A lament on approaches to mental health
I’m really frustrated by recent experiences interfacing with the mental health system for myself and for my teenager. For them, it’s really atrocious. There may be effective options for the upper classes, but they aren’t accessible to me.
This is inspired by @X08’s recent [post] (https://tildes.net/~health.mental/1iia/unable_to_feel_progress_lack_of_happiness_and_not_finding_motivation_to_keep_investing) . Obviously I don’t know about their particulars, but I’ve certainly had the experience of being a part of a group where it appears others are progressing while I am not. Partly this is a problem of how we perceive, measure, and judge “success.” “Don’t compare my insides to others’ outsides,” as the saying goes. But it is possible to a more faithful and reflective comparison, and it does happen that others similar to me* make progress where I don’t, and it’s really frustrating. I’m often wondering, what’s wrong with me that I can’t change and grow?
I don’t have a great answer, although my exceptionally shitty childhood certainly plays a great role.
What I really want to comment on, though, is how insensitive our current mental health system is to the impact disparate causes have on creating similar symptoms, and how that should inform treatment approaches. A gifted psychiatrist (of which there are shockingly few) once put it like this (paraphrasing): Before we look at treatment for depression, we have to make sure the patient isn’t just surrounded by assholes.
But it’s a real problem. CBT is touted by a lot of “weighty” authorities as a valid gold standard treatment for a wide range of MH symptoms, and is claimed to be effective regardless of causes. And it’s my opinion that there is a lot of reasonably scientifically rigorous research backing that claim up. But, it’s not all rainbows, and it’s not working for lots of people. For one, a lot of folks claiming to do CBT are really not. Actual CBT involves a lot of homework, and a lot of recipients don’t have home support and don’t do the homework. This is extra true for children and adolescents living in dysfunctional homes. But more than just patient effort, the research marking CBT as so favorable is mostly based on subjects who are only mild to moderately distressed.* The end result is everyone involved in the “evidence based” healthcare chain is signing sufferers up for CBT when that might not be the best approach. There are lots of other criticisms too. If a practitioner is not well-trained and dedicated, the practice can be very invalidating. It seeks to make the sufferer’s more cognitive process more ‘rational,’ but when that person’s experiences are really, objectively bad, it’s very rational to conclude the world is hostile and unsafe. The tool itself is prepared for this, but it takes a really effective therapist to pull off. Also, it’s not enough by itself, grieving and other healing is also required for success.
The same thing happens in 12 step groups. AA/NA is resoundingly helpful-for a certain set of alcoholics/addicts. Those who don’t make it are often exhorted to become more honest, more open-minded, or more willing.*** My observation, though, is that most of the ones that make it come from intact families with resources. This is not universally true, it’s important for me to point out that there are enough examples of success among folks with no such background to say that there is something valuable in that approach that transcends socio-economics. There are also plenty from well-resourced families who don’t make it, but many of those families are highly dysfunctional. Of this last group, folks from dysfunctional families, some of us find success in other groups. This is because AA/NA are designed for sociopaths, ACA**** is designed for the product of sociopathic parents (who are filled with shame).
I don’t know what the solution is. A lot of malaise, addiction, “maladaptive” behaviors are, I think, born in a dysfunctional society, and so long as that society remains dysfunctional, no individual focused therapy solution will create a permanent fix. I think right here and now, too, we are at one of humanity’s “high tides” of self-destruction, a result primarily of runaway capitalism (is there any other kind?). We also just came through a really nasty global trauma, everyone is feeling it some kinda way.
Thanks for attending my TEDz talk.
*Of course, when talking about something as complex as a human life, there may no way to determine how similar is enough to make valid comparisons
**Also, let’s not talk about the various biases and implementation problems with what those studies refer to as ‘validated’ assessments used for measuring level of distress
***I am, technically, an NA success story
****Adult Children Anonymous, aka Adult Children of Alcoholics and Dysfunctional Families, more info at adultchildren.org.
Agreed. As someone who once trained to be a therapist, many of the major problems in people's lives aren't problems of personal agency or recontextualization of their life events to help them find a healthier way forward. And when we treat therapy as the solution to all the things that bother us, it leads us to think of our dissatisfactions with the world as a thing to be resolved in private with a highly paid professional rather than directing that energy out into the world to cause change.
Therapy does have its place. It's way better than telling people to suffer in silence and pull themselves up by their emotional bootstraps. But it's important to talk about what therapy is good for (talking about your life to help find an emotionally healthier way forward) and what it's not (resolving systemic social and financial problems.)
Edit: I had a similar experience myself; I was so burnt out trying to run a small business by myself, and my therapist and psychiatrist said I had anxiety and encouraged me to medicate for that, and talk about my worries. But I wouldn't have been anxious if my life circumstances were different. It's hard for the professionals to see these things through their tiny one hour windows into our lives. I don't really know a solution; though more and more I like the idea of a community figure who helps everyone in that community, so they have the real context of people's lives. Not a priest, but someone who fills that role of advisor to a community.
