I am frequently fascinated and sometimes a bit horrified by the explanations that my clients give me to explain their feelings, thoughts and behaviours. The vast majority of these concerning explanations are steeped in a belief of ‘personal failure’, ‘trauma’ and blaming ‘bad parenting’. While insufficient effort to change (personal failure), traumatic experience and poor education (bad parenting etc) can contribute to poor mental health, these are rarely the cause for someone to see me. It isn’t my client’s fault though. It is an artefact of how therapy has evolved. I see these same mistakes being repeated by therapists, online advocates and text books. They are all missing the key feature – biological causes require biological solutions. They forgot that Mental Health and Medicine are tied together, if your biology is out, you will need some medical assistance.
Mental health evolved separately from most medical science. Running in parallel to ‘cognitive therapy’ is ‘medication’ and ‘neurology’. The Neurologist Dr Steven Novella, stated that “If we know what neurons are involved, it’s called neurology. If we know what medications help in the absence of the neurons, it is psychiatry. If we don’t know what medications help, nor what neurons are causing it, that’s called psychology”. Interestingly, neurological problems aren’t called mental illnesses, while both psychiatric and cognitive problems are.
More on the medical side a bit later. First we need to understand what doesn’t work.
The evolution of treating “Mental Illness” in the absence of medicine started with religion, and ranged through “you have angered the gods”, “you are wrestling with your demons”, “you have a moral failing of your character” and “those who work hard get rewarded, those who don’t get punished – you are being punished, so what did you do?” Their solution was prayer, inner self searching and working harder (but not smarter). Failure to “heal” was defined as a problem with the patient, not the treatment.
We see reflections in this with modern people stating “I caused it/it’s my fault”, “I’m not good enough”, and my favourite “I’ll just try harder”. There is an element of truth to this, if you don’t want to change, you can’t change; if you don’t think you are good enough, why would you try; and if you just do the same things repeatedly bu tharder, you only get what you’ve already got but more so.
If you are trying and it isn’t working, then the method is wrong – work smarter, not harder.
The evolution of “Mental Illness” then went through the dark era of blaming parents, sexuality, society and your own baser unconscious desires. ‘Psychobabble’ was born to help confuse the patient so they didn’t realise that the therapist had no idea either, while a failure of treatment progress was again blamed on the patient. Again, there is an element of truth here, bad parenting and societal rejection can create problems. These are fairly easy to correct for by most therapists, so if a few months of effective therapy doesn’t help, the source problem isn’t likely that.
Talk Therapies
Most therapists are not educated in medication, neurology or how neurotransmitter levels can affect your life experience, perceptions and behaviours. In the ignorance of this, therapists ignore this and assume that the patients doctor is sorting this out. Assuming, often faultily, that this is managed, the therapist turns to Talking Therapies.
CBT (Cognitive Behavioural Therapy)
Effective Talking Therapies, such as Cognitive Behavioural Therapy (CBT) and Trauma Therapy, are excellent at challenging erroneous beliefs, addressing triggers, processing experiences, and upskilling the person to improve their mental health.
While it should be obvious, many people miss the fact that this only works if the mental distress is caused by a faulty idea, maladapted behaviour (repeating the wrong solutions), external trigger or ignorance of a good solution. Additional features of good therapy include helping the person explore their experience and solution, education, upskilling, grounding, therapist normalising and the actual support of the therapist.
I am going to take a moment to differentiate between actual CBT and textbook CBT. Actual CBT is more like jazz, where the therapist will follow the form and structure of music, but tailor it to your specific needs, jumping around the paradigm as needed. Text book CBT is a glorified self help book that doesn’t actually care who you are, this is step 1 and you will do it. It is a machine going through the notes on the page and lifelessly pumping out some sound and pretending this is good music. I appreciate that I am risk of using a True Scotsman Fallacy [LINK], however I am passionate about the difference between properly executed CBT and a therapist acting like a self help book.
Other Talk Therapies
But what happens when CBT doesn’t help? What happens when challenging your core beliefs does not shift those same ideas that drive your behaviour? What if all of your behaviours are correct, and you have the core rational and logical helpful beliefs about yourself and society, yet you are still mentally distressed?
This is the problem that therapists have grappled with for the last 100 years. We challenged the beliefs that led you to making poor decisions and actions, we tried to educate you in how to do things, we encouraged you to make life changes, and yet you are still distressed, likely doing actions that you know are bad since you came to see me for help.
Babble Therapies
In their attempts to find solutions, but refusing to look at neurology and medication, therapists have tried many different models and theories to try to beat the gold standard of CBT. Therapists came up with outlandish theories to explain the gap in what they expected to happen with their patients and what they observed, leading to some very strange frameworks that only have a vague resemblance to the real world. For example, we are aware that our brains are doing things, such as beating our heart, that we are not paying attention to, so there must be processes going on that we are not conscious to – unconscious processes.
