Therapy and Non-Therapy Options for the Emotionally Distressed (It ain’t brain science!)

The New Yorker designated its July 10-16 edition as “The Therapy Issue.”

It pointed out a strange anomaly for our time. We are dedicated to mental health treatments: “If our current moment has a defining impulse, it’s the drive to feel good again. The language of the therapist’s office percolates into our everyday conversations.”

“And yet, after the pandemic, many remain sick, isolated, and out of sorts. Each week seems to bring alarming new headlines warning of widespread distress and loneliness, especially among adolescents.”

What’s going on? “Perhaps our fixation on therapy is as much a symptom as it is a cure.”

But who can question the focus on therapy? “Now we’re in a situation where everybody loves therapy, and it’s seen as the quickest path to healing, and you’re absolutely unreconstructed and unreformed if you resist it at all.”

How’s that working? Are there alternatives?

The Failure of American Psychiatry

The primary article in the issue was “What COVID Revealed About American Psychiatry. The pandemic destabilized us—and exposed the fractures in our country’s approach to mental health.”

That sounds ominous!

First, very importantly, the article establishes the three pillars of the mental health system:

Psychiatry is composed of three intertwined enterprises: community care for sufferers; a medical specialty devoted to diagnosing and treating patients; and research programs focused on mind/brain science.

But of these three, the last — in the form of neuroscience research — is by far the biggest attention grabber.

And how is it doing?

All these changes were accompanied by publicity campaigns attacking stigma. Mental disorders, we were reminded on billboards and in commercials, were no different from diabetes or any other illness. This work paid off. Today, princes, athletes, senators, and celebrities no longer hide their psychic struggles. And so, paradoxically, around three decades ago, as our commitment to care for the poor and uninsured evaporated, clinical psychiatry could boast of increased social acceptance and tools that were more effective than ever.

That’s certainly encouraging! And it was part of a great American bipartisan mission. Now what did that amount to?

Many disorders remained far from cured; some were fully treatment resistant. But, for those patients, there was still hope. Psychiatry’s researchers were tasked with discovering the causes of these disorders. It was a gargantuan job, and a lot depended on its success. . . . During the nineties, which President George H. W. Bush declared the Decade of the Brain, hundreds of millions of dollars were directed to the NIMH (National Institute of Mental Health) in that effort.

The first target was the mapping of the human genome, and the search for genetic determinants of mental illness:

As the Human Genome Project launched, and brain-scanning technology leapt forward thanks to functional MRI, pressure to find genetic and brain signatures for psychiatric illnesses grew. Yet, as the new millennium commenced, a specific scan for disorders such as schizophrenia remained elusive. Dreams of single genetic causes were dissipating. A crisis was brewing. . . ,

It turns out we can’t really use genes to understand and to cope with mental illness:

But other, more common conditions, such as schizophrenia and bipolar disorder, can only partly be predicted in terms of genetic risk, and, in most other forms of mental illness, genetic determinism further diminishes. . . .

Since then, this new paradigm has powerfully altered what psychiatric scientists look for—and what they look past. For example, researchers have discovered hundreds of genetic loci associated with schizophrenia and with major depression, and more than fifty for bipolar disorder and autism. Each time a new correlation is found, geneticists celebrate. But (according to genetics advocate E. Fuller Torrey). . “They have identified a lot of risk genes, not any that cause a disease, . . . . That’s very embarrassing to them.”. . .

To fully understand those diseases, we have to start looking to the next ring in the target. What else might be at work?

That sounds challenging. But neuroscientists were ready for the task:

We may now take aim at neurons, then jump out to neural circuits and networks, then to the entire brain with its hundred billion neurons and trillions of synapses. At any of these different levels of biology, a pathogenic event might disrupt us.

Enter the champion of the new neuroscience approach, Thomas Insel:

In 2002, at a moment when the clinical promise of the Decade of the Brain remained unfulfilled, it came time to choose a new NIMH director. Thomas Insel, a leader in the quest to find biological explanations for complex behaviors, got the job. Insel was brilliantly successful, famous for illuminating the role of the hormone oxytocin in eliciting bonding behavior in voles—an important finding in the emerging field of social neuroscience.

So where have we ended up, with all three prongs of the American (and the world following our lead) attack on mental illness, led by Insel and neuroscience?

“Insel left the NIMH in 2015. . . . In a 2017 interview, he elaborated on his departure.

