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I’ve started seeing a therapist. If you had told me 6 months ago that I would be in this position today, I would have called you insane.
I’m still fiercely critical of the “medical model” of mental health, and find much in contemporary “therapy culture” that is deeply disagreeable to me. You can’t manufacture human subjectivity on an assembly line. But, the fact that I’m seeing a classically trained Lacanian psychoanalyst rather than a more “mainstream” therapist is part of what allowed me to reconceptualize the enterprise enough that it became palatable.
I don’t have much of a point in posting this besides: if you feel like you’re stuck in a rut and things will never change, you can have hope. Sometimes radical change can happen very fast if you just give yourself a little push.
Keep in mind that tens of thousands of experts in a variety of fields over multiple decades and many paradigm shifts are actually thinking about this and working on epistemic certainty.
Not every therapist is academically minded (and many types of degrees don't engage with this at all) but despite anti-psychiatry people the field is more scientifically minded then you might imagine but it rarely comes out in frustrated opinions by people who are mad that things aren't going the way they them to.
For instance for nearly a hundred years, there was a pipeline from Psychiatry to neurology. Once medicine understood the disorder better (for example, Alzheimer disease) it moved fields. This means that Psychiatry is naturally left with the less understood stuff.
However diagnostic entities like Schizophrenia are pretty well understood with clear medical shit (such as direct identification of neurotransmitters and pathways).
The more common and less severe things (such as simple anxiety and depression) are less understood but you better bet that experts in the field have a decent enough understanding of what's a severe biochemically mediated depression and what's more likely to be SLS (shit life syndrome).
These conversations and investigations happen they just don't make it to you.
How sure are you about that? Skimming recent reviews, I'm seeing a whole lot of
The literature overall does seem extremely long on "medical shit" in the sense of suggestive genetic associations, claimed biochemical correlations and grand hypotheses, but still very short on clarity and well-verified soup-to-nuts pathways. It has the patina of science! that you'd get if you hit literally any biological thing with a bunch of GWASs, but what would be your cite for this being clear and well understood actually?
Yes I'm sure. Your linked quote is just filler words in an abstract, we know plenty about the pathophysiology of Schizophrenia with specific gene targets (although it is not fully understood), asking a question about the nigrostriatal pathway is a med student level question. It's likely appropriate to say that we have a better understanding of Schizophrenia than Parkinson's, and it's 100 percent appropriate to say we have better treatments. We understand Schizophrenia more than most of the dementia types (including the billions of dollars in research for Alzheimer’s). We understand Schizophrenia infinitely better than depression, which is why depression is a common topic when complaining about this.
Now do we understand it enough? No. We can reduce the risk of conversion from genetic risk to illness (ex: avoid weed) but not stop it, which would be the goal. But we can't also do that with Type 1 Diabetes or MS, and while we have an elevator pitch for what causes those now it's by no means a solved problem.
Schizophrenia in particular is unique in that the vast majority of cases are essentially a lifestyle disease problem - reducing morbidity and mortality is a matter of social solutions and ethics, the treatments are what we need already.
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I'm well aware that the field is very scientifically minded. In fact, that's the problem! It's too scientifically minded!
Science requires measurable outcomes. But human subjectivity can't be subjected to measurable outcomes. How can you quantify the value of a life, or a particular form of life?
I am personally unaware of any instance of someone visiting a (mainstream) mental health professional and being unable to walk away with at least something, whether that be a medical diagnosis of some sort and/or medication. It seems to me that virtually 100% of people who show up can at least get some SSRIs. How often do mental health professionals tell people "actually, there's nothing wrong with you and you don't need any treatment"? I'm sure it's happened before and I'm just ignorant. But it's incredibly striking that I cannot recall a single anecdote of this ever happening, meanwhile I can recall countless anecdotes of people getting prescribed SSRIs.
