Commusings: An Inaccurate Map of Our Pain by Gabor Maté and Daniel Maté

Hello Commune Community,

I have the extraordinary honor to host the psychologist and physician Dr. Gabor Maté in Topanga this week to break bread, hike the trails, produce a course and celebrate the launch of his new book, The Myth of Normal: Trauma, Illness and Healing in a Toxic Culture. I can confidently say that this tome is destined to be one of the most important works of social science in a generation.
 
In my recent podcast with Gabor, he presents the book’s core premise. I will paraphrase here. 
 
Remember high school biology? Ironically, the memory may be traumatic ;-). Let’s say you put a bacterial cell in a petri dish. The petri dish is full of a jelly-like substance called agar. Now, let’s say you added quality protein, a good carbon and nitrogen source and some micronutrients to the agar. You maintained a warm temperature and slightly acidic pH balance. By creating this supportive environment, you would expect the bacteria to grow and proliferate. Now, imagine that you added a toxin to the agar like bleach, hydrogen peroxide or a radio-active compound. Your expectation would justifiably change. The bacterial cell wall would degrade and the microbe would die.
 
The scientific term for a biological medium is a “culture.”
 
Of course, there’s a potent metaphor to be conjured here. Similar to a bacterial cell, if you placed a human individual into a supportive culture, one characterized by love and community, flush with organic food, access to quality health care, housing and education, then your expectation would be that that individual would have a decent chance of growing into a happy, healthy contributing member of society.
 
However, if that culture was riddled with abuse, neglect, environmental toxins, racism, poison disguised as food and the incessant drone that you are “not enough” then your expectation for this individual would not be as rosy.
 
The cresting rates of depression, mental illness and addiction are not anomalous to our systems and structures. On the contrary, these epidemics are the normal and expected consequence of a toxic culture. If we want to tackle these issues that cause so much suffering then we need to stop focusing on only treating the symptoms. We need to go upstream and re-engineer our culture!
 
We are blessed to feature an excerpt from The Myth of Normal in today’s newsletter.

Here at [email protected] and walking the tightrope on IG @jeffkrasno.

In love, include me,
Jeff

• • •

An Inaccurate Map of Our Pain:
What We Get Wrong About Mental Illness

by Gabor Maté and Daniel Maté, excerpted from The Myth of Normal

At age nineteen, a freshman journalism student at the University of Florida, Darrell Hammond was plunged into his first experience of searing mental distress. 

“I was in unspeakable terror,” the comedian recalled. “That level of fear—I don’t even know how I survived it. The doctors were treating me for depression and paranoia, and for psychosis because I told them that I had seen someone talking, and the words didn’t come out at the same time their mouth was moving.” 

He was prescribed an antidepressant, amitriptyline, as well as the antipsychotic thioridazine. Over the subsequent decades, Hammond estimated he was evaluated by up to forty psychiatrists and labeled with multiple diagnoses, including depression, bipolar disorder, and complex PTSD, and he didn’t recall what else. The assumption that guided his treatment was the same one that dominates much of medical thinking: that such torments are caused by a biological disease of the brain. 

Accordingly, he was treated with an ever-changing cocktail of medications. Throughout years of professional success, including an unprecedented fourteen-year run on Saturday Night Live, he continued to feel lost, irritable, isolated, and despondent. The only recourses he could find to interrupt his misery were self-medicating with alcohol and overt self-harm: his body still bears the scars of over fifty self-inflicted cuts.

Thirty-five years into his psychiatric odyssey, Hammond met a clinician, Dr. Nabil Kotbi at New York City’s Weill Cornell Medical College, who changed his life with two short sentences: “I don’t want you to call what you have a mental illness. You have been injured.” 

The insight that his symptoms were not the manifestations of some mysterious medical condition, Hammond told me, “was a ‘Hallelujah Chorus’ moment . . . What [Dr. Kotbi] seemed to be saying to me was that mental illness comes from somewhere very specific. It has a story, and in that story, you’re the only one that has no power.” 

