Mental illness discussions

[liv]

I am not sure I should really wade into this, because this kind of topic can really easily turn into non-mentally-ill people pontificating about how people with actual mental illnesses should live their lives while obliviously forgetting that they are likely to be talking to people who have actual personal experience. At the same time I think there is a big problem with prejudice against people with mental illnesses (as well as lack of access to treatment, which in some ways is connected to prejudice) and that's something I want to challenge.

A while back sonia linked to this article arguing that anti-depressant medications don't really work by increasing brain serotonin. I don't know whether this claim is really true; I don't have enough of a neuropharmacology background to know whether it's a crackpot theory or simply a minority but evidence-based view. The article appears on a site which is explicitly taking an anti-medication stance, and there's a lot of "evil pharmaceutical companies" business in it. OTOH there's peer-reviewed citations a couple of links deep. Since I hadn't come across this view before at all, I thought it was worth passing on as a possible hypothesis at least.

I also find it basically credible that drugs developed (and, yes, marketed) as "selective serotonin reuptake inhibitors" don't in fact exert their effects by increasing levels of serotonin in the brain. Most drugs don't turn out to operate by the mechanism originally proposed when the drugs were being developed, once they're in general clinical use and people start testing the original hypothesis to failure. SSRIs might very well be like that too. And it may be true, as some of the sources linked from Cassani's article claim, that depression in turn has a more complex aetiology than simply a deficiency of brain serotonin. Depression may well be several different diseases with an overlapping set of symptoms; for a start, bipolar depression isn't the same as depression.

The question I find interesting is, what's the moral consequence of this? You could conclude, as some of the Beyond Meds circle seem to, that SSRIs actually don't work at all, they're just expensive placebos sold to gullible and desperate people (who may not even actually be ill, just perhaps naturally unhappy at living in a fractured society) by evil pharmaceutical companies. I don't think this at all follows from the idea that SSRIs may not work the way their acronym claims, though. It seems to me equally likely that SSRIs are effective for some people with depression and related mental illnesses – though most certainly not for all – but we simply don't understand exactly how they work yet. That's scientifically interesting, of course, but a far more vital question than how SSRIs work on a molecular level, is whether they work, whether they actually do more good through improving mood disorders, than harm through side effects. That is still very much an open question, and can really only be solved empirically.

The problem with this line of argument is that there's an often unstated assumption that depression is only a "real" illness if it can be cured by taking a drug that has a known molecular target to explain its mechanism of action. If that's not the case, then some people are going to argue that depression is purely "imaginary," a moral failing, not an illness. And some more sympathetic people are going to argue that depression is essentially a social construct, a symptom of oppression, not a "medical" condition. There's some discussion in the linked articles from the Beyond Meds piece of psychiatrists, who themselves believe that the evidence is against the classical model of how SSRIs work, telling their patients that they do work by increasing serotonin levels, because being told that white lie helps to overcome the stigma of having a mental illness. But that makes no actual sense; why should it be somehow more respectable to have an illness caused by a chemical imbalance in your brain, than to have an illness whose origin is, so to speak "purely" psychological?

That connects to a discussion I've seen the edges of floating around social media. I haven't traced the outrage to its origin but as far as I can gather someone with a prominent platform declared that exercise is better for depression than medication. I imagine this may well be connected to the rather insensitive recent Mental Health Awareness Week campaign which was very big on the benefits exercise but didn't really make any allowances for the fact that not all depressed people have equal access or ability to do physical exercise (H/T to kaberett for thoroughly shredding the fail there.)

The thing is, it is literally true that exercise is "better" for depression than pharmaceutical antidepressants, in the sense that in well-designed, large-scale trials, exercise has better outcomes than medication. But that's an anti-helpful statement to be trumpeting completely out of context, because what well-designed trials also show is that the only really effective way to treat depression is a combination of exercise, drugs and psychological therapy (people argue about CBT versus talk therapies, but some kind of expert support is clearly important). Now, some people can't take drugs because they can't tolerate them, and some people can't do exercise because of physical limitations; the last thing I want to do is to blame depressed people who are in those unfortunate situations. But the fact is that therapy alone helps a small proportion of people a little bit, drugs alone help a small proportion of people a little bit, assuming you get the right match between drug and individual, which usually takes substantial trial and error. And increased physical activity helps slightly more people a little bit, but really you need all three and even then lots of depressed people never get completely better. So it's not meaningfully correct to say that "exercise is better than medication".

