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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.
Right, yes, I hear that you are asserting this. However, in skimming the literature I'm seeing lots of suggestive findings about genetic and environmental risk factors plus some very partial/local mechanisms, portions of which are being built into assorted models and hypotheses, all of which seem to be discussed with considerably more awareness of limitations than you use. The condition appears incredibly complex with neurodevelopmental, metabolic, immune involvement and I'm not immediately seeing anything that looks like a clear etiology that's supported by solid fieldwide consensus. However, I would certainly be very interested to learn about this if it exists.
Thus, could you help me understand what's going on, by providing the references you were thinking of when you initially said that schizophrenia was "well understood"?
My understanding is that the field believes that the majority of cases stem from a classic "2 hit" model. You have genetic load (with some of these genes being explicitly known) and secondary insult (with some of these insults being explicitly known, such as synthetic marijuana). Some of the details of what translates that into illness are less clear, but we can point to specific brain pathways and impacts on neurotransmitters, and this is extremely clear because of how clearly "traditional" antipsychotics work and how questionable most of the other treatments are (ex: Cobenfy).
Additionally we are talking about concerns about the medical model of mental health, with the implication being that the medical model doesn't have much to add or has some inaccuracy issues, but Schizophrenia is a good example of a disease that we know as much or more about than some "strictly medical" diseases - examples I gave were Parkinson's, Alzheimers, MS, DM1 (and sure in many ways DM2).
The existence of knowledge gaps doesn't mean we know nothing or that the models we do have have no utility, which is often the complaint.
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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”.
I think there are people, a very small number, have conditions that require therapy, and an even smaller number benefit from drugs. The problem I have is that the methods and techniques of therapy can and often do cause normal people to develop mental illness for the same reason that giving everyone statins would be likely to cause all kinds of health problems. Treatments don’t work on people who are not sick, and messing with healthy bodies makes them sick.
I think overuse of therapy and the invasion of therapy and therapeutic methods into mainstream culture is causing a lot of harm. It seems to cause people to be narcissistic and neurotic and to become chronic over thinkers in ways that create problems both for the individual and society at large. It’s lead to people choosing to turn their feelings into facts and thus operate in a way that makes their actual real life worse than it would be. If you cut everyone off you get mad at, or set yourself tons of boundaries, you’ll end up miserable and alone. If you quit jobs because you don’t like doing some unfun things, you’ll never build a basis for a career. If you only exercise when you feel like it, you’ll never do it.
CBT and DBT are the only two therapies that I think work well.
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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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