depression happens when a person loses something very valuable or has deep concerns about her life.  It doesn’t have to be the loss of a person.  It can also be the loss of a sense of security, a feeling of adequacy, a sense of certainty, a relationship, a job.  When a person has deep concerns about her life, depression can be helpful.  It forces the person to stop doing what they are doing, stop focusing outside in the world and, rather, take some time to focus inside, to deal in a serious way with issues of their life and of themselves. 

Social anxiety disorder happens when people don’t want to be around other people out of fear they will be rejected, put down, abused, misunderstood or fear about how they will react to any interaction.  In the case of one of my patients, her social anxiety was caused by the fact that, since she had been mistreated by people all of her life, she wanted to hurt other people and knew that wouldn’t work out well.

Mania occurs when a person has had a lot of pressure put on him to be very successful, exalted, outstanding and is unable to do that.  The manic episode gives the person the illusion of being very powerful, successful and exalted.  They can do anything and everything.  They are amazingly powerful, smart, capable. Or the manic episode may be a move out of the drudgery of everyday existence.  The person is tired of having to make the decisions we all have to make every day.  What am I going to do with my time, energy and money? The possibilities are endless.  But I can only do one thing at a time.  In a manic episode, the person believes he can do it all.  He doesn’t have to make those difficult choices.  In a manic episode, a person can avoid taking responsibility for making decisions and addressing the difficult, real problems of everyday life – dealing with love relationships, jobs, co-workers, bosses, children, financial difficulties, moral dilemmas, competing priorities.  Since we deal with these kinds of problems all the time, perhaps we lose sight of how difficult they can be.  They often involve conflict with other people.  They often require us to make decisions and choices that involve necessary losses and understandable regret.  Carl Jung one time defined mental illness as “the avoidance of suffering.”  People can be very creative in avoiding the difficulties of the real world. 

Panic disorder happens when a person is facing a difficult dilemma, a dilemma that doesn’t have a good solution.  It may have a better solution but not a good one.  It is such a difficult dilemma that the person doesn’t even want to be aware of it.  But the body is aware of it.  So the body gets revved up to deal with it and causes the symptoms of panic disorder.  Here’s an example.  A woman came to see me with her husband.  She was suffering from panic attacks.  I asked her if there was anything going on in her life that could account for them.  She said “No.”  We kept on talking.  It turned out that her son was about to be involved in the invasion of Iraq.  He was a foot soldier, would be engaged in mortal battle, at serious risk of being killed.  When she said that she began to cry.  She cried for a long time.  I helped her to be aware of her fear, to be with it and give in to it.  She never came back in.

Obsessive-compulsive disorder happens when a person overcontrols what he can control as a way of repressing the fear of knowing that the things which can really hurt him are out of his control.  The obsessive behavior is a way of gaining the illusion of control.  The excessive hand washing, checking and mental exercises are a way of dealing with the uncomfortable truth that we don’t have control over the things that we really need to be afraid of:  automobile drivers whose behavior may maim or kill us, natural disasters, airplane crashes, dangerous illnesses such as heart attacks, strokes, cancer and diabetes.  So the repetitive behavior gives him the illusion of having control over dangerous things so that he doesn’t have to experience the discomfort of realizing that he actually doesn’t.

Post-Traumatic Stress Disorder (PTSD) happens when a person has an experience in which she thought she was going to die and was unable to fight back or escape.  The symptoms associated with PTSD – recurrent and intrusive recollections of the event, efforts to avoid, activities, places or people which arouse recollections of the event, feelings of detachment or estrangement from others, hypervigilance – can be understood as helping the person avoid the psychic and physical pain of the traumatic experience and a reoccurrence of the trauma.  They also can be understood as a way of enabling the person to relive the experience.  It makes sense that people would want to relive traumatic experience.  Typically, people who suffer trauma carry some (usually irrational) guilt about it, believing that they somehow contributed to it happening or that they could have done something about it.  Reliving the experience holds out the possibility of resolving the guilt or imagining a different outcome, somehow making more sense out of the incident and coming to a more realistic appraisal of it.

Psychosis happens when a person who has been hurt badly – discounted, dishonored, rejected, made to feel inadequate, abused physically, verbally, emotionally – attaches his psychic energy to a deeper, more powerful but imaginary part of his psyche.  That move which is initiated by a deeper, healthier part of the psyche than the rational part is a move towards survival, healing and recovery.  In the words of John Weir Perry, a psychologist who spent a lot of time trying to understand the psyches of persons diagnosed with schizophrenia, “the psychotic process puts this power-oriented form of the self through a transformation that awakens the potential for relationship and gives it its rightful place in the structure of the personality and in the style of life.”

