I am frequently fascinated and sometimes a bit horrified by the explanations that my clients give me to explain their feelings, thoughts and behaviours. The vast majority of these concerning explanations are steeped in a belief of ‘personal failure’, misattribution to ‘trauma’ and blaming ‘bad parenting’. While insufficient effort to change, traumatic experience and poor education can contribute to poor mental health, these are rarely the cause for someone to see me. It isn’t my client’s fault though. It is an artefact of how therapy has evolved. I see these same mistakes being repeated by therapists, online advocates and text books. They are all missing the key feature – biological causes require biological solutions.
Mental health evolved separately from most medical science. Running in parallel to cognitive therapy is medication and neurology. Dr Steven Novella, a neurologist, stated that “If we know what neurons are involved, it’s called neurology. If we know what medications help in the absence of the neurons, it is psychiatry. If we don’t know what medications help, nor what neurons are causing it, that’s called psychology”. Interestingly, neurological problems aren’t called mental illnesses, while both psychiatric and cognitive problems are. More on the medical side a bit later. First we need to understand what doesn’t work.
The evolution of treating “Mental Illness” in the absence of medicine started with religion, an morphed through “you have angered the gods”, “you are wrestling with your demons”, “you have a moral failing of your character” and “those who work hard get rewarded, those who don’t get punished – what did you do?” The solution was prayer, inner self searching and working harder. Failure to “heal” was defined as a problem with the patient, not the therapy. This holdover sounds like “I caused it/it’s my fault”, “I’m not good enough”, and my favourite “I’ll just try harder”. There is an element of truth to this, if you don’t want to change, I can’t change you with therapy. However, if you are trying and it isn’t working, then the method is wrong – work smarter, not harder.
Treating “Mental Illness” then went through blaming parents, sexuality, society and your own baser unconscious desires. Psychobabble was born to help confuse the patient so they didn’t realise that the therapist had no idea either, while a failure to progress was again put on the patient. Again, there is an element of truth here, bad parenting and societal rejection can create problems. These are fairly easy to correct for, so if a few months of effective therapy doesn’t help, it isn’t likely that.
Effective talking therapies, such as Cognitive Behavioural Therapy (CBT) and Trauma Therapy, are excellent at challenging erroneous beliefs and upskilling the person to improve their mental health. This only works if their mental distress is caused by a faulty idea, maladapted behaviour (the wrong lessons), or ignorance of a good solution. Additional features of good therapy include helping the person explore their experience and solution, education, upskilling and the actual support of the therapist.
As a therapist, learning to recognise when a person’s experience is caused by biology is really important. A biological cause needs a biological solution. No amount of talking therapy will fix the focal distance of your eyes, help your pancreas to produce more insulin, fix a murmur in your heart, heal a fractured bone, or balance the neurotransmitters in your brain. While talking therapies can help you manage these a bit better, they won’t give you a good health outcome without a medical component.
But what happens when CBT doesn’t help? What happens when challenging your core beliefs does not shift those same ideas that drive your behaviour? What if all of your behaviours are correct, and you have the core rational and logical helpful beliefs about yourself and society, yet you are still mentally distressed?
Therapists have tried many different models and theories to try to supersede CBT. Most of them don’t work, because they are just rehashing religion/ideology, victim blaming and psychobabble to pretend that they know what they are doing, while having no actual impact on why the person is struggling.
The “alternative therapy” models that do work are basically CBT Purple Hat Therapies. A Purple Hat Therapy is where something flashy and distracting is done, such as “please wear this Purple Hat”, while the real therapy is performed (such as CBT). You are then told that it was the Purple Hat that healed you. You only really notice the Purple Hat because it is different to what was expected and miss the real therapy you did. These do not perform any better than raw CBT.
Over the last century and a half, various medications have been found to help some very specific symptoms and “Mental illnesses”. Over time, investigations into what these medications do to our brains and bodies has revealed direct and indirect information about what is the biologic cause behind many labels of “Mental Illness”.