So I am somewhat in sympathy with the outraged people. But some of the outrage was over the fact that if you spread the word that exercise is (somewhat) effective for depression, it will add to stigma against depression and other mental illnesses. Again, this seems to be based on the faulty assumption that illnesses are only "real" if you treat them with drugs! Depression is a real illness, and a very serious illness; it also happens to be somewhat improved by physical exercise for some people. That doesn't mean that depression is caused by people being lazy bums and not going to the gym often enough. It doesn't change the fact that depressed people also need therapy and some may need medication as well and everybody needs to be accepted in society and not blamed or ostracised for their illness. If anything is generally accepted to be a real illness it's a heart attack, and people who have had heart-attacks are also advised to do regular gentle exercise to reduce the chances of a recurrence; that's not to say that heart-attacks are purely made up as an excuse to be lazy!

The other thing that social media is outraged about at the moment is that there was a rather nasty violent crime in London yesterday, and people are valiantly trying to hold back the tide of racists who want to hold all Muslims responsible because these particular attackers happen to be Muslim. The problem is that some of these people are making comments along the lines of, they didn't kill that guy because they're Muslim, they killed him because they're crazy, violent nutters. Which. Doesn't exactly help! It's not right to blame a billion Muslims for the evil actions of two Muslims, and it's also not right to blame a billion people with mental illnesses for the evil actions of two people whose mental health history we know nothing about. Now, some people might say that when they call a violent criminal a lunatic, they're not referring to respectable illnesses like depression, but only to "major" mental illnesses which are somewhat associated with violent behaviour. For one thing this general stigma against "crazy" people affects everybody, and anyway it's not right to stigmatize any mentally ill people at all, even if you restrict the particular conditions you blame.

At the same time, there certainly are some mental illnesses that, untreated, can sometimes lead to violent outbursts. It's dangerous to ignore that, as much to the people who themselves live with major mental illness as to the general public. In the course of the discussion, somebody linked to the following article about a man who actually does suffer from schizophrenia and who is currently in the process of pleading not guilty by reason of insanity to the murder of his father. The article is very much a typical Mother Jones offering, talking about very distressing and emotive things in a quasi-objective tone, and immediately inclined to blame all badness on the government's lack of effective anti-badness measures. The tone felt somewhat othering to me as a reader; there's a little bit of a sense that "we" have to do something about the terrible danger posed by those dangerous crazy people. I mean, to be fair McClelland is coming to terms with the fact that a member of her family brutally murdered another relative, so she's not exactly in the best position to see things from the point of view of mentally ill folk.

I think the most charitable reading of the McClelland piece is not so much as an argument that society should be more willing to resort to forced treatment to restrain mentally ill people from becoming dangerously violent. Rather, she holds that there really needs to be a far better safety net of voluntary treatment available before people get to the point of "danger to self and others" where the only alternatives are to treat and confine them against their consent or to let them go on murdering rampages. The article of course is American, but I can see a trend towards similar problems in this country, because mental health services have been so severely curtailed over the last few decades. I am aware of too many incidences of mentally ill people in Britain not being able to access any sort of help or support until it's really too late.

At the point where someone is actively suicidal and / or violently endangering others, at the point where they are too distressed, paranoid etc to make a rational decision about whether they want to take the offered medication or be confined for their own safety, there really are no good options left. Equally, if your only treatment paradigm is about forcing people to take medication or to be locked up or even institutionalized long-term, that's going to make people extremely reluctant to seek help with any kind of mental illness while they are lucid enough to be able to make the decision. Because in fact it is perfectly rational to refuse treatment if the treatment means completely removing all your autonomy! It's also the case that prejudice and stigma against mentally ill people has huge influence on the sorts of actions that the medical establishment is likely to regard as being for the patient's good, even if you concede that in some circumstances people simply can't make rational decisions for themselves.

What I don't know here is how to use rhetoric responsibly. It does a lot of harm to imply that all mentally ill people, or all people with certain categories of mental illness, are dangerously violent. But it also does harm to pretend that mental illness can easily be handled by just, you know, having a "positive attitude"; decent mental health provision is absolutely necessary, both for people with mental illnesses and for wider society. I suppose I want to argue that people should be able to get help because it's morally right that we take collective responsibility for treating the sick, not necessarily because otherwise they might go on a rampage and murder their carers or some innocent bystander. And I want to argue for this in a way that isn't about making me, as a non-mentally-ill person, feel safer at the expense of others.

