WillSpirit!


∞ Where Mental Skills Heal Mental Ills ∞

A former physician writes about mental health and recovery using insights from life, science, and spiritual practice.








  • Red_Exclamation_DotDisclaimer
    • Dear Visitors:
      Although I trained and practiced as a physician, my background does not include formal instruction in psychiatry beyond basic medical education. This journal presents ideas about treatment philosophy, but must not be considered therapeutic advice. Abrupt changes in one's psychiatric medications can trigger profound cognitive, emotional, and physical symptoms, including suicidal thoughts and actions. Consequently, pharmaceutical agents should not be increased or decreased without supervision by a mental health clinician.

    • ON THE OTHER HAND, your brain belongs to you, and your opinion counts. If you decide that changing your medication regimen will serve your best interest, then I believe your providers have an obligation to help you try to achieve your goals. I want everyone to be educated about their options, and do what will be most helpful for themselves. No one should feel pushed around by dogmatic and/or limited viewpoints, whether those of psychiatrists, anti-psychiatry advocates, or myself.


Where Do We Want to Live Our Lives?

On a comment left at Storied Mind, a great blog and depression resource created by John Folk-Williams, I mused about whether or not depression is an illness.  (A recent post on this site covered the same question from a different angle.) What follows connects my reply to John’s essay with Acceptance and Commitment Therapy (ACT), which WillSpirit readers have heard me discuss many times before.

John focuses on ACT in his essay and only mentions the illness question in passing. The issue comes up because the ACT view of mental symptoms contradicts the biological disease paradigm of conventional psychiatry.

ACT is based on behaviorism, a philosophy that dominated psychological study in America for much of the early and mid-twentieth century. By the 1980′s behaviorism had been supplanted by cognitive science, a movement that was driven by neurobiology’s computational model of the brain. Behaviorism suffered intense criticism after falling from grace.

The backlash was so thorough and effective that when I first learned that ACT is a behaviorist approach, I assumed it succeeded despite that heritage and not because of it. Behaviorism has a reputation for being overly mechanistic and dehumanizing. The common caricature is that it rejects the importance of mental life and views people as automatons who don’t choose their actions but only react to environmental contingencies.

In his 1974 book, About Behaviorism, B.F. Skinner (the most prominent leader of the movement) defended his views. The text more often assumes than establishes the basic foundations of its philosophy; it insists that  inner life is a consequence rather than a cause of a person’s interaction with his or her environment but doesn’t provide much supportive evidence (although subsequent research has bolstered such assertion). So the book isn’t terribly effective as a counterattack. But it does demonstrate that Skinner looked at human behavior with an admirably practical eye.

In managing depression and other psychiatric symptoms, it is this practicality that makes a behaviorist approach effective. CBT (Cognitive Behavioral Therapy) has trained many of us to challenge negativity. But thoughts arise rapidly and seldom cooperate with attempts at control. Positive thinking is a great concept, but every uplifting thought is dogged by its counterargument. The affirmation, “I’m a good person” seldom can escape whispering rebuttals like, “but remember the time you…”

I don’t deny the helpfulness of monitoring thoughts to weed out inaccuracies and unfair self-criticism. But CBT assumes that feeling is a result of thinking, and that we can feel better if we think better; both these premises are questionable. Thinking and feeling are internal processes that mutually interact and respond to environmental input; thinking isn’t the sole determinant of how we feel. And we all know from experience that positive thinking by itself never resolves a deeply entrenched depression.

But the real problem with CBT, and most other therapies, is precisely that they teach us to focus on thoughts and feelings as we battle mental difficulty. If we are stuck in a deep funk and spending our days in bed, we are taught that if we adjust how we view our childhood, or how we think about our current situation, we will soon feel better. Having established a sunnier inner landscape, we’ll want to get up and live our lives again. Sadly, most of the time the sun simply refuses to shine no matter how much we rethink our past or challenge our negativity.

