Just Say No? Is informed consent possible in our current mental heath care climate?

My profession has been coopted. Seduced by the siren of medicalization whose sweet medical-model notes lure my colleges into a diagnostic slumber.  While we mental health therapists, psychologists and psychiatrists amble along in a prescriptive haze, it is easy to dismiss from mind the curious and magical roots of the healing arts.  In our current counseling climate, most people seeking therapy expect to receive and are given a clinical diagnosis. A diagnostic code based on the medical model of illness and disease is necessary in order to bill insurance companies who have situated themselves in the lucrative position of reimbursing clinicians for approved therapeutic services.  While diagnostic codes have become a pragmatic reality for the business of therapy, I fear my field is loosing sight of the exquisitely human, relational and mysterious art of psychotherapy.

Symptoms have been rearranged into diagnostic checklists categorized to codify evidence-based practices developed to treat mental disorders, the list of which has expanded decade by decade.  This mental health manifest destiny, we are assured, empowers patients and enables practitioners to use the most scientifically advanced treatments possible.  We are barreling headfirst down the mental-illness-as-a-brain-chemical-imbalance-disease path and I want us to slow down and take a break by a waterfall or in a sunny spot to give us time to contemplate if this road will truly take us where we want to go.

I am concerned the mainstreaming of medical modalities to treat mental illness may be making us crazy.  Or, more alarmingly, is pathologizing reasonable responses to human experiences.  The quest to mold mental illness into a brain disease model has been motivated by multiple social and political forces.  Treatment and profit, once engaged, have married in an opaque market driven ceremony and my profession is doing a celebratory prescriptive waltz. 

Mental illness does exist. Medication is one of many viable treatment options.   My worry is that this one viable treatment is expanding in every direction to the exclusion of other possibilities and to the detriment of all of us.

As a therapist, I am regularly asked to give a diagnosis or make an educated guess about whether or not someone needs medication.  When a client asks me if they should take psychiatric medication because they are depressed or anxious or worried they are bi-polar because they experience ups and downs in mood, a tiny mental health seraph urges me to scream, Hell no! This brain chemical imbalance theory supports fictional disorders designed by a cadre of big pharma sponsored psychiatrists and has absolutely no currently credible medical evidence to back it up and the medications themselves are toxic and deadly!  Another therapist seraph sits on my shoulder and whispers the stories of all the people whose lives have been saved by psychiatric medication.

I am not anti-medication, nor am I an advocate of the Just say no! approach.  I like drugs.  I have taken drugs to treat illness, heal from injuries and trauma, alter consciousness, connect with people, disconnect from the chaos of life, and sometimes just to have a good time.  I am by no means anti-drug.  I am, however, a steadfast advocate of empowered and informed choice.  I am concerned that informed choice is being coopted under the banner of consumer choice.  The psychiatric medication-marketing machine is just too big, too strong, too wealthy and too invested in the medical model for other theories and treatments to be accessible in any mainstream manner.

Mental health treatment is now almost synonymous with a mental health diagnosis and more alarmingly, with a psychiatric medication treatment protocol.  Increasingly, a mental health diagnosis is a required component for services such as having your insurance cover therapy, accessing counseling through a mental health agency and participating in some state funded programs.  School children, for example, receiving supplemental support services often face compulsory conditions: they must obtain a diagnosis and take any prescribed psychiatric medication in order to receive services.  Typically there are no other treatment modalities available.  The brain chemical imbalance disease model has become the only treatment available for many people.  That this is happening when the scientific evidence for a brain chemical imbalance theory is slim to none is disturbing.  There are no blood tests, or any other actual tests, that can prove definitively that someone has a brain chemical imbalance or a mental illness.  The philosophic roots of psychology are being ripped out from underneath our profession.  The relational importance of healing work is becoming a radical outlier.  This concerns me.

People should be involved and engaged in their healing.  In order to do this, we need to be informed, not coerced by science and it’s mental health proxies.  Informed and engaged consent is not unlimited access to direct-to-consumer psychiatric medication advertising.  As a mental health therapist, I continuously struggle with how to support my clients in making informed decisions about medication.  Informed consent is critical.  The massive amounts of pharmaceutical industry messaging that floods professional offices, personal homes, consumer advocacy groups, university research programs and media outlets is staggering.  No other mental health treatment modality has as much professional and cultural influence as the pharmaceutical industry.  How then, is informed and engaged consent possible?

I used to think that offering a space for clients to reflect on their values and beliefs about medication was enough.  Not any more.  Not in the face of medical-model-brain-chemical-imbalance marketing madness.  I can no longer in good conscious simply say, there are many options and medication is one.  The influence of big pharma sits between me and my client luring them with the sirens song of clinical trials, brain imaging photos, late night heat to heart infomercials and bouncing yelling mascots.

I don’t have a mascot or MRI machine. I do however, have the power to speak up and share my concerns about where I see my profession heading and the damage I believe is occurring in the name of scientific, psychiatric progress.  If I remain silent I am, in effect, colluding with an out of control, profit driven industry that has obtained seemingly unregulated access to and control over psychiatry, psychiatric research, psychology and mental health counseling.  I worry that we are pathologizing reasonable responses to complex human experiences and that countless normal behaviors are being diagnosed and treated with medication.  I fear this is creating a mono-social-psychological cultural landscape in which a vast range of human behaviors are equated with disease.  We need radical provocateurs, daring visionaries, audacious artists, outspoken healers, courageous warriors, brilliant loners, mischievous misfits, obsessive mechanics, insomniac bakers, anomic urban gardeners, wildlife saving savants and every other wild child, quiet adult, party animal and solitary scientist.  Nature abhors monoculture.  We are learning this lesson in devastating, bee colony collapsing ways.  Humans are incredible diverse and it is our differences that make humanity possible.  Just as different crops nurture, feed and sustain one another, we pollinate humanity through difference.  

