The Things We Do and Don't Diagnose

The trouble with the mental health industry is that it is a symptom of the disease it is trying to fix. Part hierarchical bureaucracy and part Linnaean catalogue of cultural artifacts that it calls disorders, mental health tries to reduce the ailments of the human condition to a list of criteria and numbered categories. If an industry could be said to have a memory, the mental health industry has forgotten that a lot of our problems today come from having already been objectified and categorized far too much in our linear worlds, and that you can’t classify feelings and moods the way you might with medical ailments such as Covid or a broken bone. I’m not saying there is no such thing as a mental illness, it’s that the lens through which our culture sees mood issues has some glaringly missing pieces. 

 The standard mental health model starts with the dodgy premise that depression, for instance, is caused by a genetic predisposition that leads some brains to make insufficient amounts of serotonin to keep them topped with happiness. The patient will be told, “you have a chemical imbalance,” to which the patient might think, “ah, well at least I finally know what is going on,” and this is followed by the wonderful news that this imbalance can be redressed through the judicious dispensing of mental health drugs. These drugs, usually the SSRIs, work on neural receptors to keep serotonin, the happy neurotransmitter, around in neural synapses for longer than usual. Except that brains adjust to the superfluity of serotonin over time by reducing the number of all receptors, so that things go back to the previous stasis, and if you try to go off this SSRI, you will have less serotonin and other neurotransmitters in your head than before. Plus, SSRIs don’t work for 40% -60% of people, implying that those folks for sure never had an imbalance in the first place.

 False theories persist when they serve someone’s needs, and here they serve the needs of a profession that wants to give patients a simple, plausible story of how they got sick and how they will get better. The moral at the end of the story is Prozac or one of its near neighbours. And the myth of course suits the needs of the pharmaceutical industry, which makes out like a bandit. Best of all for them, those lacunae, the missing pieces of the puzzle, stay firmly in the shadows.

 Fannie Lou Hamer said that “nobody’s free until everybody’s free,” which is not a new idea. Mikhail Bakunin, in the middle of the 19th century said, “I am truly free only when all human beings, men and women, are equally free. The freedom of other men, far from negating or limiting my freedom, is, on the contrary, its necessary premise and confirmation.” It is a catchy idea, and since the “I” in question might be a quite wealthy or powerful person, how exactly are they not free? Both Hamer and Bakunin were diagnosing an entire society, meaning that the slave owner as well as the slave is in chains, or what William Blake called the “mind-forg’d manacles.” And not wishing to ladle on too many quotes at one time, it was Rousseau who said that “man is born free but everywhere is in chains.” And we can say that this person in mental chains cannot be truly happy, no matter how well their serotonin is getting topped up.    

 A step in the right direction, replacing the defective brain mechanism theory with something that comes from our own lives, is the trauma-informed way of working with people. Trauma-informed theories quite sensibly say that if you have been through a terrible experience it can mark you for life, until you find a way to address it and heal. But the trauma theory soon starts to fray at the edges. Trauma theorists had to quickly distinguish between what they call “big T trauma” and “little-t trauma.” Big T trauma is the kind of event that no-one would give you an argument over as trauma – abuse or some kind of terrible event. Little t trauma is where the fraying begins. It starts off fine – let’s say you have a parent who was cold, neglectful and non-responsive, they can do just as much psychological damage as a parent who exploded with rage and hurt the child in discreet incidents. Big T – a physical attack, little t, night after night of being ignored and made to feel worthless. But where exactly does little t end? Some parents are not so much neglectful, they are working three jobs to keep their kids fed and come home exhausted. Some children are far more sensitive to shortfalls in parenting than others. That means that the same “developmental traumas” affect different people in totally different ways, until you’re not quite sure what the trauma was at all, It’s  just that something happened to a person, perhaps the slow drip, drip, drip of not being treated like a someone who was worth listening to or worthy of serious attention. Bad? Yes. Traumatic – well the word starts to lose its meaning.

 Monty Roberts, in Join Up: Horse Sense for People, describes how a horse, early in life, saw a bright red hat stuck to a bush on a certain trail, got spooked and reared up. Ever after that day, the horse would be skittish around that same spot, even though there was no red hat there any more. I don’t think it would be a useful template for us to say that the horse had a small t trauma, it’s just that horses behave that way, and given that they evolved as prey animals, it’s not irrational of them. Humans, similarly, develop belief systems as children that just seem to stick around and become frozen in time inside us, whether it’s that the world is a safe and wonderful place, or that you can’t trust those bastards out there. Sadly for us, the latter is more often the rule, and though mistrust, fear, loneliness and so on are all too common, they aren’t necessarily the result of what we would sensibly call trauma. They may just be the result of a family that couldn’t be perfect or even near perfect, and was passing on belief systems based of fear, domination and aggrandizement that had been going on for ten thousand years.

 The trauma theory is a step in the right direction, because it places human suffering in the arena of human affairs, our actions and inactions, rather than in our brain chemistry. The brain chemistry theory lets far too much off the hook, even though we do have brains and they are made of chemicals. The vital missing factor here that I have been referring to is alienation.  Herbert Marcuse, a critical theorist who came to fame in the sixties said in his critique of psychology, “No therapeutic argument should hamper the development of a theoretical construction which aims, not at curing individual sickness, but at diagnosing the general disorder.”

 Even the words, “mental health,” show that our theoretical construction of human pain pointedly ignores the “general disorder” of hierarchy, dehumanizing bureaucratic structures, in-groups and out-groups, extraordinary wealth inequity, and the fact that the more machines take over our work, the harder we seem to be working as a result. We are alienated in the work that we do, in our relationships with others, from the natural environment, and even from our own selves. The structures of modern society set huge burdens on the individual. Many of us are suffering deeply and traumatically, from war victims in Somalia and Ukraine to refugees trying to cross into Texas, to victims of mass incarceration. And many of us who have the luck to not be one of them have the hidden existential suffering of a profound sense of living in a world from which the certainty and meaning have been drained.  We are living out our lives of quiet desperation, clinging to the ladder of success, but not sure it’s the right ladder to be on.

 And then along come psychedelics. The mental health industry grabs a hold of them with glee, as the first really new and innovative drugs in 50 years, arriving just at the time when the whole structure of mental health diagnosis was in danger of crumbling, or at least in need of a serious revamp. Psychedelics set the brain awash with serotonin, create a top-ten in a lifetime mystical experience, and also do a brain reset, so we long as they work in the prescribed and hoped-for way. They are, logically enough, conceived of in terms of the current system, its beliefs, its limitations, and its mind-forg’d manacles.

 Let’s do something different with psychedelics than constrain them the same way we have constrained ourselves. Let us use their liberation potential, since liberation is what we need. Psychedelics are the perfect instruments to point out the missing pieces in the mental health model, because they reach out way beyond our normal conceptions into what we may call the world of spirit. They can help us wipe our bones clean of ancestral pains that go back beyond memory; they can open our eyes to what, as alienated people, we are doing to our environment, and hence ourselves; they illustrate to us that all work, every single job in the world should be about healing and nurturing our fellow humans and creatures; they tell us that the habitual and cynical wrongs of the world are an offence to all of us; and they tell us that our destiny is not about getting up that ladder of success but about seeing how deep and profound joys are all around us in the little things. An awful lot depends on red wheelbarrows. The mental health industry would happily transform the individual and leave the society they are nested in unchanged. That cannot be done. As a medicine it would fail. Psychedelics are here to turn the world upside down and maybe this time enough of us are ready to do the somersault.