Comments

[kaberett]

I want to preface this comment by saying that I don't disagree with you, and I don't think you're saying anything, I just felt the desire to vent. ;)

[CONTENT NOTE: graphic discussion of my experiences of depression.]

I get so absolutely spittingly furious with anyone who tells me I'm a dupe of big pharma for any reason. We don't know how my endometriosis works, but we know it's there! We don't know precisely how a bunch of my pain medications work, but we know they do!

And we don't know how my anti-depressants work but they do. It's like... I don't know, turning a dial that has discrete indicators: at 10mg of citalopram, I stopped being actively suicidal. At 20mg, my overall baseline mood changed to light grey. At 30mg, my baseline mood changed to cheerful, and I started wanting to learn again. And when, recently, I decreased my dosage from 40mg to 30mg? BAM, intrusive negative thoughts.

But! Additionally! As I keep going on about, the skills I'm learning in counselling are also vital to the ADs doing their job - because I'm learning to recognise negative spirals when they start, and to recognise that they don't make me weak or fallible or undeserving, and to DO SOMETHING about them before I come to in a city-centre shopping arcade and realise I've been muttering "I hate myself and want to die" out loud on loop for... longer than I can work out.

And exercise! It's fantastic for me, and for my mood, if I am mildly to moderately depressed and iff my physical health is such that I'm not going to spend a week sleeping (with knock-on effects on all other aspects of my life) after every bout of it.

And, yes, I think a lot of the problem comes in when people try to control what treatment others seek: when you get concern-trolls going on about Big Pharma Conspiracies and how this means you should Only Do Exercise, or how Shrinks Are For Crazy People, and... we don't need that toxic bullshit making it harder for us to make authentic choices about what will do us the most good, about what we're willing to experiment with right now. IN SUMMARY: one-size-fits-all approaches are bullshit.

I think the thing about mental illness not being treated as "real" unless there's an obvious biochemical cause we can point to is... very much ingrained in the dichotomy between visible and invisible illness/disability (which is a division I greatly prefer to mental/physical, which AFAIC is false categorisation based on the limits of our understanding). rah/synecdochic has great (or possibly horrifying) anecdotes about the way reactions to her moving slowly using her walking stick/wheelchair change depending on how recently she's shaved her head (so "looks like" she's in chemo) versus having longer hair (so she "looks like" she's a "healthy young woman"). And I suspect it's also that we fear what we don't understand: a broken leg is something it's very easy to wrap your head around, in terms of mechanics and prognosis and healing time; invisible illnesses, especially ones affecting cognitive function, are I think so scary in part because how can I make sure that doesn't happen to me? So if you pinpoint a chemical cause, there's Something Wrong That Can Be Fixed; if you don't, it could strike any one at any time, so there's huge emotional investment in "well, clearly it's your own fault, and if you just TRIED HARDER..." (And yes, I am deliberately drawing the analogy with victim-blaming there.)

Have you read Susan Sontag's Illness As Metaphor? It focuses on TB and cancer/AIDS, but I think it's got a lot of relevance (and does discuss how cultural ideas of TB shifted with increased medical understanding of the condition). Would be happy to lend you my copy if you'd be interested, next time we're colocated!

[kaberett]

I WORDSED EVERYWHERE. Sorry.

The other thing I want to say is that I think being actively suicidal is qualitatively different from violently endangering third parties. But that is perhaps a conversation for another time.

[jenett]

One of my friends did a hugely great riff on Hollywood Broken Leg Syndrome (which is to say, even broken legs are not always that simple) that seems relevant here. (She mentions saying that the person who got her thinking about it wrote a friendslocked post: I'll say here, with two+ years remove, that that person was me...)

Anyway, I recommend http://mrissa.livejournal.com/723084.html

The thing it always gets me thinking about when I reread it is not just the "How can I make that not happen to me." part - but also the "You will be *done* with this sometime, right?" part.

Which is not the case in chronic illness. It just .. I mean, it's right in the label. Chronic. Stuff may get better or may get worse, or may change in quality among half a dozen other spectra. But it's probably still there.

