Three Books about the Chemical Imbalance Theory of Mental Illness

Joseph Burgoin
Society and Culture
·
The Medicalization of Mental Health
20

I highly recommend the two-part article by Marcia Angell in recent issues of the New York Review of Books.   In June, she wrote a piece entitled 'The Epidemic of Mental Illness:  Why?'; then in the July issue, she followed up with another piece entitled 'The Illusions of Psychiatry.' In these two articles, she discusses several important books that address the "epidemic" of mental illness in this country, including Robert Whitaker's book
Anatomy of an Epidemic which I reviewed in three separate posts:  one about the theory that mental illness is caused by a chemical imbalance in the brain, another concerning the actual effects of psychiatric medications and the third addressing the entirely false belief that treating psychological disorders with such drugs is like taking insulin for diabetes.  Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and a former Editor in Chief of the New England Journal of Medicine; these lengthy articles are thorough and scholarly.

The other two books under review are The Emperor's New Drugs:  Exploding the Antidepressant Myth by Irving Kirsch and Unhinged:  The Trouble with Psychiatry -- a Doctor's Revelations About a Profession in Crisis by Daniel Carlat.  I haven't yet read these two latter books, but here is Marcia Angell's description of them:

"The authors emphasize different aspects of the epidemic of mental illness. Kirsch is concerned with whether antidepressants work. Whitaker, who has written an angrier book, takes on the entire spectrum of mental illness and asks whether psychoactive drugs create worse problems than they solve. Carlat, who writes more in sorrow than in anger, looks mainly at how his profession has allied itself with, and is manipulated by, the pharmaceutical industry. But despite their differences, all three are in remarkable agreement on some important matters, and they have documented their views well."

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Freud’s Theory of the Id, Ego and Superego: Lost in Translation

Joseph Burgoin
Points of Departure
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Self-Esteem and Self-Sabotage
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Sexuality
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Shame/Narcissism
16

After I had graduated from college with a degree in English Literature, I took an extension course in Introductory Psychology; with five years of therapy under my belt, I had decided to begin graduate school in order to become a psychotherapist and I needed some basic coursework in that area.  I well remember the day the instructor delivered his lecture on Freudian psychology, explaining the tri-partite division of the mind into id, ego and superego.  With great scorn, he presented Freud's theory as if those well-known terms represented actual sectors of the brain; I believe he even drew a pie-chart on the chalkboard, reducing Freud's insights to an absurdly simplistic form, and mocked it. I don't think the instructor's attitude was particularly rare.  Freud has gone into disrepute -- for some legitimate reasons, I suppose; but having read and re-read all 24 volumes of Freud's works, and taught them repeatedly to graduate students, I'm full of regret that more people don't understand how truly amazing, insightful and ground-breaking a thinker he was.  He also won the Goethe Prize for Literature -- he's a fabulous writer.

One of the challenges of reading Freud is the official translation into English, prepared under the supervision of James Strachey at the British Psychoanalytic Institute, between 1943 and 1974.  While a meticulous piece of scholarship, and an indispensable resource for anyone truly interested in Freud, The Standard Edition of the Complete Psychological Works of Sigmund Freud regularly substitutes clinical-scientific words for the everyday expressive language employed by Freud in German. One of the most important of these concerns the translation of das Es, das Ich and das Uber-Ich into the id, ego and super-ego, respectively.  (These terms actually go back to earlier efforts by Ernest Jones to bring Freud to the English-speaking world; Strachey and his team adopted those translations as they had already gained acceptance.)  A literal translation would be "the I", "the It", and "the Over-I".   Those terms have a very different feel -- less conceptual and scientific, more in the realm of our actual experience.

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A Hiking Meditation

Joseph Burgoin
Defense Mechanisms
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Destinations
·
Unbearable Emotion
13

We're in Colorado now for the summer, and last weekend, we took our first hike.  Because my mind is prone to chatter at such times, I try to turn these hikes into a kind of walking meditation:  focusing on my breath, my bodily sensations and the natural beauty here in the Rockies.  I would say that I was successful in reaching silence about 5-10% of the time, and not for sustained periods.  In part, this is just the way my mind works; "thinking" has always been one of my primary defense mechanisms, and it's deeply ingrained in my neural pathways.  Also, because I'm so focused on writing this blog, in my thoughts I'm continually composing descriptions of what I notice, putting my observations into words that I can later post.  Last week's hike was no different.