This should shift the category of these particular conditions (such as anxiety, depression, autism, adhd, schizophrenia, voice hearing, bipolar affective disorder and many more), from Psychiatry/Psychology to Neurology. But it hasn’t. These are still considered to be “Mental illnesses” rather than divergent neurology (Autism and ADHD) or a neurological condition.
With the recognition of what many of these medications do, and which medications work for which symptoms, we now know that many labels of “Mental Illness” are just the presentation of symptoms of some basic neurotransmitter imbalances. Anxiety Disorder, for example, is one of the symptoms of either too little of the neurotransmitter Norepinephrine (most of the time), or too much (some of the time). Other symptoms for the same biological cause (Norepinephrine imbalance) can be Aggression, Impulsiveness, Self-Harm, Suicidal Ideation, Rejection Sensitivity, OCD, Mysophobia (fear of germs), Social Anxiety, Sensory Hypersensitivity, Meltdowns and Hyperactivity to name but a few. While Norepinephrine isn’t the only thing that can cause these symptoms, in my experience it is the most common.
Despite our new knowledge, these symptoms continue to be given a “Mental Illness” label and are treated with talking therapy or the wrong medication. I have a client who has been through trauma therapy around 10 times with various therapists for their social phobia. Their treatment outcome was a belief that he wasn’t trying hard enough and thus he is to blame for not getting over his trauma. That really isn’t helpful. His GP treated him with the typical anti-anxiety medications, which don’t actually address the base cause. I identified that he was doing the right things as outlined by Trauma Therapy, and therefore his ongoing symptom was likely biological. With the cooperation of his doctor (his psychiatrist didn’t believe the model), my client began a biological remedy (medication) to treat his probable biological condition with a significant positive result. That is, it works. We are now trying to tweak the medication to give him 24 hour positive results instead of only 12 hours.
I can already hear the counter argument forming in some people out there. Let me address the most likely arguments.
What if he could just learn not to be socially anxious, isn’t no medication better? Yes, it would be better, if his anxiety was based on an idea and maladapted behaviours. It isn’t, it is caused by biology. We know this, because “educating” the client did not change their experience, so it wasn’t a lack of knowledge. If a neurotransmitter medication could give you that knowledge, I want to try the one that tells me how to do Kung-Fu.
What if he just wasn’t trying hard enough? Anyone that says “you aren’t trying hard enough to get over your anxiety” is arguing from a privileged position of never having experienced real anxiety. Laziness, willpower and effort is not the problem.
What if the medication is concealing rather than treating? Certain sedatives can block and conceal the route course of something like anxiety. This medication is not a sedative. It is actually treating the route course. Explaining exactly how that medication works is beyond the scope of this.
If all mental illness is just a biological problem, then why don’t we just give everyone medicine? For a start, not all struggles that people see me for are classified as mental illness. Secondly, for the same reason we neither give everyone insulin treatments (as not everyone has diabetes), the same insulin treatment (every person is an individual with diverse needs) and insulin treatment in the absence of education about what diabetes is and how best to treat it.
I’m going to say this again, for the people up the back who weren’t paying attention throughout this monolog.
Talking therapies are fantastic to help correct maladaptive behaviours, erroneous core beliefs and upskill ignorance. I use it frequently with my clients for when their mental distress is due to one of these. Learning smarter solutions to problems that have defied the person’s current skills is excellent and the base point of talking therapy. Good therapists are excellent at helping you keep on track and providing additional support when you need it. When this is all that is needed, well done, your job is done.
As a therapist, learning to recognise when a person’s experience is caused by biology is really important. A biological problem needs a biological solution. No amount of talking therapy will fix the focal distance of your eyes, help your pancreas to produce more insulin, fix a murmur in your heart, heal a fractured bone, or balance the neurotransmitters in your brain. Once the biological condition is stable, now you can see if further talking therapy is needed and get on with that. Then your job is done.
So please, stop victim blaming people for failing to will power their way through a biological condition.