(For the record: the health foo in my case turned out to be thyroid issues and vitamin D deficiency. They both messed my brain up *good* for a while - I completely lost executive function skills for about 9 months, and it's brought in some patterns around anxiety and very very specific mood shifts that I didn't have. But it's also very clearly "I take a pill and things are not *all* better, but they are much better, and I can then apply the other coping skills I now have energy and focus and attention for, so that I can fix the remaining side effects/symptoms/residual bits." Because my body? It just does not make the one hormone enough, and it does not store the vitamin enough. I don't see any reason why brain chemistry is that different from the rest of the body.)

[liv]

Thank you, this is an awesome rant. I am really glad that you found an anti-depressant that works for you. I don't in the least think you're a dupe of Big Pharma because you use drugs to help manage various of your conditions. I obviously care about mechanism, that's my research after all, but whether drugs work is a vastly more important question than how.

I think you're absolutely right about one-size-fits-all. Depression is a complex illness, people and their lives are complicated, there's not one definitive treatment. I have a bit of a theory that it's connected to the thing I rant about sometimes about people's misconceptions of what science is. There's this idea that because medicine is a scientific discipline these days, there should be one right answer. jenett below linked to the "chronic illness is not a broken leg" rant; I think there's a similar thing about how most of medicine is not like antibiotics.

Good point about invisible versus visible. I think that's not quite the same thing as mental or physical; endometriosis is pretty convincingly both an invisible illness and a physical illness. But I do also agree that mental versus physical is in many circumstances not a helpful dichotomy. I think sometimes it's useful to know whether a person is more likely to benefit from, say, surgery or counselling, because making the inappropriate choice is going to be harmful. But all illnesses have a psychological component because the experience of the illness is part of the person's experience and therefore their psychology, and all illnesses have a physical component if nothing else because brains are made out of stuff.

There's some really interesting stuff going on across the department from me about diagnosing and treating depression in elderly patients who present with back pain or arthritis. Turns out that people's experience of pain is much better correlated with their depression scores than with musculoskeletal features visible by radiology. And I don't think anyone's claiming that eg osteoarthritis is a primarily psychological illness!

You're quite right about victim blaming as a way to shield oneself from the fear that this random bad thing might happen to you. And the stereotyping that you can judge someone's medical condition by looking at them ties into that too.

I'm very interested in Sontag's book, I've not read it, I've only seen your very enthusiastic post about the introduction! jack has my copy of Triton to lend you, and plausibly he could borrow the Sontag on my behalf? Otherwise, are you likely to be at beer festival this weekend, or potentially available to meet up on Monday?

[pretty_panther]

Urgh. I hate when people try to say that these drugs don't work. They won't work for everyone but nothing ever works for everyone. For some people these drugs save their life. I deal with my depression with meds and therapy and so does my mother but for a long time it was just the pills to slowly pull her out of it because she was so deep down that she wouldn't go to therapy. She wouldn't do anything, period. Plus, I'm sure plenty of people that have forgotten their meds for a day will attest to the withdrawal freak out the body goes through. Placebos won't do that. It is like you say, different things work for different people and not all people can exercise or take meds or engage in therapy. I can't exercise on a regular basis and even if I do exercise I'm one of those rare folks that gets no endorphin rush. I just...I hate that people try to make mental health simple because it just isn't in any way.

I'm still gathering my thoughts on the attack to be honest. I'm still trying to decide if I believe it is a terror attack or just a one-off incident that happens to be shocking and happens to be by two muslims.

[liv]

There are some people who are philosophically anti meds, and I have varying degrees of sympathy for that view. I mean, from poking around on the Beyond Meds site it looks like Cassani herself is one of the people who were unlucky enough to experience bad long-term side-effects of her anti-depressant medication, so I'm not surprised that she is opposed to the drugs. She says somewhere in an introductory post: I’m also extremely open to the huge differences in our personal experiences and have great respect for the choices individuals make whether they choose to medicate or not, which seems pretty fair to me.

I am glad that you've been able to find some drugs have proved effective for your and your mother. Anecdotally I've quite often heard that people need anti-depressant medication to be in a position where they can engage with therapy or commit to regular exercise, even if ends up being those activities that eventually help them recover. Mental health isn't simple, all of health isn't simple. If you can't exercise you can't, if exercise doesn't do much for you then that's how it is, it's not you that's wrong, it's the theory that's over-simplistic.

