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.


  1. I think swinging too far in either direction is probably not helpful. Biological or nurture reductionism don't cover the whole picture and we are discovering that a lot of the time it's not only a "mix" of the two, but an interaction. Epigenetics is only in its infancy but it has already provided some interesting insights on this (such as type of early nurture modifying the expression of neurotransmitter receptor genes in different areas of the brain, in rodent studies).

    I agree that there's an unfortunate tendency for these issues to become politicised (e.g. my example above could be translated by "pop science journalism" into "bad mothering leads to increased stress levels in children"), because most people are not very science-literate, media and politicians want soundbites, etc. (But what's new? Science, being a cultural practice, and serving purposes that are ultimately cultural, has pretty much always been used to justify/fuel the prejudices du jour.)

  2. Ah, to be crazy. In the famous words of Seal "We're never gonna' survive unless we get a little crazy."

    I think a distinction has to be made between crazy good and crazy bad. I mean, i'm of the opinion that parajumpers (you know, "so that others may live") who jump out into enemy territory to rescue downed pilots are "gone batty nutzoid insane", but nobody in their life would say that they need treatment, or would they?

    Anyway, "trauma bad for the mind", this is pretty much a no brainer (perhaps literally).

    But in terms of biology, what is there really to say? I guess if schizophrenia runs in the family, then there may be some gene that causes it...

    The thing that i find ironic about antipsychotic medication, as someone who has been on them (i know right, now everything i've said has been tainted), is that they essentially do the same kind of numbing that analgesics do. Perhaps not to the same extent, but i suspect resperidone, as well as prozac and the others just takes a person down a few notches so that their manic episodes become a thing of the past.

  3. "All mental illness is caused by trauma."
    "Oh right. What about this guy, who's never suffered trauma?"
    "He has. His mother was a bit too cold/warm/distant/present. Or maybe his father. Or his cat."
    "That's not 'trauma'."
    "It is now".

  4. Epigenetics is going to be big part if psychiatric understanding in the future. I think it is inevitable. As one of my old professors was so fond of repeating endlessly, "It is not nature versus nurture; it is nature and nurture!" It, of course, is the interaction. There are plenty of familiar examples on the physical side like physical hight, for instance, multiple genes in interaction with multiple environmental factors, particularly diet. Diabetes. Heart disease. Just to name a few.

    But for now, if we want to be truthful, we have to say the etiology of schizophrenia remains unclear. We don't even know if it is a single thing.

  5. Clinicians always seem to talk a lot about 'evidence-based practice' but tend to not be quite so keen when it comes to actually, y'know, practicing in an evidence-based way.

    Also - love Neuroskeptic's comment above!

  6. Using trauma and trauma theories to explain many psychiatric illnesses does a huge disservice to the people who have sustained traumas of all sorts.

    It waters-down the seriousness of trauma as it stands alone rather than as a cause of everything.

    The people who sustain trauma are then marginalized.

  7. "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." This statement should be posted in every office and in the opening paragraphs of every DSM and mental health publication. Honesty and an admission of ignorance leads to true understanding and an abolition of said ignorance. http://thelimitlessman.com

  8. IMHO, if you ask the people who research the background factors in mental illness you WILL NOT find a division between supporters of "trauma" and supporters of "biology". The PRESS is more likely to emphasise one or the other to get attention= $$. The "schizophrenogenic mother" vs. "antipsychiatry" proponents were really very small, extreme groups during their time, too, while most clinicians & social workers were trying to steer a path between conflicting theories & cold hard realities in the lives of patients & clients. Current clinicians have their own individual biases as well, but most bring a large repertoire of techniques to their treatment settings. Younger clinicians & of course, trainees, are often more "wedded" to one side of the argument, but usually mellow out & become more balanced with experience. I'm quite amazed at how flexible my own shrink seems compared with when she was 20 years younger & in a different context!

  9. Yes you make a good point. I do think (and hope) that researchers have a greater grasp of multifactoral models and ideas. Clinicians also, for the most part, tend toward an eclectic and complex view. But that being said, the loudest clinicians (and consumer advocates) tend to speak too often in reductionist language and always in psychology there are "fads" that sweep through the field fueled by popular culture as much as anything else I suppose.