In the decades between his first encounter with the mental health system and his meeting this particular psychiatrist, no one had asked Hammond about traumatic childhood experiences. 

“I can’t describe what it was like to go into a doctor’s office, in acute pain, and have them look at me and go, ‘You shouldn’t be feeling this way.’ No one at the time was saying, ‘Hey, you’re probably a victim of child abuse.’

At that time, if you felt bad for no apparent reason, they called you bipolar. That’s all they knew. ‘He has unexplainable highs and lows,’ you know. They treated me with [the mood stabilizers] lithium and then Depakote. Neither of those were successful. Nothing was really successful until the truth about my life was acknowledged.” 

The truth of Hammond’s life included a cavalcade of abuse at the hands of his mother.

While mental ailments certainly exhibit some features of illness—the brain seeming to function like a disordered organ—mainstream psychiatry takes the biological emphasis too far, reducing everything mostly to an imbalance of DNA-dictated brain chemicals.

In its predominantly biological approach, psychiatry commits the same error as other medical specialties: it takes complex processes intricately bound with life experience and emotional development, slaps the “disease” label on them, and calls it a day. Little in the training of doctors prepares them to wonder about their patients’ lived experience, much less to seek the sources of their malaises therein. 

If anything, this limitation is especially calamitous in the realm of mental suffering, and even less justified. After all, unlike in cancer or rheumatoid arthritis, no physical findings, blood tests, biopsies, radiographs, or scans can either support or rule out psychiatric diagnoses. That statement may surprise many readers, so it bears repeating. There are no measurable physical markers of mental illness other than the subjective (a person’s description of their own mood, say) and the behavioral (sleep patterns, appetite, etc.).

Like all concepts, mental illness is a construct—a particular frame we have developed to understand a phenomenon and explain what we observe. It may be valid in some respects and erroneous in others; it most definitely isn’t objective. Unchecked, it becomes an all-encompassing lens through which we perceive and interpret. Such a way of seeing can say as much about the biases and values of the culture that gives rise to it as about the phenomenon being seen, whether a religious concept like “sinful” or a biomedical one like “mentally ill.” 

In some cultures, for example, people with visions may become prophets or shamans. In ours, most likely they would be deemed insane. One wonders how a Joan of Arc or the medieval saint and composer of sacred music Hildegard of Bingen would fare at the hands of the contemporary mental health system. I once speculated out loud, in front of an audience of hundreds, what would happen if I strode up to the prime minister of Canada and pronounced, Joan-like, that I have seen the future in which he leads the global fight against climate change, beginning with giving up his reliance on campaign funding from the fossil fuel industry.

Other than modern culture’s typical, left-brain materialist bent, how did we arrive at this view of mental illness as an essentially biologically rooted phenomenon? In part, it seems to be a holdover from a once tantalizing aspiration in medical science, a mission unaccomplished. “Psychiatry today stands on the threshold of becoming an exact science, as precise and quantifiable as molecular genetics,” wrote the journalist Jon Franklin in a Pulitzer Prize-winning series in 1984.

As with the ultimately unfulfilled promise of the genomic revolution to explain health and illness, the initial enthusiasm for the prospect of a science-based psychiatry was virtually unbounded. Nearly forty years later we are no closer to crossing this imagined threshold; if anything, we are further away. When the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published by the American Psychiatric Association in 2013, Dr. David Kupfer, head of the task force responsible for it, acknowledged as much. “In the future,” he stated in a press release, “we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

The journalist and author Robert Whitaker, formerly the  director of publications for Harvard Medical School, was a firm believer in the chemical-imbalance theory of mental illness—until he wasn’t. “When I first started writing about psychiatry, I believed that to be true,” he told me. “I mean, why wouldn’t I?” 