I think you're extremely sensible to wait to gather your thoughts about the shocking attack. Much better idea than this minute-by-minute news/social media/ cycle where everybody has to have an opinion within five minutes of seeing the headline!

[randomling]

I'm struggling to have useful stuff to contribute here, but I wanted to say that I read this, and it was a really interesting read. I'm also someone who has depression, and this didn't read offensive or wrongheaded to me.

And I agree that taking collective responsibility for treating the sick is a moral obligation of society's.

So... um, yeah, I'm not very articulate at the moment, but thank you for writing this.

[liv]

Thank you, I'm really glad you found this interesting and non-offensive. Don't worry, I won't take you as the spokesperson for all depressed people everywhere, I'm still open to being told that I've got it wrong as a non-depressed person. But the fact that it didn't offend you is comforting, and thank you for commenting to say so.

[monanotlisa]

Interesting; thanks for outlining some of these issues.

[liv]

Cheers, glad you found it interesting. Do read all the comments, there's some awesome stuff in the discussion because my friends are often more knowledgeable and wiser than me.

[azurelunatic]

I think perhaps the thing to remember is that mental illness, treated or untreated, is under most circumstances the hardest on the person experiencing it. Not the people around them, even though it's not easy living with a person who has a mental illness. Mental illness is *crap* to live with, otherwise it wouldn't be an illness. I don't know what the statistics are in the UK for people with mental illness as victims of violence, but I am betting that it is similar to the US stats, which are Bad.

So if you've got an illness that's making you feel like crap, it needs to be treated. Hints that your illness is making you feel like crap include it getting in the way of school or work, getting in the way of fun things you wanted to do, having to very carefully weigh the cost of doing the fun thing you wanted to do vs. the effort and/or pain and/or other side effects associated with doing the fun thing you wanted to do. (Hints that your job or school may be crap and/or abusive: you are very willing and able to do the fun things you wanted to do, but the thought of going to work/school makes you want to kill yourself, and/or you find yourself making excuses about why you can't go to work/school, but you're happy to spend work/study-like time and effort on a hobby.)

There are often barriers to getting treatment: stigma; in the US, cost; from what I've heard of the UK, sometimes doctors not taking someone seriously; lack of medical understanding of the available treatments; lack of medical understanding in pairing effective treatment to patient; lack of any effective treatment at all for the underlying cause.

[azurelunatic]

(I have depression which is currently under control with a combination of past counseling, and current St. John's Wort, vitamin D, and caffeine. I would like to get evaluated for the attention focus problem spectrum, if my insurance will cover it and I can focus enough on the topic to arrange an appointment.)

Recognition of what it's like *to* live with an untreated invisible illness, and to convey that this isn't "normal", and that it's possible to do things to make it not suck so much, would probably help too. Depression runs in my family, and in retrospect, my father railing on about people who were "weak enough" to kill themselves was probably him speaking out of fear that one day his control might slip at the crucial moment, and he might kill himself too. Recognizing that it is in fact possible for people to go through their lives without various symptoms like regular suicidal ideation, and that if you're experiencing this symptom, you should probably get it checked out, is one of the first steps. No, actually, *not* everyone spends their day like that.

Hating yourself so much that you'd prefer to be dead is very unpleasant, and it's possible to actually sort of enjoy your own company.
Embarrassment is a thing that happens, and wishing you were dead when it happens is unpleasant; it shouldn't have to ruin your day/week/month.
Stumbling through your day with grey zero emotions except occasionally on special occasions when you might get happy, or maybe you get mad occasionally, is very dull, and it's nice to experience the brief pleasure of a good cuppa, even though the obnoxiousness of routine obnoxious tasks is wearing.
Feeling a zapping sensation from inside your brain is a thing that can happen, and without anyone having installed any chips or anything; you should probably get that checked out if it happens a lot. (It can also be very unpleasant; I imagine I'd be very cross about it if it happened to me more than every once in a very great while, mostly when I was a teenager.)
Spending a significant amount of time thinking about all the horrible things that might happen, especially in an unfamiliar situation, can be sort of comforting because if you think of all the possibilities then you'll be prepared, but if it's keeping you from doing things that might be fun that other people seem to be unconcerned about, or keeping you up, it might be affecting stuff?

Et cetera.

