I believe the question of whether to medicate or not cannot be kept separate from the question of whether or not to consider individuals responsible for their own state of mind, as well as their behavior. That in turn cannot be kept separate from the related question of what it really means for a human being to be “responsible,” and the question of how something that looks like “free will” emerges out of biological systems.
At this point in our culture, the majority of both the general culture and of the mental health industry have endorsed a paradigm that says that mentally healthy individuals are responsible for their mental activity, but that those who are “mentally ill” or who have a “biochemical imbalance” are not. The latter are advised to try drugs to correct the “imbalance” and to try more drugs if the first ones don’t work.
What is missing in this perspective is any sense that people can take responsibility for their own mental wellbeing and behavior, even after they have been overwhelmed by serious problems of some kind.
I would argue that this abdication of responsibility occurs not so much because we are a weak and lazy society, but because we have misunderstood what it means to be responsible in the first place. Because of this misunderstanding, when we try to be responsible, we are likely to do it in a way that makes us vulnerable to becoming overwhelmed, and then once we become overwhelmed we think this must be due to something wrong with us. This follows from our cultural belief that being responsible for oneself should be easy and simple, and not require contact with anything deep. The resulting sense of “something wrong with us” is then interpreted to be something chemically wrong, fixable by a pill, or perhaps by a dozen pills in an ever changing “cocktail.”
Simple systems operate in a linear, consistent and predictable manner. Many people associate “science” with boiling everything down to that which is simple and predictable. Our culture tends to assume that things operate in this fashion. But it turns out that only linear systems are consistently predictable, and non-linear systems, of which humans are an example, are not. Humans become even more unpredictable when they have been perturbed by major events such as trauma, or if they have genes that facilitate creativity, or when they are going through certain developmental stages.
If we ourselves are a non-linear, unpredictable system, how can we take responsibility for controlling ourselves? Certainly we cannot do this by applying any consistent formula, as any such formula could only work part of the time. If our nature is to be fundamentally mysterious, then how can we know for sure what it is inside ourselves we are encountering at any given time, and if we don’t even know what we are encountering, how can we respond to it in a way that allows us to be in control?
As a practical matter, responsibility is something that emerges in people over time. When we are children, our minds are a mystery to us, and strange things happen within them all the time. But we learn through a process of experimentation to respond to what is happening in our minds in a way that gives us a kind of control, within limits. Later, when we encounter new life events or new changes within us, we find we are going out of control again, but we again experiment with responding to what is happening, and find a new kind of control.
After awhile, we may learn to take this sense of being “in control” for granted, and forget that it is just the outer layer of a mysterious process that we will never fully understand. Then, when something changes radically changes inside us, maybe in response to some life events that we aren’t equipped to handle, or perhaps as part of a developmental process we don’t understand, we might be surprised to find that our existing ways of responding to ourselves don’t achieve a sense of being in control anymore, or even spin us further out of control.
What is critical at this point is how we, and others, interpret this breakdown in control.
There could be an interpretation that we are “bad” which means we deliberately decided to go out of control and cause problems, and we should be punished. At the opposite, and more medical, extreme, there could be an interpretation that we aren’t responsible at all, but since we have no responsibility, we need something external to us to take control over us – whether that be institutionalization or just control through drugs.
There is another option however. That is, we could make an interpretation that this lapse in self control is temporary, and that what is needed is experimentation to find out the best way to respond to this new and unexpected development within ourselves and our world. In other words, we could repeat the process that allowed us to develop self control in the first place.
When we accept that both our minds and the world outside of our minds are mysterious, then we accept that we don’t know for sure what it is we are encountering at any time. For example, we don’t know how much of what we see is because of our way of looking at things versus what things are “in themselves.” But what we can do is take responsibility for investigating, for having an I/thou encounter with what we find, which means experimenting, and that includes being vulnerable and being open to doubting ourselves. This means we consider the possibility that anything going wrong may be in our approach to what we encounter and not just in the “other,” or the fault may be in the way our conscious mind is handling things, we don’t just jump to the conclusion that there is an “illness” in us (or in the other) that needs to be medicated away.
What does it mean when a person can’t sleep, or has disturbing feelings, thoughts, voices, impulses or expressions? Where did they come from? What is to be done about them? Must they be eliminated, or are they in some way a helpful contribution, an indicator of something that needs to be attended to? When we can be curious about this, rather than have fixed answers, we can find solutions that match the particular person and situation.
