Tuesday, May 10, 2011

Bipolar Paradigm Swings

But seriously folks, there really is a problem with the trauma fad.  Just the other day, I had a therapist tell me, without blinking an eye, that 95% of mental illness is caused by trauma.  And, as you might imagine, coming from a therapist, the statement was made with the upmost in self-important tones with flavor highlights of virtuous condescension.

Yes, obviously, she read it off a brochure, or somewhere in all that blather on the web that has taken the place of brochures.  But where did this “fact” originate in the first place?

Looking back to the mid-20th century, there were any number of theorists who promoted the idea that schizophrenia was caused by trauma, or at least, early childhood events and social environment.  Generally speaking, dating back to this era, we have the idea that a child bonds with a parent (the word “attachment” is quite chic at the moment), the parent psychologically hurts the child’s sense of self—typically through abuse, neglect or ambivalence (this is the basic trauma)—and, the child ultimately develops schizophrenia or just about any other diagnosis you can think of for that matter.  Here we have the infamous “schizophrenicgenic” mother who relates to her child in an ambivalent or abusive manner and causes the child to become insane in adulthood.  The theoretic underpinning is the (now dated) belief that schizophrenia is a result of a weak ego that disintegrates and is overwhelmed by the id when the subject is faced with the challenges and pressures of adult life.

Essentially, childhood trauma perpetrated by an adult (to who the child is bonded) results in the development of a weak ego.  A weak ego results (later in life) in flooding of impulses and internal stimuli emanating from the subconscious.  Hence, insanity.  Neat little theory and it was quite the rage in the 50’s but slowly declined in subsequent decades and by 1990 had very little following in professional circles.

You can dig even deeper into the intellectual history of psychology.  Freud comes to mind and he had his antecedents in previous beliefs about the causes of insanity going all the way back to Plato and Hippocrates.  Hippocrates, as you might imagine, saw insanity as caused by an imbalance of humors in the body, but Plato interpreted it as reason being overwhelmed by emotion (but before you get too excited keep in mind that Plato also advocated that people who were sick and not likely to contribute should simply be killed).  This is just to point out the old nature versus nurture or, more correctly, mind (or spirit) versus body debate goes way back to ancient times and has been with us ever since.

Fast forward:  Prozac was approved by the FDA in 1987.  One of the first atypical antipsychotics, Clozaril, was made available in 1989.  The schizophrenicgenic mother idea had been on the decline for a very long time and the biomedical model was on the rise, driven by pharmaceuticals and helped along by National Alliance for the Mentally Ill, an advocacy group whose core mission was to combat the blame-the-parents stigma resultant from the schizophrenicgenic mother hypothesis.

All this is really to point out the pendulum swing in mental health ideology.  The biomedical approach was on a high in the 1990’s, most famously expressed in the NAMI slogan, “Mental Illness Is a No-Fault Brain Disease.”  At the height of it, you couldn’t use the word trauma without being jumped on and re-educated on the biological basis of mental illness.

My, how things change.  In 15 years, things have more or less reversed, and clinicians are barraged with trademarked treatment models and consumer activists and mental health reform all aimed at eradicating what we were training people in 15 years ago.  Even key players in the designing of the DSM-III and IV are coming out publicly to denounce the very basis of psychiatric diagnosing.   Now the only word that matters is trauma.  Trauma is the cause of mental illness and the only possible cure is to understand and validate the trauma.  We seem to have come full circle.  Attachment theory again finds the source of all psychopathology to emanate from problems in early attachment and early developmental trauma.  We are pretty much back to the schizophrenicgenic mother concept in all but name.*

I exaggerate only slightly for emphasis.

The, I hope obvious, problem with all this is that these bipolar paradigm swings are not based on advances in knowledge so much as fickle swings in popular sentiment.

We are simply replacing one reductionist model (mental illness is a no-fault brain disease) with another reductionist model (95% of mental illness is caused by trauma).  Not that reductionism is all bad.  Even Stephen J. Gould pointed out the crucial importance of reductionism in the scientific process.  Newton described gravity with a simple but elegant formula.  Darwin reduced all that complex biological diversity down to a few core principles of evolution.  But, this is not what we are seeing in mental health.  Although it wears the cloak of empiricism, it looks a lot more like political ideology or hopeful religious beliefs.  It all comes down to wishful thinking.  People build treatment models and cherry pick research results, all in order to bolster what they already believe or what they want to believe.

The mental health field would be a much more healthy and functional endeavor if we all just decided to be honest with ourselves and each other.  We want to help people, but we don’t really know what the hell we are doing.

* Of course, as gender beliefs have changed over the years, it is now more likely that we will see the father as the source of trauma/abuse/neglect/ambivalence as opposed to the mother.