[kaberett]

The thing that stopped me seeking appropriate treatment for my depression - for years - was the conviction that people wouldn't take my chronic pain seriously as an independent feature, chalking it up to somatisation of depression instead of SEVERE FUCKING ENDOMETRIOSIS. Ahem.

[liv]

Yes, absolutely this. That's why I'm not really totally happy with the Mother Jones piece which seems to veer towards "oh, it's so haaaaaard having a schizophrenic family member!" Sometimes it's bad for society if somebody's mental illness causes them to commit violent crimes, but it's always bad to be the actual person who has the mental illness, and that's got to be more important.

And yes, you're absolutely right about the barriers to treatment, including the fact that there isn't any effective, tolerable treatment for a lot of conditions. I do agree that stigma is one such barrier, and that's why I'm pushing back against the mental illness = amoral and violent stereotype.

[highlyeccentric]

On the Sterotonin thing, this may be a more reliable coverage of the issue? What I took away from that is that SSRIs work, but not because the depressed brain has a natively low level of sterotonin.

[highlyeccentric]

Ah, i see, the beyond meds post also linked to that! Well, I got it from FreeThoughtBlogs, and a generally pro-meds blogger.

[rachelmanija]

Yes, I'm not sure why the "depression is caused by low serotonin" thing has such wide currency. People assume that if SSRIs increase the amount of serotonin in circulation, and doing that makes their depression go away, then the depression must have been caused by a serotonin deficiency. But that doesn't necessarily follow. You might as well say that if taking aspirin cures a headache, then headaches must be caused by an aspirin deficiency.

I think there is some sort of actual link between depression and neurotransmitters (not just serotonin), unlike my headache/aspirin analogy. But I think it's a much more complicated and variable one.

To start with, I don't think that depression is a single illness with a single cause, course, or treatment. I think it's more like cancer - hundreds or even thousands of different illnesses with enough similar traits that it makes sense to have an umbrella term.

(Student therapist, person with history of depression, have taken Prozac.)

[nicki]

The problem with treating mental illness is that we are essentially still at the treating symptomology stage. So it's like treating a patient with "fever" was in the olden days: asprin works for a little while but the fever comes back, certain kinds of breadmold can help but not always, does fever come from wounds? sometimes. Um, bad night air?

We don't really know the root causes of the group of symptoms we label as "depression" though we're pretty sure they aren't all the same, so the treatment plans aren't always as much a routine structure as we might prefer.

[liv]

Nice analogy, yes. It's naturally appealing to me to conclude, ok, we don't really know how all this stuff works, let's DO MORE RESEARCH! And yes, I agree that depression may well be more like a syndrome than a specific illness with a single, obvious treatment.

[siderea]

You trolling me? ;)

The idea that Selective Serotonin Reuptake Inhibitors don't actually selectively inhibit serotonin reuptake was old news to me when we discussed it in my pharm class, in the winter of 2008. Various other theories have been floated; I haven't kept up.

And yes, not understanding a mechanism is entirely different from saying something doesn't work. We had scurvy nailed well over a hundred years before we knew what a vitamin was.

There's some discussion in the linked articles from the Beyond Meds piece of psychiatrists, who themselves believe that the evidence is against the classical model of how SSRIs work, telling their patients that they do work by increasing serotonin levels, because being told that white lie helps to overcome the stigma of having a mental illness. But that makes no actual sense; why should it be somehow more respectable to have an illness caused by a chemical imbalance in your brain, than to have an illness whose origin is, so to speak "purely" psychological?

Yes, well, welcome to psychology: just because something makes no sense, doesn't mean it isn't true. :)

This is a big thing, these days, and it makes my skin crawl a bit, the way some clinicians use it, but a lot of people find the idea of their mental illness being an electro-mechanical short in their noggins to be greatly relieving. I have vasty vast amounts to say on this topic, and the underlying sense that it does make (see "folk psychology") but I have to go to bed.

CBT versus talk therapies

CBT is a talk therapy. The opposite of CBT is "all the other sorts of psychotherapy besides CBT".

Please be warned, I have a massive rant on this topic, too. CBT meant something once upon a time. It increasingly is a snakeoil term. A recent study in the UK of practitioners claiming to do CBT found only something like a third of them to actual do anything in session recognizable as CBT, and that one thing was, IMO, the least justifiable as "CBT". "CBT" has become massively debased. Anyone can call anything "CBT". (None of which to say that the original CBT didn't have its own intrinsic problems.)