There is a caveat here.  I am not saying that these ways in which people avoid pain, protect themselves, feel more powerful and successful, feel more in control, face life crises, deal with difficult dilemmas, connect with divine presences are choices in the way we understand choice.  People don’t choose these thoughts, feelings, perceptions and behaviors in the way we understand the word “choose”.  Rather, these experiences are driven by a deeper part of the psyche, a part of the psyche that operates below the level of consciousness and that is fundamentally healthy.

I’m going to some length here because over the past 30 years Americans have been bombarded with the message that mental illnesses are caused by brain disorders, chemical imbalances and genetic problems.  That has introduced mystery into the nature of mental illness.  It has led people to believe mental illnesses are alien visitations, things that come out of the blue, things that are unrelated to the lives and concerns of people.  What is causing these brain disorders, chemical imbalances and genetic anomalies?  Part of my objective here is to give you a different idea, to help you understand there is nothing mysterious about mental illnesses.  They are how people are coping with their lives, how they are reacting to their life experiences and life situation and to concerns they have about their lives and themselves.

What evidence is there to support this idea that mental illnesses are how people are reacting to their lives and to concerns they have about their lives and themselves?  Here is one piece of evidence.  People who have certain characteristics are more likely to be diagnosed with certain mental illnesses than other people.  So people who have the following characteristics are more likely or less likely to be diagnosed with depression than other people:

·       People who derive their sense of self-worth from social relationships and have experienced an interpersonal loss;

·       Women who use a ruminating style of thinking;

·       People who score low on self-esteem and high on stress;

·       Persons who score high on a Self-Defeating Personality Scale;

·       Persons who suffer from chronic pain;

·       Persons with less emotional strength and resiliency and lower levels of ego control;

·       Persons who experienced poorer pre-morbid functioning – particularly adolescent social functioning.

Following are the characteristics of persons who are more likely to be diagnosed with bipolar disorder:

·       Difficulty in realistic goal-setting;

·       Low in persistence and conscientiousness, high in neuroticism and openness to experience on the Eysensenk Scale;

·       Low in self-complexity and, therefore, more susceptible to mood swings in response to life events – especially intensely dependent relationships which are disrupted;

·       Deficient in tasks  requiring response inhibition, delayed gratification and sustained attention;

·       The ability to hold antithetical and contradictory ideas or concepts in their minds at the same time;

·       Tendency to deny the experience and necessity of loss;

·       Tendency to see things as either black or white, good or bad, not able to see the greyness of things, thus vulnerable to extreme swings of mood in response to minor triggers in the environment;

·       Have been betrayed by a significant parent figure and are compelled to force the parent to love them again.

·       Have lost the esteem of a loved person and deny it through regression to a stat of not having to make the choices that are required in maturation.

Following are the characteristics of people who are more likely to be diagnosed with psychosis:

·       People who have suffered emotional, physical or sexual abuse, especially in childhood;

·       People who have experienced 7 or more adverse childhood experiences, i.e. childhood physical abuse, childhood sexual abuse, childhood emotional neglect, parental loss, mental illness in household, substance abuse in household, , criminality in household.

This is evidence that the experiences people have had and the personality characteristics which have resulted from those experiences have a significant impact on their chances of being diagnosed with a mental illness. This is evidence that the moods, behaviors, thoughts and emotions associated with diagnoses of mental illness are not alien visitations.  They are understandable and meaningful reactions to peoples’ life experiences, life situations and concerns they have about their lives, the world and themselves.

There is another reason why how people understand mental illness makes a difference.  How they understand mental illness determines the kind of treatment they seek.  If they think it is an alien visitation, something that came out of the blue, the result of a chemical imbalance, brain disorder or genetic anomaly, they are likely to seek treatment in the form of medication and less likely to seek treatment in the form of psychotherapy.

In my opinion, the benefit-risk ratio of treatment with psychotherapy is much better than the benefit-risk ratio of treatment with medication.   Here is my assessment of those benefit-risk ratios:

Treatment with medication

Benefits:

You may feel somewhat more energetic and alive if you take an upper like Prozac, Paxil, Adderall or Ritalin or somewhat less anxious and agitated if you take a downer like Ativan, Xanax, Zyprexa or Risperdal.  In the case of antidepressants the research says that the feeling better is largely due to the placebo effect but, nevertheless you may be feeling better. 

In the case of antipsychotics like Zyprexa, Abilify, Geodon and Risperdal, the medicine may bring you down enough so you will feel less afraid and be more able to engage in conversation.

Risks:

You’ll suffer from serious “side effects” including increased incidence and risk of:

Sexual dysfunction

Akathisia – extremely uncomfortable and dangerous restlessness

Mania

Violence

Suicide

Emotional blunting – loss of conscience and caring

Depersonalization – a sense of loss of contact with yourself

In the case of antipsychotics “side effects” include:

Tardive dyskinesia – a Parkinson-like loss of control over muscles and gait.