EDIT to try and lay my cards on the table a little more. I am perfectly aware that some people have very debilitating psychiatric conditions that prevent them from functioning, and modern medicine has produced at least some interventions that allow these people to begin functioning again, and it’s a real lifesaver in those cases, and that’s all great. I have no problem with that. What I do have a problem with is that large segments of society have been brainwashed into an almost cult like mentality that keeps them on the therapy treadmill for years because they’ve been lead to believe that any sort of pain or negative affect at all is pathological. No one ever sat them down and said “look, pain is a part of life kid, get used to it”.
High-quality care involves things like doing nothing, prescribing lifestyle interventions, and therapy as a first line and sometimes only line.
I know this happens. It really does, but -
Corporate medicine disincentivizes this - most physicians are owned now and most patients show up expecting medication and get mad if they are told to exercise to fix their mild depression.
The traditional model for mild to moderate pathology is that you sit down with a psychiatrist for 90-120 minutes, they get to know you, they talk through what you are experiencing and they try and address things without medication. Most physicians prefer this.
The current corporate model is that you show up, have a 20 minutes appointment, say you are depressed and want it fixed, and get prescribed Zoloft.
That absolutely does work for some people but it isn't great and it's something physicians don't have much control over and they do complain about.
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That doesn't matter. If he said he can come up with a better theory, but if all he's saying is that the current theories as garbage, there should be nothing surprising if he's right. There were times when science was so undeveloped that "thousands of experts in a variety of fields over multiple decades and many paradigm shifts" were doing little more than writing fanfics. Given the results psychology is delivering, his take being correct is what should be expected.
Ultimately the point is that the people complaining about the scientific state of mental health research don't really seem to know anything about the state of mental health research.
It's easy to grab one specific thing (commonly: the trans issue) and assume it's representative of the whole field but that isn't a fair conclusion nor is it accurate.
I see the same thing happen all the time with general medicine, people here often complain about their doctor being a barrier to the medication they want, and that's a topic, and a high frequency topic because outpatient medicine is a lot of medicine by number of patient encounters, but it's a very small portion of medicine by the number of jobs or specialties or research topics. Insight into that one specific issue does not provide a lot of experience with respect to the whole field.
Well, I freely admit it's been ages since I even tried skimming an actual paper, so my impression comes from feed scrolling, but wasn't there a "oops, SSRIs are no better than placebo" thing relatively recently? Isn't there still a 50+% replication failure rate?
The conversation about SSRIs is more complicated than just "such and such recent paper says X." But that's not the point. The point is that their is a variety of pathology in Psychiatry and the Psychiatry adjacent fields and focusing your thoughts on SSRIs and low severity pathology misses dementia, autoimmune encephalitis, schizophrenia, bipolar disorder, and so on.
If you are lucky all you have to think about is depression/anxiety/adhd/"autism spectrum" but that's not all the stuff!
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Congratulations! I once eschewed therapy, too, but after Serious Shit went down in my family a little over a decade now, I became open to the idea, even though it took almost six years and a total breakdown before I actually started seeing a therapist myself. In the almost five years since I started, it's become an integral part of my own life, and I'm not even sure that I'll be slowing down anytime soon. There's a strange sort of alchemy that happens when I'm getting my thoughts and experiences out of my own head and sharing them with someone that I can trust that helps me to understand myself, my choices, and my experiences much more fully. Minimizing that to the idea that I'm paying someone far out the ass to basically redirect me back towards taking care of my own self and making the choices that are best for me and damn the torpedoes really doesn't do the experience justice. I've thought a lot about doing an effortpost on this, but I have yet to be brave enough to do it.
This part I don't blame you for at all. I can understand why medicine seemed so promising 50-odd years ago when, "the screaming stopped," as the OGs used to say in reference to the efficacy of the first wave of antipsychotics. These days it's obvious that there's far, far more to mental illness than simple neurochemistry, especially when considering things like spontaneous-seeming remission of schizophrenia, but as always, the old joke about how many therapists it takes to change a light bulb is evergreen, and when it comes to treating symptoms, drugs are at least something, even if only a placebo. And as I said in this exchange, the narcissistic and personality disordered types have thoroughly weaponized therapeutic concepts for their own ends, which in a way is a sign of its success, but also deeply corrosive to the overall field. We have, IMAO, over-corrected.
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