At the same time, those brief periods of quiet during the hike helped to calm me, after the stresses of the week.  I also made some interesting observations about why and when I found it more difficult to achieve quiet.  It gave me some insight into the origins of defenses and their connection to pain.  While in my case, it had to do with physical pain, there's also a relationship between defense mechanisms and emotional/psychic pain.  These ideas connect to some thoughts concerning helpless I put forward in my post about post-traumatic stress disorder.

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Why Empathy Fails

Joseph Burgoin
Defense Mechanisms
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Points of Departure
·
The Psychotherapy Relationship
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Unbearable Emotion
38

In order to empathize with another person, you have to recognize that he actually exists apart from and without specific reference to you.  You must understand that she has a distinct identity and an interior life of her own, with which you might possibly empathize.  While there are some interesting exceptions to this rule, it's a useful place to start a discussion of why some people can't empathize, or why their ability to feel empathy is severely restricted.  We can look at the spectrum of psychological disorders in terms of ability to recognize and tolerate separateness, then understand the ways that this ability will limit our capacity to feel for other people.

In psychotic disorders, for example, where splitting and projection dominate, other people serve as containers for disowned parts of our own psyche.  As a result, we may try to avoid them -- annihilate them, in the most profound cases; or if idealization is involved, we may want to merge with and "own" them instead (think celebrity stalkers, for instance).  But because we're so busy projecting into them, we can't see those people for who they really are; we can't empathize with their internal experience.  People who present with autism symptoms famously lack the ability to empathize.  Autistic defenses seek either to shut out the external world because it feels too threatening (shell-like defenses) or to obscure and erase personal boundaries because separateness is intolerable (confusional defenses); the awareness of other people as separate and distinct is therefore severely compromised. Empathy is virtually impossible.

Lack of empathy is a primary diagnostic criteria for narcissistic personality disorder, as well.  For these individuals, other people serve mainly to provide narcissistic feedback or to contain our shame.  If you exist (in my personal universe) merely in order to admire me, then I can't see who you are or how you feel.  If you exist so that I may feel superior to you (the container for all my projected damage), I likewise can't empathize with your actual feelings.  Even in less troubled people, narcissistic behavior of various kinds reflects a limited ability to recognize or take an interest in others, restricting the capacity to empathize with them.  This is an experience we've all had in our everyday lives:  the self-absorbed friend who talks on and on about herself, or dumps his problems into us, with no interest in us or our feelings.  (I discussed this dynamic in my post on the toilet function of friendship.)

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Working with Borderline Personality Disorder

Joseph Burgoin
Love and Hatred
·
The Psychotherapy Relationship
278

Over the years, I've worked long-term with a number of clients who presented as borderline personality disorder symptoms, and also short-term (i.e., unsuccessfully) with many more.  As a graduate student, early in my internship, the director of our clinic identified me as someone who could work with the more difficult and disturbed clients who came for treatment.  Even after I earned my license and went into private practice, my colleagues sent me such cases.  Low person on the totem pole often gets the least desirable referrals -- that is, the ones who can't afford to pay your full fee and at the same time make you work ten times as hard.

If I have a speciality, it is borderline personality disorder treatment; it's the type of work I find most rewarding, despite its challenges, and where I do my best work.  I suspect that most therapists prefer to work with the YAVIS client (an acronym that stands for Young, Attractive, Verbal, Intelligent and Successful), but I find I don't do as well with such people.  In part, it's because their defenses work so much better at blocking out the really difficult emotions and conflicts (the sort of issues I usually address); it takes much longer to shed light on those feelings, even when I can detect them, and I often push too hard too soon.  I work in the transference, and with the YAVIS client, it usually takes much longer to develop.

With borderline personality disorder treatment, the transference begins when you open the door on the very first day you meet (it may also begin that way with other clients, but it's less obvious and harder to detect).  For example, at the clinic where I first worked as an intern, I went out to greet a new client for her second or third session and she said, passing by me into the corridor that led to my office, "She's back there waiting for you."  As I understood it, she had instantly split off and expelled the needy party of herself and left her behind in the waiting room.  (The YAVIS client would never say such a thing!)  This client had developed an instant, intense and unbearable attachment to me though we'd met just once or twice before; after only a session or two, the breaks between sessions felt like unbearable abandonment.

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