Our culture needs greater awareness of the limits of our ability to make linear sense of things. The presumption of linearity is a key factor that has contributed to making it so difficult for people to see that psychiatric drugs are harming people. If something seems to make things better in a few weeks, then linear expectations would have us believe that the long term effect will also be good. But within a highly non-linear complex system, there is no reason to trust this will be true – in fact, the very linearity of the interaction, always the same drug effect, is actually damaging to humans who are nonlinear systems that need instead sensitive interactions with mystery, interactions with other non-linear systems such as other people, creatures, ecosystems etc. Drugs dull such interactions.
While “madness” may emerge out of the spontaneous experimentation of our minds, it turns out we need that same spontaneous experimentation in order to figure out a way of responding to what is happening in our minds. The mental health system instead pushes drugs reduce such experimentation – this causes the madness to appear diminished, but it also impairs the person’s ability to really regain a sense of responsibility and self control.
It is interesting to observe that none of us are as “in control” of ourselves as we think we are. Recent research shows that “by monitoring the micro patterns of activity in the frontopolar cortex, the researchers could predict which hand the participant would choose 7 SECONDS before the participant was aware of the decision.”
When we are aware of the limits of our own conscious awareness, we are more willing to be curious about what is happening within our minds, to learn about what is disturbing to us by interacting with it, forming a relationship with it, seeing what happens as we try various ways of responding to it. So what we take responsibility for is not somehow knowing in advance what to do (which can only be done with linear systems, which are predictable and “straightforward”), but rather for being curious, open to feedback, open to learning what works and what doesn’t, and also aware that what seems to work at first may actually be making things worse – the trickster spirit is alive and well in complex systems, despite our culture’s desire that he/she be banned!
Traditional explanations of inner experience in terms of spirituality often cultivated awareness of mystery. While it is not necessary to use traditional spiritual language or metaphors in order to develop understandings of ourselves, it is necessary, I believe, to acknowledge the reality of mystery if we are to effectively encourage a sense of responsibility within individuals and social groups.
Mystery and nonlinearity applies to our responsibility for interactions with others as well as interactions with aspects of ourselves. Parents for example should be prepared for unpredictable kinds of interactions. There is this expectation in our culture that if one follows some defined set of instructions, a “good” child should be guaranteed, unless of course the child has a biological illness like ADHD or bipolar! This belief system creates incompetent parents, parents who feel they have to make a choice between believing that they themselves are “bad” as in they failed to follow the linear instructions that every “good” parent should know, or believing that their child is “ill” and that care should be turned over to the psychiatrist for diagnosis and chemical repair.
In contrast, a parent who is aware that his or her child is a mystery, and is a complex and inherently unpredictable non-linear system, will instead approach signs of trouble with curiosity and an open mind. Such a parent will be open to feedback about what works with this particular child, and will always consider the possibility that if the parent and others communicated differently to the child, any problems might be resolved. This does not guarantee a positive outcome, because in non-linear interactions nothing can be guaranteed, but the chances of success are much greater. The child now lives in a world of human beings who respond to him or her in a way that models both self respect and humility, and out of such interactions, the child can learn to also have both self respect and humility, firmness and flexibility, etc. Problems do not entirely disappear, but become manageable.
Competent therapists are able to help people restore this sense of mystery, this willingness to engage. But therapists are often instead like parents who believe there should be some set of defined instructions that should always work, and if the problem doesn’t resolve by using such tactics, then the problem must be a biological illness, and the therapist isn’t responsible at all. Instead, what the person really needs is a medication check.
A responsible society would never be sure that particular “problems” exist within individuals; rather, it would always be open to the idea that it might be responding inappropriately to those individuals, and would be open to experimenting with doing things differently. Such a society would take more responsibility for preventing trauma in childhood, preventing other traumas like homelessness, and preventing coercive mental health interventions that create more trauma. And it would be aware that “quick fix” solutions could make things worse in the long run, and would take responsibility for noticing when that might be happening.