Cognitive impairment

Brain shrinkage

Early death – persons who take antipsychotics die on average 25 years younger than people who don’t take them

If and when you stop taking the medicine you will suffer serious withdrawal effects.  In the case of anti-anxiety medicine such as Ativan and Xanax, that can involve years of debilitating recovery.  In the case of antipsychotic medicine you may experience supersensitivity psychosis. This is because the medicine has caused your brain to compensate for the reduced dopamine by increasing the density of dopamine receptors so, when you stop taking the medicine, your brain will be supersensitive to the increased dopamine. Since the medicines you are taking act on the brain in the same way that cocaine, heroin and meta-amphetamines act on the brain, you will suffer the same kind of withdrawal effects as do persons who use illegal drugs.

If and when you stop taking the medicine you are likely to experience a relapse of the symptoms that led you to seek treatment.

Treatment with psychotherapy:

Benefits:

You will get help in

·       Understanding your symptoms and in using that understanding to develop a good relationship with yourself, i.e. to get to know yourself; 

·       Gaining self-management skills and knowledge that you will be able to use for the rest of your life; 

·       Understanding what makes you tick;

·       Understanding why you do what you do and don’t do what you don’t do;

·       Becoming aware of what you want and don’t want;

·       Developing compassion for yourself;

·       Becoming aware of the beliefs, assumptions, attitudes and habits which drive your behavior but which lie below the level of your consciousness;

·       Learning how to deal with the difficult dilemmas we all face from time to time;

·       Becoming able to connect with others in satisfying ways without giving up too much of yourself, 

·       Managing your fears so that you can avoid what you need to avoid and walk with the fears you need to walk with;

·       Becoming more accepting and comfortable with parts of yourself that are scary, painful and shameful and which have been taking lots of energy to hide from yourself and others;

·       Learning how to become more aware of what you want and how to get it without threatening your relationships and;

·       Becoming more able to use your strengths, talents and faculties in satisfying and contributing ways. 

As you learn how to manage your thoughts, feelings, intentions and perceptions in healthier ways, your brain will change in beneficial ways.

Risks:

You might waste some time and money.

You might receive some advice or messages that will get in the way of you becoming healthier and which might send you down the wrong path for a while.

You will likely experience some painful emotions in the process of accepting what is true about yourself and your life, recovering from trauma and getting to know the parts of yourself that are perverse and troubling.

There is evidence that treatment with psychotherapy is more effective than treatment with medicine.  In the case of depression patients treated with psychotherapy and medicine report similar levels of improvement but the ones treated with psychotherapy have a much lower relapse rate and their improvement is more long-lasting.  In the case of people experiencing psychosis the evidence tells us that people who never take the medicine or stop taking it have a much higher rate of recovery than people who take the medicine and stay on it.

In my opinion, the worst way of understanding the symptoms of mental illness is as a result of brain disorder, biochemical imbalance or genetic anomaly.  If you believe that, you believe you have no control over the faculties you use to live your life.

The logic goes like this:

The symptoms of mental illness are moods, thoughts, emotions, intentions, perceptions and behavior.

You believe that mental illness is caused by brain disorder, biochemical imbalance and genetic anomaly.

Therefore, you believe your thoughts, moods, intentions, perceptions and behavior are caused by brain function, biochemistry and genetic dynamics.

You don’t have control over your brain function, biochemistry or genetic dynamics.

Therefore, you believe you don’t have any control over your moods, thoughts, intentions, perceptions or behavior.

That is a very cynical and disempowering belief.  You believe you have no control over the faculties you use to live your life.  You believe you are at the mercy of physiological dynamics over which you have no control.

There are other reasons for my belief that this is the worst way to understand the symptoms of mental illness.  This belief makes it unlikely you will explore the symptoms and use that exploration to get to know yourself better.  That is a great loss.  You will also lose the opportunity to get help from a therapist in learning how to use your thoughts, emotions, moods, intentions, perceptions and behavior to live the way you want to live.  That is also a great loss.

Here is the bottom line. Given the present state of scientific sophistication, we are not able to determine through scientific investigation which is the most valid way of understanding the symptoms of mental illness.  Therefore, perhaps the best answer to this dilemma is one suggested by Bradley Lewis in his book Moving Beyond Prozac, DSM and the New Psychiatry: The Birth of Postpsychiatry.  When faced with research findings for which there are various interpretations, Lewis says, we should choose the interpretation which is associated with the best outcomes for people.  We should take a practical approach in the good, old tradition of American pragmatism.        If we did that, we would clearly choose to understand the symptoms of mental illness as reactions to life experiences and life circumstances and concerns that people have about their lives and themselves and we would treat them with various forms of psychotherapy – not just meeting with a therapist but also support groups, supported housing, mindfulness meditation, yoga, dance therapy, music therapy, art therapy, help with finding something meaningful to do, help with connecting with other people.