Psychiatry and psychology need to widen, rather than narrow, the enormous range of acceptable normality in behavior, personality, and psychological constitution and embrace both the science and the art of healing.   It will take serious effort to counter the cultural influence of pharmaceutical driven care so that multiple treatment modalities are widely accessible for the general public and that the craft of healing work is recognized as being viable even as it eludes scientific verifiability.  Consumers, clients and clinicians will need to continue to collaborate, speak truth to power, support seemingly “radical” alternatives, mainstream multiple healing modalities, challenge science to research towards collective good, and organize in solidarity across different therapeutic approaches, fields and professions.   

How do you decide what to share?

How do I choose what to share with the people in my life? What do I share with the person who I wake up with on a regular basis, sometimes still dreaming, sometimes hiding behind the veil of sleep while the nightmares fade or a vision of hope whispers quietly for me to let it go, let the nightmares go.

What do I share with the people who I sometimes think just magically tumbled into my world in a numbed out hazy whirlwind of fleeting vulnerability and who I hope won’t get blown like a sun bleached tumbleweed back out of my life.

Because I’m trying to get stable, de-stabilize the dysfunctional familiar and figure out what it means to be stable all at once. Stable. Like a rock. Like a homing device. Like a shiver. Stable like a traveler who is always packing, even when they are at home. Stable like an expert at good-byes who has learned how to say hello and let it sit there without anticipating the end. Stable like someone who can be still, rest, reflect. Like someone who can take stock in what gets upheld as the right way, which is often the white way and taking stock in this way means finding the skin under the skin. The soft underbelly that tenaciously contains everything I have come to know as me and the hard outer shell that reflects my socially constructed self like a pair of mirrored sunglasses pinching the skin on your nose.

What to share?

The wisps of steamed conversations with the people I bring in the closest and yet keep the furthest at bay. What boundaries, or lack of boundaries, do we share? What transgressions do we silently agree on? What’s an arms length when you’re wrapped around the center of someone? How do we trust people to love us, people who have been taught to abuse us but make the decision not to? How do you trust yourself to not to lash back anticipating an unimaginable but well-known pain that never comes? How do you trust the density of skin touching skin, a silent shiver of contentment that you resent sometimes because you know how it feels when it fades into the background absorbed by noisy, punchy, invasive thoughts crowding in like blackberry vines sucking onto every surface with thorny delight.

I am taking this opportunity to stand firm on the unstable ground of love. Be unshakeable yet shaken and stirred. A time to ask, how you deconstruct love as an anti-racist. How you fuck as a revolutionary? How do you bicker with those who climb under your skin, inside you, while sharing borders which while open, clearly designate where you both begin and end? What does it mean to hold your own ground and give yourself into history while looking forward? And fucking?

I know how it feels to cross borders of sexual guardedness—to fuck with your guard up and down—to be utterly vulnerable yet unreachable. Untouchable. Untraceable. Unarmed, but critically dangerous. These paths I know—I can trace and re-trace them in the outline of my feet, my steps always facing forward even when they have swerved from an unsteady nervousness or a drunken bravado. You can travel and talk in so many directions. You can back down or back up or back track or back someone else up. You do this when everyone around you backs up, rams forward, pitches into madness or tries on happiness for a while. And while dipping and swirling on my crisscrossing paths, it seems surprising, even alarming that the outlines of both my feet continue to face forward. Until now, when the shadows of my toes curl under to face east, west, north, south without picking a direction but taking in history from as many directions as possible.

Like a city metro map, these paths and borders decussate, intersect and merge--political, sexual, emotional, psychological, psychosomatic, imaginary, elementary and fundamental. Cityscapes of blue lines, red dashes, yellow highlighted points of interest.

Meanwhile back in my own head and bed the person I wake up with dress and re-dress ourselves in various layers of vulnerability in an attempt to touch ground for the first time in both of our lives.

How do you touch ground and be grounded in the uncertainty of what is right because we only seem to know “right” when what is wrong fucks us up.

How do you fuck while being present to your privilege and honor the thin skin you developed to let the things that shouldn’t stay inside you, out?

These self help books and tapes, videos and reality shows, talk shows and talking head productions, produce people productively prioritizing various pains into the “right” spaces, which is often cramming them into the “white spaces” that seem to share the same space as my forward facing feet.

Continental plates are drifting apart; borders are exchanging meaningful glances rearranging themselves in acts of self-defense, self-denial and self-aggrandizement.

History remains history, even when parts remain undocumented. And the undocumented will present us with a history that will not remain invisible to the cameras or the eyes of those who choose to listen.

How do you heal the wounds of invisibility? How do you learn to love intensely in such a mirage of stability rumbling beneath the flat-footed falseness of normalcy?

What do you choose to share with your lovers, past, present and future who may be able to whisper sweet social change into your ear with the hot breath of an anti-racist but can still fuck you over after fucking you well because the tools of survival leave you layered in contradictions.

How do you remain fluid while having a firm sense of self and clear boarders?

How do you decide what to share when you are not sure what is being recorded, documented, disposed of?

How do you hold onto to necessary secrets when your every move can telegraph parts of your story to anyone who dares to pay attention?

You share by being vulnerable,
and that’s hard.

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