His disillusionment arose from research he uncovered while reporting for the Boston Globe. “I said to people, ‘Can you just tell me where you found that depression is due to serotonin or where you actually found that schizophrenia is due to too much dopamine?’ I asked to read the source materials and, I swear to God, they said, ‘Well, we didn’t really find that. It’s a metaphor.’ The most amazing thing was, when you trace it in their own research, you find they didn’t find it! The divergence from what you’re being told from what is in their own scientific literature—that’s the key—it was just stunning to me.” These conspicuous non-findings are documented in Whitaker’s book Anatomy of an Epidemic and have been corroborated in other literature. 

Contrary to what I, too, used to believe, a diagnosis like ADHD or depression or bipolar illness explains nothing. No diagnosis ever does. Diagnoses are abstractions, or summaries: sometimes helpful, always incomplete. They are professional shorthand for describing constellations of symptoms a person may report, or of other people’s observations of someone’s behavior patterns, thoughts, and emotions. For the individual in question, a diagnosis may seem to account for and validate a lifetime of experiences previously too diffuse or nebulous to put one’s finger on. That can be a first and positive step toward healing. I know this from firsthand experience.

The dead end comes when we assume or believe that the diagnosis equals an explanation—an especially futile view when it comes to illnesses of something as inherently abstract as the mind. As the British psychologist Lucy Johnstone said to me, “In physical illness you have, in principle, a way of checking it out. You can say, ‘Let’s look at the blood test or the enzyme levels.’ And you could, in most cases, confirm or disconfirm it. But in psychiatry, it’s simply a circular argument, isn’t it? Why does this person have mood swings? Because they have bipolar disorder. How do you know they have bipolar disorder? Because they have mood swings.” 

My mind goes to A. A. Milne’s Pooh and Piglet walking in the snow in an unwitting circle, shuddering as they come across yet more “Heffalump” tracks at every turn.

An oft-heard objection to mental health diagnoses, particularly with regard to children, is that they “pathologize” or “stigmatize” ordinary, healthy feelings or behaviors. Aren’t kids supposed to get bored or antsy, angry or sad? My answer would be yes—and it’s not that simple. 

While overdiagnosis is certainly a risk, I don’t see the spike in, say, ADHD cases over the past decades as being due solely to gullible parents, hapless teachers, overzealous school shrinks, and unscrupulous drug companies. The world into which kids are being born these days might as well have been designed to promote disruptions of cognitive function and emotional self-regulation. Everything I have seen tells me we are witnessing a sea change in children’s mental well-being.

Why, then, do I persist in my critique of the diagnostic model? Because diagnoses reveal nothing about the underlying events and dynamics that animate the perceptions and experiences in question. 

They keep our gaze trained on effects and not their myriad causes. There could be multiple reasons why a child may have trouble paying attention or be restless, disengaged, and fidgety: anxiety, stresses at home, boredom with material she finds uninteresting, resistance to the constraints of sitting in a classroom, fear of bullying, an authoritarian teacher, trauma—even birth month, believe it or not. 

A University of British Columbia study looked at the prescription records of almost one million B.C. schoolchildren over an eleven-year period and found that kids born in December were 39 percent more likely to be diagnosed with ADHD than classmates born the previous January. The reason? December kids entered the same grade nearly a year younger than their January counterparts—they were eleven months behind in brain development. They were being medicated not for a “genetic brain disorder” but for naturally delayed maturation of the brain circuits of attention and self-regulation.

The psychiatrist, author, and leading trauma researcher Bruce Perry  has come to disdain diagnoses almost completely. This is no knee-jerk prejudice: his dim view of the norms and practices of his field follows decades spent assessing tens of thousands of troubled children, and extensive contributions to the vast literature on adversity and what we define as “disorders.” 

