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Wednesday, October 13, 2010

I’m having a love-hate relationship with science

I’m having a love-hate relationship with science. I love all the information on new brain science and the plasticity of the human brain. It inspires me and makes me feel hopeful to see the amazing resiliency of human beings. I benefit from new scientific discoveries on a daily basis. Every time I take medication for cramps, get an X-ray, swallow an anti-biotic, get stitches or have surgery I thank science. I worry, however, that the recent explosion of brain based science in psychiatry and mental health is focusing too much on symptomology and loosing the narrative, social and cultural meaning making of human experience. As a therapist, I work in a field that is making new scientific breakthroughs regularly, many of which are redefining mental illness as a “real disease” like diabetes, and discovering new antidotes, similar to insulin, with which to treat these newly deemed “real diseases.” While exciting, these findings, driven by research funded primarily by pharmaceutical companies, are creating a new paradigm that is distancing our cultural understanding of mental illness from social, political, economic, historical and environmental contexts. These findings, marketed directly to consumers, bring the myth of scientific objectivity into a mainstream consciousness. Science, however, has never been objective. Look up The Tuskegee syphilis experiment, Dr. Linnaeus, Drapetomania, Hysteria, google US government researchers, Guatemala and syphilis, or read Overdosed American for a place to begin an exploration of just how un-objective the world of science has been.

The belief that as psychology and psychiatry move more towards a medical model the more objective and “real” the fields will become concerns me. The new brain-based scientific paradigm currently booming in our psychiatric and mental health systems has radically altered how clinicians, doctors, psychiatrists, social workers and clients view what is healthy and what is pathological. This disease model of mental health and mental illness first entered into scientific discourse around the late 1800’s with the search for a “magic bullet” for internal diseases. Based on research by German scientist Paul Ehrlich, a new paradigm was introduced based on the belief that if invading organisms could be identified and killed, a disease could be cured. “If we picture an organism as infected by a certain species of bacterium, it will be easy to effect a cure if substances have been discovered which have a specific affinity for these bacteria and act on these alone. If they posses no affinity for the normal constituents of the body, such substances would then be magic bullets.”

In the world of mental health and psychiatry, this “magic bullet paradigm has manifested as the belief that “diseases” like Bipolar, Depression, ADHD, Oppositional Defiant Disorder among a few listed in the newest edition of the DSM IV (The current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders), are caused by chemical imbalances in the brain. These claims have not been scientifically proven. “There is not scientific evidence whatsoever that clinical depression is due to any kind of biological deficit state.” wrote Colin Ross, Associate Professor of Psychiatry at Southwest Medical Center in his book, Pseudoscience in Biological Psychiatry (p.111). David Healy, a psychiatrist and author who has written many books on the history of psychiatry and is “one of the world's leading scholars on anti-depressants” has raised concerns about the use and safety of SSRI’s. After a lecture in which he raised concerns about evidence based research (funded primarily by pharmaceutical companies) the University of Toronto withdrew a formal job offer raising myriad concerns about the possible influence of large corporations on intellectual debate in universities.

According to Dr. Healy, “We are in an era, which is popularly portrayed as an "Evidence Based Medicine" era…Arguably, the term ‘Evidence Biased Medicine’ would be more appropriate. Clinical trials in psychiatry have never showed that anything worked…What clinical trials demonstrate are treatment effects. In some cases, these effects are minimal…One may have to strain with the eye of faith to detect the treatment effect…If our drugs really worked, we shouldn't have 3 times the number of patients detained now compared with before, 15 times the number of admissions and lengthier service bed stays for mood and other disorders that we have now. This isn't what happened in the case of a treatment that works, such as penicillin for GPI…Within the studies that are reported, data such as quality of life scale results on antidepressants have been almost uniformly suppressed. To call this science is misleading.”

A magic bullet that can zero in on its target like a heat seeking missile and eliminate a disease without much collateral damage is an amazing thing to contemplate. Were it to be true it would be a phenomenal scientific discovery. The reality, however, is much more complex. There is no scientific evidence that “diseases” like Bipolar Disorder, Major Depression or ADHD, are caused by an imbalance of serotonin or any other neurotransmitter. There have been discovers of correlation between depression and changes in serotonin and MRI imagery has allowed scientists to see links between attention, emotions, memory and specific areas of the brain. But correlation does not equal causation.