A while back, PhilosophyTube did a video on Stoicism which drew parallels to therapy. One of the questions they brought up was that if therapy (or stoicism) is designed to make you accept things, then what happens when you try to accept things that should not be accepted? For a more extreme example, let's say a person was being sexually assaulted by someone close to them; we certainly wouldn't want them to just accept it, would we? I can't help but feel that sometimes we use therapy to get people to try to cope with continued emotional abuse instead of actually addressing the real problem which is there is a person who is continually being abused!
What interactions constitute abuse is also a very fine line that tends to be different based on situations that an outside observer wouldn't be privy to. If you see a parent telling their kid they're starting to get fat, that could easily be an act of care from that parent, but you aren't likely to have been there long enough to know that it's the first time or the 20th time they've told them that. Issues like abuse will never have a one-size-fits-all solution because as it is we're terrible at understanding when we're seeing it outside of blatant violence.
The providers in the group I was in that you should only accept and validate that which is valid. You should not validate the invalid - sexual assault is not valid, therefore you should not accept it. However, past sexual assaults is something you have to accept: You have to accept that it happened to you or you cannot work on it. It's not about continued abuse or anything still happening. It's only about working on past traumas and keeping you from falling back into unhelpful/dangerous coping methods and patterns of behavior. At least that was the point of the group I was in.
That fine line you bring up is exactly what I struggled with a lot. There are obvious examples like sexual assault which should never be accepted, but when you start to approach grey areas, I just couldn't figure out what was valid and invalid. I learned a lot of things about how to find out, like checking the facts of the situation, imagining what I would think if it happened to a friend, etc. But I still struggled with it so much. I didn't know what should be validated, and every time I brought it up to the providers, they just said that I had to use my DBT skills. Well I still couldn't figure it out and it seemed like they were deaf to my problems with it.. it's a big part of why I failed (as per my comment below).
I have no experience with AA/NA so I can't speak to that part, but I am very much inclined to agree with you about the other stuff.
I had DBT, not CBT, but you can draw the same threads. It is touted as the treatment for people with BPD. I can tell you without hesitation though that I am doing so much fucking worse after 6 months of it than I did in the 6 months before starting it. It is aimed specifically at helping patients get past addictive, dangerous, and suicidal behaviors (my problem is self harm) but for me, it has only gotten worse. But I am also one of those people you're talking about who wasn't doing the work. I just couldn't. Most days, it was a struggle just to leave my apartment and show up. Just showering and feeding myself is a struggle. So of course I didn't have the motivation, energy, resources and whatever else to do all the homework on top of all that. So this week my therapist said that it no longer "makes sense" to continue my treatment with her and the group.
I'm going to start mood stabilizing medication this week, but that's it for therapy. 6 months of DBT down the drain. And about 2 years total at that psych facility. Only for them to tell me to fuck off and abandon me (it's how it feels, anyway). I have been in and out of therapy since I was a teenager and I'm in my early 30's now.
My conclusion to it all is that therapy doesn't fucking work when your childhood was bad, when your young adulthood was bad, when your life is objectively bad. There are measures as to what makes a person successful, healthy, happy, etc., and I am just not fulfilling any of those criteria. So therapy this past year, and DBT especially, honestly just felt like gaslighting. I not blind to the positive things that do happen in my life, but they are so rare that it is an actual surprise for me when I have a good day. It feels completely foreign to me.
These types of therapy are a catch 22 in my opinion: I can't get back on track and succeed in life without successful therapy, but therapy can't succeed when I don't have a successful life.
Ooof, I feel that. That was basically the cause of my childhood depression. Moving across state lines (and more specifically away from my father) was the solution. I'm OK today because of my grandparents (God bless their souls) took me in. But I feel like that was more-or-less luck. Nobody could see that home was a problem for me until I was out of school and my father harassed me until the point I had a breakdown that ended up with me being committed to a mental hospital.
But the thing is, what mechanism could have realistically been put in place to prevent that from happening?
I've actually had three government interventions during my childhood. I've also been temporarily put into custody of the state and been held overnight in a juvenile detention facility. I only have good opinions of one of them, but that might have simply been because I was too young to remember the details other than it was nice to be away from the home that I hated. Two of them involved the police, and they made both of them dramatically worse. The time I was jailed was because I had punched my stepmother after I was trying to defend my sister from my parents' combined harassment. The other time was the mental hospital episode and though that had a positive effect overall it was handled extremely poorly and things got much worse before they got better.
I guess what I'm trying to say is that mental health interventions do exist, but they are all rather shotgun approaches that trigger too late because the damage is already done. But the thing about that is that needing intervention is, in itself, a failure. And there's a good arguement to be made that these situations come up because of the way our society is built, much in the same way sexual assault can be.
In addition to my home life, my school life wasn't great either. In the 4th grade, I had a classmate named Ella who was bullied, and in retrospect I can recognize that it was because of side-effects of her bad home. She was often wearing dirty clothes and smelling as if she hadn't showered. It wasn't even the end of the school year when I started getting bullied for similar reasons. This is why I personally support the idea of public boarding schools. In an ideal world we would make society more communal, but if we could at least make it normal to send kids off to live in a healthy communal environment - even if it's not 7 days a week - would help prevent issues of mental health that spring from the home and provide a wealth of social benefits that will help kids build on top of for the rest of their lives. For an issue where I don't think there's one right answer, this is what I feel is the best option.