And don't even get me started about supposedly "Evidenced Based Practice".

The problem is that some of these people are making comments along the lines of, they didn't kill that guy because they're Muslim, they killed him because they're crazy, violent nutters. Which. Doesn't exactly help! It's not right to blame a billion Muslims for the evil actions of two Muslims, and it's also not right to blame a billion people with mental illnesses for the evil actions of two people whose mental health history we know nothing about.

Sorry, strongly disagree with you.

1) Pointing out that the suspects in a terrible crime might be mentally ill is not blaming a billion people with mental illnesses for two people's evil actions. It's pointing out that they might be mentally ill, and that might have something to do with their actions.

2) There's a term for the way people whose mental illnesses don't involve violence towards others repress the discussion of disorders that do have violence as a symptom, and repress the discussion of the symptoms and life circumstances of people who do have violent symptoms. That term is privilege.

There are a whole bunch of not-too-rare mental illnesses which have violent symptoms. Could everybody suck it up and deal? Thanks. I know its frustrating to have to let them in to the tent, too. It would be so much more convenient to insist that they didn't exist, or at least don't count. That way the image of people with mental illnesses could get cleaned up so those who pass could get social acceptance.

Yeah, the Gay Civil Rights movement tried that in the 70s and 80s, throwing Trans* people under the bus for the sake of social acceptability with straights. The contemporaneous Second Wave Feminist Movement had internecine warfare over whether to tolerate Lesbians, or whether that would just validate fears that all Feminists were manhaters. Could we NOT repeat this particular bit of history?

Instead of flying under the banner of "We're not all like that! They're not really us!", try planting your flag on, "PEOPLE WITH VIOLENT MENTAL ILLNESSES ARE PEOPLE TOO AND WORTHY OF COMPASSION AND MEDICAL CARE AND SUPPORT."

3) Actually, there's one thing we do seem to know about their mental health. In the moments of their crimes, they felt that throwing their lives away to kill a near-random passer-by was a reasonable thing to do. While it may be found that this was a principled position adopted and executed in full grasp of reality and with full possession of their mental faculties... that shouldn't be anybody's first guess. Asking, "what's wrong with them?" is a perfectly reasonable question.

But of course, reactions to proposing that a criminal has a mental illness are mediated by the same imputed moral consequences that cause people to prefer to hear their mental illness is a "brain disorder". Unfortunately, those consequences include simultaneously "not at fault"/"not morally continent", which is causes a double-bind, and freakout ensues.

Anyways. I may be posting a rant about how "stigma of mental illness" is becoming a chronic derail, but it's not aimed at you. It's been fomenting in my mind for a while.

[naath]

I see a lot of people saying "people with mental illness are more likely to be victims than perpetrators of violent crime"; it frustrates me a lot because it is NOT THE SAME AS "people who perpetrate violent crimes are no more likely to have a mental illness than people who do not".

I am not kind of doctor or mental health expert or criminologist - I have no useful evidence on whether either of those statements are true. But know enough statistics to know that there are important differences between them.

(sorry that was a bit unrelated)

Also sort of tangential I do find it odd when some people state things along the lines of "being willing to do a criminal thing is in itself a sign of mental illness". Also worrying. Worrying because I really don't like the idea of "you did a thing we don't like; you must undergo this treatment that will make you not do things we don't like" (because, eg, Turing).

I guess if you restrict "criminal thing" to "violently attacking people" (a subject on which the law is more likely to be right than laws against being gay) then maybe? I guess it might be very helpful to more widely offer mental health treatments to criminals, because the abysmal situation with access to mental health it shouldn't be assumed that everyone who wants treatment will have managed to access it. But I do think that "violently attacking people" can be done for "sane" reasons.

[liv]

I wouldn't dream of trolling you, but it had occurred to me that you would likely have strong and well-informed views about this topic!

I completely agree with PEOPLE WITH VIOLENT MENTAL ILLNESSES ARE PEOPLE TOO AND WORTHY OF COMPASSION AND MEDICAL CARE AND SUPPORT. That's what I was trying to say with: there certainly are some mental illnesses that, untreated, can sometimes lead to violent outbursts. It's dangerous to ignore that, as much to the people who themselves live with major mental illness as to the general public and decent mental health provision is absolutely necessary, both for people with mental illnesses and for wider society... it's morally right that we take collective responsibility for treating the sick. I didn't declare it quite as forcefully as you do in this comment, because I'm still tentatively poking around at the edges of this political reality, but it was very much intended to be the conclusion of my post.