In the bigger picture, I believe we will never achieve this sort of responsibility until we accept our own mysterious nature. We are all unfathomable beings, that is, when we look deeper inside we always find something that contradicts what we just said or how we have been representing ourselves. But this condition we are in, where any time we “make sense” we are always leaving something important out, does not mean there is something wrong with us. It just means that we are human, we are complex non-linear beings who cannot be reduced to a formula. The more we believe we should be a certain way inside, the more likely we are to find something wrong with ourselves, and then to try to “straighten it out,” often with chemicals, and usually to our own detriment. The alternative? Accepting that we are mysterious, and taking responsibility for learning to live with it, and with the other mysterious beings with whom we co-inhabit this planet.
An interesting post! I have a few questions, though, as I don’t believe I’ve understood some of the points you raise completely. (Sorry for double-posting, if that’s the case, but the comment I just tried to post disappeared!)
1) Do I understand you correctly in thinking that no emotional state – regardless of its severity/extremeness – is ever pathological?
1a) If that’s the case, how do you define illness?
2) Can you explain in a bit more detail what you mean by the fact that““madness” may emerge out of the spontaneous experimentation of our minds”?
3) You say that “we could make an interpretation that this lapse in self control is temporary, and that what is needed is experimentation to find out the best way to respond to this new and unexpected development within ourselves and our world.” Do you believe then that it is at all times possible to formulate a genuinely adequate response to the event(s) which caused the notion of self-control to crumble in the first place? If yes, is such a stance defensible from a moral point of view?
4) If I understand correctly, you’re strongly discouraging the use of medication but you seem to approve of psychotherapy if “therapists are able to help people restore this sense of mystery”. But if no emotional state is pathological, if there’s nothing to treat, why the need for any sort of professional intervention at all? (Therapists are mental health professionals/experts just like psychiatrists.) Wouldn’t an empathic friend/peer/religious minister do just as well if not better? In what way are therapists any better equipped to deal with life, as it were, then anyone else?
5) And finally ? You say that “A responsible society would never be sure that particular “problems” exist within individuals; …”. Does that mean that you support constitutive evaluativist externalism, that is, the view that “disturbed behaviour is constituted in or by disturbed relationships” and that “[i]nterpersonal contexts are themselves literally pathological”, or a more middle-of-the-road view where the brain mediates such states? (See Thornton “Essential Philosophy of Psychiatry”, OUP, Oxford, 2007 as well as his blog post titled “Evaluativism versus objectivism”: http://inthespaceofreasons.blogspot.com/2011/12/evaluativism-versus-objectivism.html )
Cheers.
Hi Irene,
Thanks for your interesting comment and set of questions!
I wouldn’t define any emotional state as “pathological.” That said, it is certainly true that emotional states can be the result of some kind of pathology (having the flu can make someone cranky, having a brain injury can make a person quick to rage or something, etc.) And emotional states can certainly cause extreme problems when they are mismatched with the environment – if I am enraged at an innocent person or in the wrong circumstance I can do lots of damage, even though the same emotional state, matched with a different circumstance, might give me the intensity I need in some kind of emergency (that’s why we evolved to have emotions, after all.)
I don’t believe in calling mental or emotional states “illness” as I think that is a bad metaphor.
As far as madness resulting from spontaneous experimentation of our minds – a fair amount of research shows that when people are faced with a problem they don’t know how to solve in a straightforward way, they start experimenting with making less probable associations, and thinking in weird ways. Sometimes this results in a creative solution to the problem. Sometimes it just makes people see patterns where none exists, or it makes them superstitious or paranoid etc. This effect is found in people in general, but it is one hypothesis that “madness” results from more extreme challenges or when people who may have a tendency to engage in this process more extremely than do others (such as people with a genetic tendency to be more creative) experience challenges which go outside the ability of their normal ways of thinking to solve.
I do believe that, as you put it, “it is at all times possible to formulate a genuinely adequate response to the event(s) which caused the notion of self-control to crumble in the first place.” That is, it is at least possible to develop an adequate response, as in recovery is always possible, that doesn’t mean that everyone will necessarily manage to recover, even under favorable circumstances. I don’t think I know what you mean by your follow up question, ” If yes, is such a stance defensible from a moral point of view?” Maybe you could explain that to me?
While I wouldn’t call any emotional or mental state “pathological” it’s also true that lots of those states can cause problems, even extreme problems, if we don’t know how to respond to them. Two people might feel extreme rage or suspiciousness toward an innocent person: one person may act on it with horrible consequences, while another observes the emotion, explores its origin and comes to understand it, and makes a very different meaning out of it.
