Mental Health Can Never Come Down to the Hard Science
As a practicing therapist, it is a great challenge to overstate the utility of research and grounded theory as it forms the archetype by which treatment is guided. No competent therapist can enter into a session and fly by the seat of their pants every time. To do so, beyond its likelihood to lack effectiveness, would be unethical, according to the American Counseling Association.
Research-backed and evidence-based treatment is the path by which progress is made. It determines the likelihood of efficacious treatment; this is to say that a course of treatment lacking research and peer-reviewed backing is significantly less likely to boast positive results. Planning an individual’s treatment, whether it includes individual psychotherapy guided by a relevant therapeutic posture, psychopharmacology, case management services, et cetera, should be done so in a manner unique to each individual and prioritizing the success of that individual. The American Psychological Association adopted a policy years back, one which “…emphasizes integrating the best-available research with clinical expertise in the context of the patient’s culture, individual characteristics, and personal preferences” (Cook et al., 2017). Cook et al. go on to argue that evidenced-based practice can improve outcomes because it does not rely on an individual clinician’s experience or opinion, but rather the research and experimentation of scores of clinicians and researchers.
It may be said that research is the backbone to mental health counseling. Perhaps, that is true. However, in a nuanced, person-centered field like mental health, the importance of the other organs and bodily structures cannot be discounted. The backbone may hold it all upright to stand underneath the scrutiny and stigma that is often hurled at the fields of psychiatry, psychology, and counseling, but the proper functions of the eyes, tongue, skin, et cetera define the fields’ ability to impact patients and clients alike, in a most human sense of empowerment.
There’s a reason that therapeutic interventions have come to incorporate many ethereal, aesthetic activities of being human into treatment. There’s art therapy, play or game therapy, cinema therapy, bibliotherapy, poetry therapy, and more. As a brief overview, bibliotherapy increases an individuals declarative level of knowledge and connects readers with stories and experiences. As William Nicholson succinctly words it, often misattributed to C. S. Lewis, “We read to know that we are not alone.” Likewise, play therapy addresses a human desire as old as humanity itself. Play builds cooperation, which is to build the therapeutic relationship between client and clinician. Storytelling, via any medium, also serves the human understanding of its unique condition. Reading, cinema, and poetry all serve to connect and inform what it means to be human, and mental health is a boastful component of understanding and coming to terms with one’s own humanity.
“If a serious statement is defined as one that may be made in terms of waking life, poetry will never rise to the level of seriousness. It lies beyond seriousness, on that more primitive and original level where the child, the animal, the savage, and the seer belong, in the region of dream, enchantment, ecstasy, laughter. To understand poetry, we must be capable of donning the child’s soul like a magic cloak and of forsaking man’s wisdom for the child’s.”
It serves this narrative that research endorses the effectiveness of each therapeutic posture listed above, when applied correctly. However, that is less so the purpose of this writing. This writing is to assert that those postures serve the diversity of experiences of those engaging with the mental health field. It does not take peer-reviewed journals and gatekeeping, bespectacled researchers to know this is true.
As Rachel Aviv writes in Strangers to Ourselves: Unsettled Minds and the Stories That Make Us, the answer to every question continually changes based on the angle (i.e., worldview) of each individual asking. To say that the answer(s), even reality itself, contains nuance is a wild understatement. Much of modern psychology exists between two overarching schemas: mental existence as a result of the psychodynamic and the biochemical. Simply put, mental health is thought of by some as a matter of fortitude and character and by others as a matter of chemical balances in the brain.
This is where the need for nuance cries loudest. In a bit a bombshell article, Moncrieff et al. (2022) asserted a scathing rejection of the influential serotonin-depression theory, by writing, “The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations” (p. 3243). Deacon (2013) rejects the near exclusive hold that the biomedical (or biochemical) posture holds on American healthcare and policy, favoring an adoption of a biopsychosocial model. Lebowtiz and Appelbaum (2019) also detail some of the criticisms of a biomedical explanation for psychopathology, stating that it is limited in purview and can also negatively impact the therapeutic alliance.
The biomedical model is perhaps a convenient default choice for American practitioners. It certainly fits an American worldview, whereby convenience and self-deflection take precedence. A person diagnosed with major depression can simply take a pill to be fixed. Give it a few weeks on the bupropion. All better, right? Less attention is needed for that individual’s incongruent lifestyle, living in discord with his own values, working in a job and as part of a social fabric which he despises. All can be made well with a single pill, so this model asserts. There’s no need for behavior change and no requirement that negative behavior and maladaptive coping mechanisms be addressed. Well, if this were entirely true, the mental health crisis would be solved, given that more people than ever are consuming psychotropic medications as a means of coping with human existence.
Lebowitz and Appelbaum continue writing, “Although it has been popular at some points in the past to view psychiatric symptoms as resulting from demonic possession, the influence of the moon, or a deficiency of maternal warmth during childhood, this review focuses on a conceptual framework that has become increasingly dominant in recent decades in which mental disorders are viewed as medical diseases rooted in biology.” A person that considers themselves a rationalist, and certainly the average graduate student, would read this passage and scoff. Of course, the absurdity of moon phrases and demonic possession cannot explain major depressive disorder or schizophrenia; this fact should not even need to be debated. But this line of criticism misses the purposes of those aforementioned frameworks. The understanding of mental health, and indeed human existence in general, is often less academic, less rational, and more human than certain practitioners and researchers can grasp. Therapists and other practitioners should focus as much on this aspect of psychotherapy as they do on the research. Books, cinema, art, all of these help us better understand the human experience. Put simply, it’s not about a literal demonic possession, it’s the experience of feeling like a demon is inside someone. Or as one theologian argued regarding human origins, It’s not about whether or not a snake literally spoke, it’s about what the snake said.
A person can simultaneously be so defined by their mental anguish and so ingratiated into the mental health establishment that describing this suffering can be done only via psychological jargon. This is a failure of treatment, in my opinion. There are facets of our personhood that the hard science and jargon fail to capture. These facets, and the individual stories behind them, cannot be forgotten in the midst of quantitative data, clip boards, and bad policy.
American Counseling Association. (2014). 2014 ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladdress.pdf
Cook, S. C., Schwartz, A. C., & Kaslow, N. J. (2017). Evidence-Based Psychotherapy: Advantages and Challenges. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 14(3), 537–545. https://doi.org/10.1007/s13311-017-0549-4
Deacon B. J. (2013). The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. Clinical psychology review, 33(7), 846–861. https://doi.org/10.1016/j.cpr.2012.09.007
Lebowitz, M. S., & Appelbaum, P. S. (2019). Biomedical Explanations of Psychopathology and Their Implications for Attitudes and Beliefs About Mental Disorders. Annual review of clinical psychology, 15, 555–577. https://doi.org/10.1146/annurev-clinpsy-050718-095416
Moncrieff, J., Cooper, R.E., Stockmann, T. et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry 28, 3243–3256 (2023). https://doi.org/10.1038/s41380-022-01661-0
Cover photo courtesy of Unsplash.