This led to the idea of the unconscious desires model to explain odd behaviour. Further this led, in combination with some religious ideas, to the ego, super ego and the id. Each of these has some kind of basis in reality, such as the thoughts you know you are having and the reasons you think you are using to justify your actions are conscious decisions, while there are things you didn’t really think through before you thought they were a good idea, such as that extra bar of chocolate, which are likely servicing unconscious needs. Medically, your hunger for certain products kicked in to try to adjust your neurotransmitter levels and alter your blood sugar. In the absence of a medical understanding, the therapist my hypothesis that your unconscious mind is breaking your conscious diet plan due to a self hatred born of a poor interaction with your mother in your childhood leading to self sabotage.
Thus the advent of Babble Therapies, where complex jargon that has no real meaning in the real world is used to confuse and baffle the patient, allowing the biological reasons for actions to be shunted on to some unpleasant experience that is painted as trauma, or some childhood experience that is blamed on parents.
People often initially improve while seeing a Babble Therapist. Many experiments have shown that the most common improvement in patients is due to the patient feeling that someone is taking them seriously and wants to help them. The warm, calm, assuring voiced therapist who builds rapport (connection) with their patient will see a quick improvement in the patient’s demeanour due to building that belief in the patient that their problems can be fixed.
In the long run, though, most Babble Therapies don’t work, because they are just rehashing religion/ideology, victim blaming and psychobabble to pretend that they know what they are doing, while having no actual impact on why the person is struggling. Worse, many Babble Therapies, such as psycho analysis and schema therapy, leave the patient worse off, as they misattribute the causes of their discomfort on the wrong things.
Purple Hat Therapies
The “alternative therapy” models that do work are basically CBT Purple Hat Therapies.
A Purple Hat Therapy is where something flashy and distracting is done, such as “please wear this Purple Hat”, while the real therapy is performed (such as CBT). You are then told that it was the Purple Hat that healed you. You only really notice the Purple Hat because it is different and out of place, seeming to be magical and easy, and you miss the real therapy you did while distracted. Despite their claims, these do not perform any better than properly implemented raw CBT.
An excellent example of a Purple Hat Therapy is EMDR. EMDR is just CBT with some woo and physical movement added in. EMDR was doing only moderately well for the first 10 or so years until they added in more CBT to their treatment model, where EMDR then performed as well as CBT in fair tests. Many EMDR papers were made showing that EMDR worked better than CBT in experiments run by EMDR therapists, where these superior results disappeared when those studies were replicated fairly.
An argument against Purple Hat Therapies is that it undermines the patient from understanding that they actually did put in the work to change their life, understand what it is that they did that worked, and thus how to do this again if things go wrong in the future. People who improve thinking it is the Purple Hat, have to go back and get that Purple Hat next time.
Medicine and Medication
As a therapist, learning to recognise when a person’s experience is caused by biology is incredibly important.
A biological cause needs a biological solution.
No amount of talking therapy will fix the focal distance of your eyes, help your pancreas to produce more insulin, fix a murmur in your heart, heal a fractured bone, or balance the neurotransmitters in your brain. While talking therapies can help you manage these a bit better, they won’t give you a good health outcome without a medical component.
The vast majority of biologically driven mental distress is due to imbalanced neurotransmitters. The big seven neurotransmitters to balance are serotonin, melatonin, dopamine, noradrenaline, adrenaline, endorphins and oxytocin. There are other neurochemical and neurological conditions that can also cause various distress. We have a section dedicated to exploring all of these here [LINK].
Your General Practitioner is doctor who is generally not well trained in mental health, neither the recognition of causes, therapy nor the medication. Generally they will quickly and accurately assess that you are experiencing anxiety and or depression symptoms, often then directly diagnosing you with an Anxiety Disorder or Depression Disorder and prescribe SSRI medication to try to treat the most likely neurotransmitter error, low serotonin.
When this works, fantastic. The GP will often tell you the medication will take about 6 weeks to kick in. Coincidentally, I am sure, most situational crises will also resolve themselves in about 6 weeks.
Too frequently the SSRI doesn’t help. When this is the case, it is important to see someone better qualified to help. If you have struggled with mental ill health for more than 2 years, you likely have one of the other neurotransmitters out of balance.
Over the last century and a half, various medications have been found to help some very specific symptoms and “Mental illnesses”. Over time, investigations into what these medications do to our brains and bodies has revealed direct and indirect information about what is the biologic cause behind many labels of “Mental Illness”.
