Sunday, July 28, 2019

The Chemical Imbalance Imbalance

Kelli María Korducki is not a psychiatrist. She is not even a mental health professional. She is a consumer of the mental health treatment that is currently available in America and apparently in Canada. 

In today’s New York Times she offers a critique of the psychoparmaceutical approach to treating mental illness. She is not the first and will not be the last to emphasize that our current belief that mental illness is produced by a chemical imbalance has not produced very much treatment success.

We will note, as she suggests, that lumping all forms of mental illness in a biochemical mass fails to distinguish between those forms that are brain diseases or metabolic imbalances and those that are clearly not.

But then there’s the counterargument. Talk therapy, especially the kind proposed by insight oriented therapy, has never been very effective either. The world embraced medication because therapists were failing on their jobs. They were not curing or even treating much of anything. 

Korducki seems to believe that talk therapy is the solution to problems, but she does not distinguish the multitude of talk therapies. There is a significant difference between classical psychoanalysis and cognitive therapy. Without making the distinction the argument falls slightly flat.

At the least, Korducki offers a cogent indictment of today’s psychiatric profession, beginning, as she does with the advent of Prozac. Of course, it was not just the arrival of SSRIs but the way that psychiatrists and drug companies marketed them as the cure for whatever ails you. After all, one psychiatrist claimed that Prozac could make you into someone else. Overreach??

She writes:

The mainstreaming of S.S.R.I.s and other psychopharmaceuticals didn’t eradicate stigmas against mental illness, but it certainly normalized a sense of their prevalence. (A 2003 study concluded that child and adolescent psychotropic prescription rates alone had nearly tripled since the late 1980s.) It also shaped the tone of conversation.
No longer were mental illnesses necessarily discussed as a shameful aberration, but rather as chemically preordained sicknesses: functions of what became known as a “chemical imbalance.”

No longer a shameful aberration… that is a two edged sword. Attaching shame to mental illness would normally have served to bring people to their senses. It would tell them that they needed to change their ways, perhaps to improve their behavior. Removing shame from the equation shame allowed people to do as they pleased, when they pleased, with whom they pleased and not feel bad about it.

Psychiatry declared war on shame, but it did not understand that shame is our moral sense. When you feel ashamed you have probably done something that is shameful. To numb our moral sense, as the culture has, allows more bad behavior-- because the medications numb us to the normal emotional reactions.

Once Korducki figured out that the numbing effect of the drugs could not be sustained, she recognized that she bore some blame for her own conduct:

Internalizing my diagnoses as inscriptions of emotional destiny also alleviated my sense of personal blame for the inability to will away my black dogs. When the drugs failed to deliver the cure I’d been promised, I didn’t dare reveal my shameful secret: that maybe the issue wasn’t just with chemicals in my brain, but a bad and broken me.
Nearly two decades later, I quake with anger at the wholesale failure of mental health care in America — a rigid and restrictive system that leaves even the reasonably privileged, like me, with little to work with, and so many others with nothing.

Fair enough, the mental health system in America has been a colossal failure. Any time you hear a politician explain that we can solve all of our problems by offering more mental health treatment you should be thinking that, in truth, the treatment available today solves next to nothing.

In truth, psychiatrists do not know how to do talk therapy. They do not really care to do it. They prefer to do quick interviews and to write prescriptions. It’s far more lucrative because they bill a twenty minute interview  at roughly the same rate as an hourly consultation. Thus, by my math, this allows psychiatrists to triple their income… without addressing anyone life issues:

Psychiatrists are full doctors with the ability to issue diagnoses and prescribe medication. But these days, many of them spend much less time than they did in the past practicing psychotherapy, or what we might call “talk therapy.” Instead, they tend to meet with patients briefly and write prescriptions. As a result, “psychiatry” has more or less become shorthand for an industry of medication management.

Korducki continues to elaborate the potential causes of emotional distress:

The jury is out on the extent to which mental illness is hard-wired, but black-and-white narratives of psychopathology neglect the tremendous psychological impacts of social and material circumstance: access to the basics of survival; the burdens of intergenerational trauma and insufficient social support systems; the existential gut punch of pervasive injustice.

She is correct to explain that mental health is not just a personal or individual matter. A nation can become depressed. A nation can suffer humiliation. The result will be that individuals suffer mental illness, through no real fault of their own. Consider that the cure for depression is pride-- not hope-- and you will see that politicians' enhancing or reducing national pride will have a direct impact on the emotional well being of citizens.

Korducki errs when she tries to blame it all on injustice. She would do better not to blame it on capitalism… unless she can explain the state of mental illness in nations that have destroyed themselves and their people by undertaking lame social experiments.

She ought to emphasize that some part of people’s suffering derives from their own behavior and the behavior of their friends. Living a world where everyone is rude, crude and lewd does not help anyone to find emotional tranquility.

But, Korducki has drawn the correct conclusion from many of the extra-medical discoveries about mental health. She understands, as more and more people do, that exercise and diet and social connections are the best treatment for many forms of what are called mental illness:

I also make it a daily priority to get at least some light exercise, whether a walk or a jog or a bicycle commute. I maintain a regular yoga practice, try to eat a balanced diet and get enough sleep, read constantly, and work to nurture social connections and build community. All of these, I’ve learned, I can do to maintain my emotional and psychological well-being, and the key word here is “maintain.” It’s about process, not prognosis.

And also:

Rather than view my psychological experience as a biologically fated roller coaster, I’ve come to think of my mental health as a reflection of the complex ebbs and flows of life; accordingly, I’ve developed tools to better mitigate that which I can’t control, an agency I once wouldn’t have imagined possible. I feel, for the first time, like a person who belongs to the world.

My reservations notwithstanding, I welcome Korducki’s contribution to the debate.


UbuMaccabee said...

Light exercise? Try heavy exercise instead. Mark Rippetoe is a good place to start. Otherwise, good work, lady. And good luck.

“If you are going to do a thing, go whole hog, and never mind the postage.” G.G.

Sam L. said...

Talk therapy would do me no good. I'm known as Silent Sam. (I take after Gary Cooper.)