I’m not opposed to all use of medication, especially when we can’t think of any other way to keep a person safe in the short term, but I think we should always be aware of ways the medication itself may be impairing the ability of the person to come up with a better response to the troublesome emotional or mental state. Therapy is likely better for the longer term because it allows a person to develop such a response. And therapists don’t have a patent on healing relationships – friends or ministers or whatever are sometimes more helpful – but therapists who are good can often help with difficult mental and emotional stuff that might not make sense to many people not trained to deal with them.
I don’t have time to look into “constitutive evaluativist externalism” so I won’t say whether I endorse it or not. I do think that mental activity is all about interactions, complex nonlinear ones of course. The person interacts with the world, these interactions result in further interactions between parts of the person that happen internally (not just in the brain but in other parts of the body) and these interactions affect the way the person then interacts with others, etc., in complex feedback loops. When people are having mental and emotional difficulties, the people around them often end up responding in ways that make the difficulties worse, in what is called “parallel process.” I’m with the Open Dialogue people who say that problems like psychosis can’t really be understood as just happening within people. But I don’t think I can get into more detail on that within a comment…….
Ron,
Thank you for indulging me with such a comprehensive response!
Regarding my last question, I was somewhat confused as to what your view is on where the “pathology” should lie. In the paragraph beginning with “[a] responsible society would never be sure that particular “problems” exist within individuals; …” you seem to argue that the problem is not to be located within the individual herself but in the social/relational context. If that is so, I don’t understand how or why psychotherapy should work as you argue elsewhere in the post. If that is the case, the various psychiatric drugs should of course be of no use either. (In your answer to my original question, you endorse the view, if I understood you correctly, that If it is the social environment that is sick, psychotherapy, presumably then, would have no or a very limited impact on the difficulties being dealt with. What would be needed then are interventions that go beyond a single individual’s psychology and have the character of comprehensive social policies.
But if the pathology or the problems engendered by extreme emotional states [the view you support] is at least sometimes partly located with the individual, I don’t see how you position is significantly different from a bio-medical model of mental health that accepts social causes as well as the biological one. Of course, both your model and a medical bio-social model are diametrically opposed to a model that situates the extreme emotional states in biology alone.
Regarding the question about the possibility “to formulate a genuinely adequate response to the event(s) which caused the notion of self-control to crumble in the first place”, I think it’s rather controversial to claim that “it is … possible to develop an adequate response, as in recovery is always possible …”. By claiming that, you seem to tacitly accept the view that no kind of suffering and pain brought about by outside events could permanently “break the world” the individual inhabits. It also seems that you believe that suffering and pain can always be transcended and given meaning to, that is, that all suffering is inherently teleological. The meaning is therefore out there for taking, potentially within everyone’s reach. Although I’d agree with you that that may be the case most of the time, I’d disagree that such reasoning would and even should apply in the instances of extreme suffering, for instance, the experience many Bosniak women were subjected to during the war in Bosnia-Herzegovina where many were imprisoned as sex slaves by the Serbian army commanders and were raped and gang raped on daily basis, in some cases for months on end.
Hi Irene,
You raise some deep questions, so it does seem your comments are worth responding to!
As far as where the problem “really” lies, I think being confused may be the best response in many cases! The problems I encounter when I try to help people seem to be all over the place – inside people, in their relationships, in their families, inside the professional helpers themselves, in institutions, etc. But just because a problem may be in a family system doesn’t mean there also isn’t a solution that an individual might learn that would allow a positive and constructive approach, and wellbeing, even in the middle of the overall problem – so individual therapy can still work. And drugs can be “helpful” in allowing a person say to dullen their sensibilities enough to not be overly affected by a hostile system of some sort, even though a better solution would be to fix the system itself. It is the nature of complex systems that their are multiple ways to make them “work” as well as multiple ways they can go wrong.
We are all vastly imperfect beings, full of problems, and all of our systems, groups, families, societies etc. are also full of problems. We can find meaningful lives within them, but we can also work on changing them. The problems we experience inside us are often versions of the problems that exist outside, and it is also true that the problems we experience inside are often projected or broadcast outside of ourselves – as in one disturbed person throws a group into chaos! In real life, it is often difficult to see where problems started – each person is responding to some messed up thing others did – sometimes the answer seems to be generations ago, as in families still affected by the Holocaust or genocide against Native Americans.