I spent thirteen years at NIMH really pushing on the neuroscience and genetics of mental disorders. And when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness. I hold myself accountable for that. . . . I think it became an academic exercise. . . . You want to pick up measures that actually are of value to patients, families, and providers. And [the research program] got way too complicated. It wasn’t really tied to clinical outcomes in a way that would matter.

Twenty billion dollars in useless (for any practical purpose) expenditures! And Insel got out of town before the sheriff arrived. I mean, what does his being “accountable” mean?

What about one of the other pillars, the community approach?

Western nations built asylums that were mostly justified in humanitarian terms, but those places of respite eventually became too-big-to-care institutions that warehoused and brutalized their occupants. In postwar America, as the welfare state came under increasing attack, and criticism of these so-called snake pits grew louder, state asylums closed. The sickest and poorest never made it to underfunded—or often unfunded—community mental-health centers. With the emergence of managed-care insurance, in the nineteen-eighties, shockingly short in-patient hospital stays led to still symptomatic patients’ being routinely discharged to the street or swept up into prison. There wasn’t funding for anything better.

Uh-oh — sounds like we’re in trouble! And we are. The neuroscientific approach has drained resources from human institutional approaches — intentionally so:

In the eighties, Senator Pete Domenici, a loyal supporter of mental-health efforts, told the Stanford neuroscientist Jack Barchas—a point person in the effort to stop cuts to mental-health spending by the Reagan Administration—that, although the country could not afford to care for all of its mentally ill, it could support finding cures for their diseases. . . .

This shunting off dealing with human beings and their actual lives has accelerated.

[In the US] during the past few decades, each [of the three prongs] has gone its own way. This fragmentation has been dramatic, tragic, and certain to compromise our capacity to respond to the post-covid crisis. . . .

What Works?

What would an alternative approach be? Perhaps dealing with human beings in a kind, concerned, connected way in a comforting setting?

Sound like a good idea?

It’s being tried, as another article in The New Yorker described, as applied in the ER system that deals with so much of America’s mental health crisis: “Reinventing the ER. For America’s Mental Health Crisis. EmPATH Units are advancing a radical new approach to psychiatric emergencies.”

This article describes the stressful, alienating experience of entering the ER for a mental health crisis, where people wait to be seen by specialists. Instead, the new approach (EmPATH — like “empathy”) groups them in a pleasant environment with food and diversions that calm them down. They talk to caregivers who have empathy and listening skills, and invariably they can go home calmer and have better outcomes going forward.

(In some, more severe cases, medications and overnight stays may be provided.)

What might we call this approach? Humane? Sensible? Based on the fundamental principles of what we know works with human beings?

Let’s turn briefly to a third article in the series, which deals with media representations of mental illness and its treatment: “We Have Reached Peak Therapy TV. Three critics discuss the changing role of the therapist on television, from Frasier and The Sopranos to Shrinking and Couples Therapy.”

Americans are now more comfortable with therapy — “And in the backdrop of this boom is, of course, the destigmatization of mental illness in the broader culture, as well as the rise of therapy-speak.” Yet as the whole therapy series is meant to convey, we are not a happier, mentally healthier society as a result.

Not only have we seen more shows dramatizing therapy but we’ve also seen shows in which therapy is less of a plot point and more of a shorthand for a character dealing with mental and emotional pain. Mental and emotional pain have become more prevalent as character traits in general. So maybe that’s partly the reason for the surge. First, there was this idea that characters needed to have traumatic backstories to be real, to be deep, and so perhaps it was inevitable that the next phase would be these people examining their pasts.

We won’t go into that here, other than to cite one offhand comment in the media article, about Ted Lasso: “Thinking about Ted Lasso, it seems like the past ten years of TV have seen the transition from journeys of transgression and dysfunction to journeys of redemption and healing. . . . Broken people are hurting, but, by gosh, they have soul and spirit, and they’ll get where they need to go.”

Conclusion

We can derive five critical points from the New Yorker discussions:

1. Why, after 40-50 years of research and therapeutic innovation, is Americans’ mental health worse than ever?
2. Real world crises (Covid) impact people so dramatically they leave research and therapy in the dust.
3. People want, seek and respond to real human contact and practically oriented help.
4. They also long for hope and inspiration.
5. Is what emerges from all of this really “therapy” as a detached medical specialty — or almost the reverse (represented by EmPATH) — basic human care and concern in a supportive, positive environment?

This is the Life Process Program approach.

 

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If you enjoyed this blog, you may also enjoy our latest podcast episode, in which we discuss this New Yorker series, and what makes for helpful therapy and interventions. 

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