People with violent mental illnesses absolutely are worthy of compassion. That's why I'm very very chary about the direction that McClelland seems to be heading in, though I've certainly seen much worse examples, where the implication is that we absolutely have to deal with schizophrenia through forced treatment and institutionalization.

I do take your point about trying to win social acceptance for people with relatively privileged mental illnesses such as mood disorders should not be at the expense of people with disorders that have violent symptoms. I most certainly don't want to claim that people whose illnesses make them prone to violence don't exist or don't count. And I am willing to consider that I need to shout louder about this because the "don't stigmatize mental illness" crowd has a bigger megaphone at the moment. On the other hand, it seems to me like the "mentally ill people are morally deficient" view has the biggest megaphone of all, and it is important to me to speak up against that.

Regarding these two suspects: look, you've got a couple of young Black men, (sorry, but they're no more African or American than I am), from a bad area of London, thoroughly disenfranchized and socially excluded, in a context where there's very few legitimate avenues to win respect, particularly no available jobs. They've probably had a lot of experience of people in uniform and representatives of authority treating them like utter shit. If I'm going to go for wildly uninformed speculation about what led to them committing this atrocious act, my first guess would not be untreated schizophrenia or any other kind of psychotic break. My first guess would be that they found some crowd where your ticket to love and acceptance is simply your level of religious / nationalist fervour, and you're not automatic scum because of your skin colour, your accent, your lack of money and status-conferring possessions. Maybe a charismatic leader egged them on, more likely they got so hyped up on peer approval that they went too far. I wouldn't be surprised to learn that they're mentally ill or severely damaged by drug or alcohol dependence, but I also wouldn't necessarily assume it.

Really good point about simultaneously "not at fault"/"not morally continent", which is causes a double-bind. That feels like the core of this, thank you.

[liv]

Thanks for the interesting comments about treatment options, too. It's certainly confirmatory that "maybe SSRIs don't actually do that" was being taught in your pharm class. Absolutely true that many many treatments work even if we don't have a precise mechanism for how.

I'm interested in your more knowledgeable view of lying to patients about the aetiology of their illness and the mechanism of the drugs they're being prescribed for reasons of underlying sense. If you have time sometime that would be great, if not, well, thank you for pointing me in the general direction.

Thanks for the skeptical view of CBT, too. I'm relying on the no doubt extremely simplified notes I have for my students which start with CBT is not a talk therapy. Certainly it's psychotherapy, but my lay impression of it is that it doesn't involve very much talking between therapist and patient. In fact I've most often seen it in the context of people being sent to a website to use self-directed tools; maybe that's one of the snake oil versions you're alluding to, and real CBT ought to involve a relationship between patient and practitioner.

What SSRIs do

[tig_b]

I was busy typing a much longer piece, when the Chrome gremlin ate it, so this is the short version.

Background
I have degrees in Biology and Pyschology, plus Statistics.
I have endometriosis, asthma, etc., etc. and Complex PTSD.

I take sertraline, in conjunction with CBT therapy. I know this doesn't work for everyone, but SSRIs do help me.

This is a technical article, but some of it is more accessible:
"UNDERSTANDING SEROTONIN SIGNALING VIA FAST-SCAN CYCLIC VOLTAMMETRY"
http://pubs.acs.org/doi/pdf/10.1021/cn4001022

[jjhunter]

Lots of interesting food for thought here - I can see why kaberett signal boosted! I think I'm going to sit on my impulse to dive in any further right now, and come back when my own reflections have had a chance to percolate and ferment some more.

In the absence of more new words now, I will share some old words, because I appreciate the care liv is taking throughout zir post re: not pontificating / privileging zir lack of actual personal experience, and instead seeking out the insight those who do have it might bring to bear. I can't speak for the various illness being discussed that sometimes involve violence to others, but in terms of emotional violence to self? One of the worst things about depression, especially severe depression, is that even when you're not depressed, chances are it's probably chronic, and one way or another you'll learn what you can do with your life has to take that into account.

[...]

that is what i mean when i say 'depressed'
and 'history of depression' means there's no defense
perfect enough to keep it from coming back