“When I got into psychiatry,” Dr. Perry told me, “it became clear really quickly that the diagnoses were not connected to the physiology, that they were just descriptive, and that there were hundreds of physiological routes to somebody having an attention problem, for example. And yet the profession acted as if these descriptive labels were really a thing . . . I knew that if we were doing ‘research,’ if we were using these hollow descriptors which we call ‘diagnoses’ and then study interventions and outcomes, we would just get garbage. And that’s what we’ve done.”

Based on my observations in family practice and my understanding of human development, I have followed the same lines. When I work with any mental health condition, say depression or anxiety or ADHD or addiction, I’m not so interested in the formal diagnosis as such. My “diagnostic” focus goes to the specific challenges the person is facing in their life and the traumas animating those challenges. As for “prescriptions,” I am primarily interested in what will promote the healing of the psychic wounds the ongoing traumatic patterns represent.

Now, here’s a perhaps surprising assertion: I’m not anti-pharmacology. No one who’s felt or witnessed the beneficial effects of psychiatric drugs can deny that neurobiology must, indeed, play a role in the dynamics and potential easing of mental distress, just as it does in all our experiences.

Sometimes the healing of which I just spoke can be helped along—not made to happen, certainly, but assisted—by the intelligent use of these medications. That is not just my professional opinion but my personal experience as well.

In my mid-forties, I decided to go on the serotonin-enhancing drug Prozac. (Among the brain’s principal neurotransmitters, or chemical messengers, serotonin is believed to be active in such functions as mood regulation and the dampening of aggression.) The skepticism I harbored about this growing trend to medicate millions was eclipsed by my hunger for respite from the daily severities of my state of mind, as summed up grimly in a diary entry from that time: “I have no energy for life. I have spent every weekend for the past two months—every free weekend—in an enervated, passive, demoralized state, depressed and depressing to be with.”

I was soon a different person. Within days, my wife noted with relief the softening of my facial features. I now greeted mornings with vim instead of venom, lost my irritability around my family, smiled and laughed a lot more, and could feel and express tenderness where before I’d been cold and brittle. It was as if someone had bandaged my aching heart so that it no longer hurt or bruised at the slightest touch. I found myself marveling to my sister-in-law: “You mean people can feel like this normally? I had no idea!” 

As happens with many new converts, my initial reticence quickly gave way to a period of outsize enthusiasm. In my medical practice I became something of a Prozac booster, succumbing to the error of looking for pathology where there was only everyday unhappiness. “You have a chemical imbalance in your brain—you are lacking serotonin,” I would earnestly explain to patients in whom I detected symptoms of depression, prescription pad at the ready. 

Little did I know that I was uttering scientific nonfacts. Yes, the medication was helping me, at least in the short term. And yes, I have witnessed other cases where psychiatric drugs were life-enhancing and even lifesaving. But we have to avoid the fallacy of inferring from medication’s (in some cases) observable benefits that the proven origin of mental illness rests in the biochemistry of the brain, let alone that physiological disturbances are genetically caused.

That a medication has a certain positive effect reveals nothing about the genesis of a symptom. If aspirin eases a headache, can the headache be explained by an inherited brain deficiency of acetylsalicylic acid, the pill’s active ingredient? If a shot of bourbon relaxes you, is your tense nervous system suffering from a DNA-dictated whiskey shortage? 

There are fifty or more neurotransmitters in the brain whose complex interactions we are only now beginning to explore, not to mention the almost infinite possibilities inherent in the lifelong intersection of experience with the biology of body and brain. Once again, the physiology of the brain is a manifestation and a product of life in motion and in context.

Further, as Bruce Perry writes, “The brain is a historical organ. It stores our personal narrative.” Since it does so in the form of its chemistry and its neural networks, it is no wonder that difficult experiences may result in disturbed neurobiology. Even when brain scans show certain abnormalities—as they do, for example, in many traumatized people—these do not prove that the “disorder” has a neurochemical source.

This is a partial excerpt of Chapter 17 from THE MYTH OF NORMAL by arrangement with Avery Books, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © 2022, Gabor Maté