I don’t have any argument against a bio-psycho-social model if that is understood broadly. (I wouldn’t call it a “medical bio-social model” because that seems to give some privilege to “medical” solutions, and I don’t think that is warranted.)
I don’t think I’m saying that no amount of suffering and pain can “break the world” of those who experience them. In fact, I think a lot of what happens in psychosis is that people experience their selves and their world to be broken into bits. But I am saying this does not have to be permanent: as long as the person lives, a new sense of self and world can be reborn. Recovery is still possible.
I think you are getting a bit ahead of me when you suggest I am saying ” that all suffering is inherently teleological.” I think what I’m saying is that we can invent a way of looking at things that gives it a meaning we can work with, that comes out of the process of experimenting I was talking about. I think others have written about the finding of meaning even in extreme situations: Victor Frankl’s “Man’s Search for Meaning” is a fine example. It’s hard to get more extreme than a Nazi concentration camp. But finding meaning is still possible, even if difficult. Of course, we are so much better off preventing atrocities if we can, but when we cannot, there are still options that people might find. (And options that people need to find, if they are ever to reconcile with traumatic memories, which often still exist as though they were happening in the present until the person finds some way to reconcile with them.)
A while back I wrote a little essay that also relates to meaning within trauma, it’s at
https://recoveryfrompsychosis.org/2011/01/trauma-psychosis-and-spirituality-whats-the-connection/
Ron,
Thanks for going into more detail about your thoughts on where the “pathology” lies – I see now what you were getting at in the original post, something that very much mirrors my own thinking on the subject.
I have to say, though, that I disagree with and forcefully resist the tendency to present the suffering of the victims and survivors of the Churben in the positive light only. I don’t understand why instead of engaging with the subject and perhaps acknowledging that a permanent loss of meaning is just as real and worthy a reaction, this rather unpleasant consequence of evil and extreme suffering is usually rationalised away. (I’d argue in the similar fashion for survivors and victims of extreme suffering and evil in general.)
Yes, you’re right in saying that Frankl managed to transcend his own suffering but it is perhaps more important to emphasise that none of the victims – some six million of them – did as all of them perished at the hands of the Nazis in ghettos, extermination and concentration camps, in the killing fields. It is also important to point out that not all survivors managed to achieve transcendence either: for every Victor Frankl there is a Jean Améry, Paul Celan or a Primo Levi, all of whom committed suicide. (I do understand that the fact of Levi’s suicide is a matter controversy, though.) I very much agree with Rosenfeld and Langer* on this subject in that such an inordinate tendency towards the positive seems only to sanitise what the nature and essence of the Churben was as well subject the actual suffering endured to cheep sentimentalisation.
Thanks again for an interesting debate!
* See, for instance, Langer, “Using and Abusing the Holocaust”, Indiana University Press: Bloomington, 2006; Rosenfeld, “The End of the Holocaust”, Indiana University Press: Bloomington, 2011.
I think we are getting to a point where we don’t really have any fundamental disagreements. I would very much agree with you that our first priority should be to help people avoid traumatizing events in the first place, as even if people survive physically, it may be that they will never recover in other ways.
However, I also think it is important to emphasize that it is still possible that they might recover a sense of meaning or even experience what some are calling “post traumatic growth.” Ideally, we will have a mental health system that knows how to make that more likely, after trauma and/or psychosis. I hear that you worry that this emphasis on the possibility of recovery will lead to minimizing the trauma in the first place – that is certainly something to avoid, but the opposite extreme, telling people that what happened to them is so horrible that there is no possibility of recovery, is not helpful either. The middle ground, which acknowledges the horror but also notices that recovery is still possible, is where I think we need to be.
Just a few corrections:
1) This sentence should have read as: (In your answer to my original question, you endorse the view, if I understood you correctly, that some of the problems are indeed situated in the individual for you say that “[t]he person interacts with the world, these interactions result in further interactions between parts of the person that happen internally (not just in the brain but in other parts of the body) and these interactions affect the way the person then interacts with others …”.)
2) … as well as the biological ones.
3) The meaning is therefore out there for the taking, …
Just wanted to great article/post/blog.
Thanks