Skinner would reply that our staying in bed results from learning, not from thinking or feeling. Something in our environment has taught us that lying down pays off. Maybe we get sympathy. Maybe we avoid facing stress. There is a reward that sustains the behavior despite the fact that it undermines our progress in life.

The answer to depression isn’t to wait for our inner state to improve while we do little to alter externals. Rather, we should act on the outer world, which will provide new consequences and teach us better behavior. If I attend a community picnic when depressed, two benefits accrue: I interact with others and so increase my social connections, and I spend some time outdoors. These positive outcomes, especially if repeated a few times, will teach me to adopt similar outgoing behavior in the future. Waiting for the depression to lift before attending such an event would win me neither more friends nor contact with nature. My future behavior would be unlikely to change.

Which finally brings me to the substance of my comment on Storied Mind and the question of whether depression is an illness. Here is an excerpt:

…whether depression is an illness or not [is] a semantic question, and it can have different answers depending on one’s stage in dealing with the problem. If ‘illness’ means a condition that feels unpleasant and limits life, then yes, depression can be (and usually starts out as) an illness. But if it means a definable brain disease that can be treated with specific medications, one can only say that at this point there is little evidence to support that view. I’ve followed this research for years and have yet to see any findings that solidly (or even plausibly) demonstrate organic pathology. For every suggestive piece of evidence one can find powerful refuting arguments.

Although the disease concept helps relieve us of shame and so can be helpful early on, eventually we want more than escape from blame. We want better living. ACT offers an approach to achieving that…  what works is living life with purpose without so much emphasis on how [we] feel or what [we] think…

I no longer react reflexively out of fear, anxiety, insecurity, or negative self-talk. As I’ve begun to live a richer life despite my frequent feelings of sadness, regret, and fear, I’ve started to see that the ‘illness’ concept no longer serves me as it did earlier…

I would add, in light of the behaviorist perspective, that if the answer to depression lies in interacting differently with the environment, then it seems unlikely that the problem resides in the brain. Instead the difficulty is, and has always been, a consequence of the world around us and how it’s taught us to respond to circumstances. This is a radical concept when compared with the traditional view on mental distress. It takes the problem out of the realm of thoughts and feelings and places it in the real world. And isn’t that where we want to live our lives?

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Where Do We Want to Live Our Lives? was published on April 5th, 2012 . 5 comments






Some Problems with Psychiatric Diagnosis

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One of the sites I’m fond of is Hopeworks Community. A number of things can appeal to me about a site. Some are heartfelt. Some are lyrical. Some provide pragmatic advice. Some take political stances. In fact, most do all these things. Hopeworks provides reasoned analysis of issues relevant to people affected by mental illness (but see Hopeworks and what I write below for some discussion of the ‘illness’ concept). Any time I get engaged in a topic, my fingers go nuts and before long my text has morphed from an intended sentence or two into a mini-essay. That happened yesterday on Hopeworks, when I wrote a comment discussing two posts: ‘What diagnosis depends on‘, and ‘On the words we use‘. The subjects were diagnosis and semantics in mental illness. Important subjects. Since I was happy with my little response, and since I won’t have much time to write today, I am posting my discussion below.

I promised to write about the relationship between ‘who we are’ and ‘what goes on in our brain’. That topic is so vast that covering it in a blog post is presumptuous to the point of grandiosity. But I do have some ideas that can be squeezed into one of my longish essays. The interrelationship between mind and body (especially, of course, brain) fascinates me, as it has philosophers for ages. I want to do it justice. I have touched on it before, and no doubt I will come back to the subject over and over until the day I die (hopefully a long time from now, for those who monitor me for suicide risk). So the much-anticipated essay will be produced soon. But not today.

Instead, here is my 2¢ about diagnostics and the labels that result.