This should shift the category of these particular conditions (such as anxiety, depression, autism, ADHD [LINK], schizophrenia, voice hearing, bipolar affective disorder and many more), from Psychiatry/Psychology to Neurology. But it hasn’t. These are still considered to be “Mental illnesses” rather than divergent neurology (Autism and ADHD) or a neurological condition (schizophrenia).
With the recognition of what many of these medications do, and which medications work for which symptoms, we now know that many labels of “Mental Illness” are just the presentation of symptoms of some basic neurotransmitter imbalances. Anxiety Disorder, for example, is one of the symptoms of either too little of the neurotransmitter Norepinephrine (most of the time), or too much (some of the time). Other symptoms for the same biological cause (Norepinephrine imbalance) can be Aggression, Impulsiveness, Self-Harm, Suicidal Ideation, Rejection Sensitivity, OCD, Mysophobia (fear of germs), Social Anxiety, Sensory Hypersensitivity, Meltdowns and Hyperactivity to name but a few. While Norepinephrine isn’t the only thing that can cause these symptoms, in my experience it is the most common.
Despite our new knowledge, these symptoms continue to be given a “Mental Illness” label and are treated with talking therapy or the wrong medication.
Case Example: Social Phobia and Sundowner Melt Downs
I have a client who has been through trauma therapy around 10 times with various therapists for their social phobia and sundowner meltdowns. His treatment outcome was a belief that he wasn’t trying hard enough and thus he is to blame for not getting over his trauma. That really isn’t helpful. His GP treated him with the typical anti-anxiety medications, which don’t actually address the base cause. I identified that he was doing the right things as outlined by Trauma Therapy, and therefore his ongoing experience was likely biologically caused. With the cooperation of his doctor (his psychiatrist didn’t believe the model), my client began a biological remedy (medication) to treat his probable biological condition with a significant positive result (it worked). We are now trying to tweak the medication to give him 24 hour positive results instead of only 12 hours.
I can already hear the counter argument forming in some people out there. Let me address the most likely arguments.
What if he could just learn not to be socially anxious, isn’t no medication better?
Yes, it would be better, if his anxiety was based on an idea and maladapted behaviours. It isn’t, it is caused by biology. We know this, because “educating” the client did not change their experience, so it wasn’t a lack of knowledge. The medication did work. If a medication could give you that knowledge better than education, I want to try the one that tells me how to do Kung-Fu.
What if he just wasn’t trying hard enough?
Anyone that says “you aren’t trying hard enough to get over your anxiety” is arguing from a privileged position of never having experienced real anxiety. Laziness, willpower and effort is not the problem.
What if the medication is concealing rather than treating?
Certain sedatives can block and conceal the route course of something like anxiety, such as benzo diazepam and medical cannabis. This medication is not a sedative. It is actually treating the route cause. Explaining exactly how that medication works is beyond the scope of this.
If all mental illness is just a biological problem, then why don’t we just give everyone medicine?
For a start, not all struggles that people see me for are classified as mental illness. Secondly, for the same reason we neither give everyone insulin treatments (as not everyone has diabetes), the same insulin treatment for diabetics (every person is an individual with diverse needs) and insulin treatment in the absence of education about what diabetes is and how best to treat it (biological therapy without education therapy).
I’m going to say this again, for the people up the back who weren’t paying attention throughout this monolog.
Talking therapies are fantastic to help correct maladaptive behaviours, erroneous core beliefs and upskill ignorance. I use it frequently with my clients for when their mental distress is due to one of these. Learning smarter solutions to problems that have defied the person’s current skills is excellent and the base point of talking therapy. Good therapists are excellent at helping you keep on track and providing additional support when you need it. When this is all that is needed, well done, your job is done.
Sometimes we need to go further and do practice behaviours like desensitisation, processing experiences, re-learning our power and choice, actions to change our circumstances, specific neurological differences due to specific neurodivergence and so on, which should all be within the scope of a good therapist.
As a therapist, learning to recognise when a part or most of person’s experience is caused by biology is really important. A biological problem needs a biological solution. No amount of talking therapy will fix the focal distance of your eyes, help your pancreas to produce more insulin, fix a murmur in your heart, heal a fractured bone, or balance the neurotransmitters in your brain. Once the biological condition is stable, now you can see if further talking therapy is needed and get on with that. Then your job is done.
When our friends are trying a medication to see if that will help, it is important to support their trial and give them honest feedback about if it looks like it is helping them or not. Don’t discourage them from the trial unless. If you have specific knowledge about their condition and that medication, you can discuss it with them.
So please, stop victim blaming people for failing to will power their way through a biological condition. Often, in complex situations, it is important to balance Mental Health and Medicine.