Science’s most recent partner, big pharmaceutical companies, further complicates my love-hate relationship. That most research is being funded and marketed by the same groups with a vested interest in not only discovering various diseases, but in a pharmacological cure, concerns me as well. Medication has become the “evidence based” magic bullet of the day and it is the front line response to recently discovered “diseases” to the point where doctors, psychiatrists, and clinicians can be told they are doing harm if they do not advocate and prescribe medications. At the same time, focus on social, political, economic, cultural and historical factors in regards to mental health and mental illness are being made inconsequential, unimportant or irrelevant. These factors are seen as minor players that may influence the color of some symptoms rather than potential root causes of symptoms. While I am not anti-medication—I know far too many people professionally and personally whose lives have been dramatically improved by medications of all kinds—my alarm stems from the overwhelming power of this new paradigm to eclipse other potential frameworks. In the early part of the past century there were debates as to the various potential causes and cures for a variety of “mental illnesses” and mental illness itself affected far fewer individuals. Currently there is little debate in the mainstream world of psychiatry, psychology and mental health about whether the new evidence based model should be the primary model and not much debate in the mainstream as to whether or not mood disorders are caused by an imbalance of brain chemicals. This scientific theory of an imbalance of brain chemistry is one theory. Just one theory. A theory, I might add that has not been proven through clinical trials. So why not support, research and expand on other theories? Why not include in mainstream discussions of causes and cures for mental illness how art and music have influenced the various ways people heal from trauma and abuse? Or how economic uncertainty and the disappearance of the American middle class impact an individual’s experience of anxiety or depression? Maybe more studies on how the radical changes in how food is manufactured and distributed in the last century has impacted our mental as well as physical health. Or why people diagnosed with schizophrenia living in less “developed” countries and who then are less likely to be put on anti-psychotics have a better prognosis than people living in the United States?

By isolating emotions and moods as malfunctions of the brain that can be traced to specific and objective symptoms and then treated with specific and evidenced based treatment protocols, the normative range of human responses to real life events has effectively been stripped of any cultural narrative, social value(s), personal beliefs, and historical context. The meanings of emotions has been managed, marketed, medicated and manipulated. If we have no meaning except a chemical imbalance in the brain, we are much more vulnerable to clinging to faith in “magic bullets”. For instance, depression is a reasonable response to uncertainly. Indeed, it was not that long ago that a depressed person was described as sensitive and empathetic. Now they have a brain disorder. A brain disorder that can be targeted and cured by evidenced based magic bullets called anti-depressants. The faith that science, rather than culture, can more accurately describe complex psychological phenomena and human experience is rooted in the belief that science, through “objectivity,” trumps culture and social context and that science in itself is not culturally produced or gains its significance and power from specific social and cultural contexts. All science is a product of culture. How one asks questions, which questions get asked, what gets researched, funded, promoted, who has access to medical school and research programs, how science is defined and viewed in the context of a society are all informed by culture. The current climate in the United States values science because it is viewed as separate from social, political and cultural paradigms. Science is viewed not a cultural and social product, but an objective field that produces objective data. This is dangerous. Science is rooted in culture, politics, economics and social values and these are not fixed objective things, but fluctuating and ever changing, which is why it is so critical to be able to debate and challenge treatment protocols as well as offer multiple and varying modalities of healing.

Healing is very deep and very personal work. There is no one right way to heal and no one right way to feel better. There is not even one objective state of “feeling better”. That said, I do want people to feel better but not at the expense of their health, well-being and certainly not by pathologizing a reasonable response to a complex, uncertain world. I want there to be options for healing and well-being that are rooted in a complex understanding of how culture, history, politics, genealogy, faith, personal experience, as well as biology and brain chemistry all inform our experience and understanding of complicated emotions like depression, anxiety, grief, joy and love. There are many people offering critical explorations of the evidence based research model of mental health, mental illness and magic bullet cures. And, I have read a few books recently that have prompted me to think deeply about how I hold space for people contemplating the role psychiatric medications may play in the trajectory of their healing. I am no longer certain that being neutral or “objective” with the intention of letting people decide on their own is enough. The brain chemistry model has been so naturalized in the present moment that medication has become “common-sense”.

There is a tremendous amount of social, political, economic and marketing power behind pharmaceutical companies and the evidence based treatment protocols founded on the research they promote. The sheer weight of this kind of power makes me wonder if the voices that challenge the notion that a brain-based disease model of mental health is the “best” model are loud enough to be heard in the mainstream. I am wondering where my own voice fits into this complex and ever evolving picture. And while I do not have any answers, I feel it is important to encourage anyone interested in exploring these issues to read the books listed below, talk with friends, family, counselors, doctors, and then critique and challenge what you read and hear. It is important that all voices are heard when we discussing and exploring the definitions, the causes and possible cures of mental illness. Science, evidence based research, and brain chemical imbalance theories have been doing a lot of talking lately (thank you for speaking up science!), but it’s time to sit back and let some other folks take the floor.

Overdosed America: The Broken Promise of American Medicine by John Abramson
Anatomy of An Epidemic by Robert Whitaker
The Creation of Psychopharmacology by David Healy
Crazy Like Us: The Globalization of the American Psyche by Ethan Watters
Manufacturing Depression: The Secret History of a Modern Disease by Gary Greenberg