[Comment to Hopeworks with regard to psychiatric diagnosis:] Having had medical training, and even one-time aspirations to become a psychiatrist, I started out with faith in the DSM. The more time I spend as a patient, and reading blogs, and thinking about how I’m going to get to a better place, I see the fallacy in labeling people as mentally ill. My latest thinking is that our brains are as different as our mugs. Maybe I even brought this up on your blog before. You can categorize faces: male, female, European, African, Asian, old, young, attractive, ugly. And you can separate facial expressions: happy, sad, angry, etc. But just saying someone (like me) is a male, of European descent, middle-aged and with a look of concentration at this moment does not mean that is all I am or will ever be. It is not enough information for you to recognize me on the street, or to know what would work to make me more comfortable with being alive.

Psychiatric diagnoses have that level of precision. Some people have fluctuating moods. Some are chronically sad. Some worry all the time about everything. Some hear voices and have ‘odd’ ideas. Each of these persons can be diagnosed with a DSM label, and so by that definition they are mentally ill.

It’s a bit like saying only a particular race or gender is capable of running things. Only a certain emotional make-up is healthy; deviate far from that norm and you have a disease. Maybe you should be locked up and sterilized. You certainly can’t be in a position of leadership or responsibility (is anyone else old enough to remember Thomas Eagleton?).

Like you say, what matters is what works. And what works is what makes life a more satisfying experience. Dulling emotional responses, or squelching internal voices may help accomplish that for some people. But not for all. Some would be happier to be left with their minds in their native condition. Some can get a lot more happiness out of life by accepting their quirky brains than they ever can by acquiescing to long-term psychiatric drugs.

As someone who once bought the mental disease model intellectually and emotionally, I am astounded to find myself about to write that I am not sure that mental illness is a valid construct. I took all my meds diligently for years (I was a very ‘compliant’ patient). But I still felt rotten. Now I feel better even though I am on a milder chemical cocktail (hopefully soon to be none at all). So was I really sick? Or just confused?

I spend time on the local psychiatric unit, counseling patients about their legal rights when they face involuntary confinement. Some of these people are quite out-of-control, and would have trouble being safe on the streets. I can’t say what the answer is in those cases. Maybe when things go that far there really is a sickness going on. But that does not mean that the person has a mind that can never be trusted again. That they now should carry a lifetime diagnosis of, say, bipolar I. That they will require drugs forever, and can never learn to live safely and well without medication. Maybe it is the all-too-frequent permanence of mental illness diagnoses that is their biggest problem.

We are all different. ‘Some of us are more different than others.’ The problem with the ‘illness’ label, is that it automatically means there is something defective. Maybe all that is wrong is that our eyes are open. That we see and feel more pain, or are more in touch with imaginative influences in our minds. Or we are more conscientious and want everything to be just right. Or impulsive. Or scared. These are not illnesses, they are responses to life. Maybe they are exaggerated and do not serve us well. Maybe medications can help us live fuller lives. But I object to being told my brain is abnormal, and that the person who never soars into ecstasy or crashes into sadness is healthier and (by implication) better.

It cannot be overstated: what matters is what works. If having a diagnosis in hand makes one feel vindicated, so now they can show people they aren’t just lazy or selfishly pessimistic, then it is a good thing. If it helps select a medication to get someone balanced enough that they can go home and work on better solutions, then maybe a diagnosis is useful. The same if being given a name of their ‘lllness’ leads a person to the most helpful shelf in the bookstore. But if it means I can never get long-term care insurance (I can’t), or be trusted to practice medicine (a psychiatry program I applied to reported me to the medical board), or that I will always need to take medications that wreck my body and undermine my self-image, then they are most definitely not OK. thornsThat kind of thing happens so often, that it is easy to understand why people with mental/ emotional/ behavioral/ brain/ psychiatric – illnesses/ conditions/ disorders/ diseases/ abnormalities/ challenges/ dysfunction/ gifts object to the psychiatric model. When diagnostics work they help a little. But when they are overused, misinterpreted, or otherwise go awry, they do an incredible amount of harm.

(I slightly modified this post on 2009 August 17, c. 08:30 PDT.)

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Some Problems with Psychiatric Diagnosis was published on August 16th, 2009 . 19 comments






Justification of a Name: WillSpirit Explained

This post is actually the About writeup that I put on my website the first day. It explores why WillSpirit seemed appropriate as a blog name. What I think this blog is ‘about’ changes regularly, so this old piece needs to go somewhere else. Placing it at the head of my blog entries will preserve it as part of my archives and also provide a useful introduction to anyone who wants to start at the beginning and read through. The piece shows my initial concepts, which have since evolved. I continue, for instance, to work on the connection between spirit and feelings. The word spirit sometimes has the connotation soul, and that is not what I meant in this first entry. At that time, I was aware that what seems like our soul is sometimes just our feeling side influencing us in its usual subtle and nonverbal way. That is why I thought the word spirit would be an apt counterpart to will. But as time has passed my attitudes have changed and I’ve explored spirit and soulfulness from other angles, including metaphysical ones. In any event, spirit has multiple usages. Consider: “she is in fine spirits today!” and: “he is such a spirited boy!”  Both show our automatic connection of spirit with emotion.

With that as background, here is what I wrote as my initial musing:

The idea, so far, is to explore how to bring our thinking selves and our feeling selves into harmony. The thinking self (what I call the WILL) works with abstraction of sensory information, logic, and words. It constructs models of reality and then makes decisions based on its interpretation of those constructions. Its decision making style is best described as analytical. The feeling self (I call it the SPIRIT, for reasons that I’ll explain at some later time) uses feelings, emotional logic, and symbols to interpret reality on a moment-to-moment basis, and then makes choices based on a synthesis of what it understands about the current internal and external states. Its decisions are often called ‘intuitive’. 

Both the will and the spirit have value. We make the best decisions, and feel the best, when both are active. Unfortunately, that seems to be a hard balance to achieve. Because our society has historically encouraged analytical as opposed to intuitive reasoning, the will tends to be overvalued. It often believes it is the only part of the mind that matters. It also has a thing about control, and seems to have trouble with the ‘big picture’. As a result, it often refuses to accept that it must share decision making with the spirit. In fact, it is not uncommon for the will to deny the existence of the spirit altogether. It values things that are ‘right’ (as opposed to ‘wrong’) and ‘true’ (and not ‘false’). It sees things in black and white. 

The spirit, for its part, is fully aware of the will. It just doesn’t take it seriously. It believes analysis to be shallow and unable to capture what really matters in life. Because it operates on moment-to-moment feelings, it has a hard time projecting into the future and seeing long term consequences. The spirit emphasizes love and altruism. It knows that black and white are abstractions, and sees situations in shades of gray. Even better, it knows color. 

One problem with this work is the tendency to make value judgements. The will is a newer part of the brain. It has specific skills, but it is not fundamentally who we are. This does not make it something “bad,” however. It just means we have to recognize its true nature and make use of it without identifying with it. Acceptance and Commitment Therapy (ACT) has appeared in the psychotherapy world within recent years. It is based on the premise that we need to detach from our thinking. It is worth exploring. Here is one link to get you started.

It is tempting to equate the will and the spirit with the left and the right brain, respectively. The right brain does seem to have a more symbolic and intuitive style, and the left brain a more analytical and verbal one. However, it is not necessarily helpful to make that anatomical connection, even if it is valid. We do not experience our brains as divided in half down the middle. Instead we recognize shifting influences within ourselves that roughly fall into these two categories. 

The point of this website is to explore how to harmonize the forces within, for the good of ourselves, our communities, and our planet. We need the will to be directive and defined, and we need the spirit to be creative and flexible. I believe the battle between these two parts of ourselves (you might call them subroutines, to cautiously use a computer analogy) causes much of the discord on this planet. Until the will listens to the spirit, and the spirit goes along with the will, we will remain confused, angry, and looking for someone to blame for our internal frustration and unhappiness. 

I hope to explore these issues in my writing. I also look forward to discovering like-minded communities and resources. So here I am, just getting started, trying stuff out, bringing things together.

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Justification of a Name: WillSpirit Explained was published on May 30th, 2009 . 3 comments






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