By Ron Unger — first printed on his blog.
In the mental health field currently, when people experience intense anxiety and depression, and when they experience mania and/or psychosis, the experience is understood to be a “disorder” or a “biological dysfunction” that is of no use and should “corrected” by any means that might be effective in doing so. The most straightforward way of doing this is conceived to be a drug that might directly reverse the theorized “biochemical imbalance” though other methods are tried, particularly when drugs don’t work.
The primary opposition to this point of view in our culture comes from those who deny the existence of mental disorders at all: they see “diagnosis” in the mental health field as being an illegitimate enterprise, and the DSM as a work of quackery designed to make money for drug companies and for “mental health professionals.” It is noted that there is no physical test for any sort of “mental disorder” and no objective way of determining what should be called a disorder. It is then imagined that people would do fine if saved from those in the mental health field who attempt to diagnose and then “help” them.
A middle ground between these two extreme views is however emerging. In this view, the mental states that get diagnosed as “disorders” tend to be specialized states of mind which do tend to cause trouble for people, but which can also be seen as part of an evolved, problem solving strategy used by the mind. That is, while these mental states may not be consciously chosen by the person and may cause problems, they also may solve important problems, and so in any given case it may be unclear whether they are doing more harm than good.
An example of a “biological” evolved problem solving strategy that both causes problems but also potentially solves problems is that of a fever. Fevers cause many problems, and if quite high may cause brain damage or even death, yet we have evolved to have fevers because they often help solve the problem of infections.
“Anxiety” can be seen as an evolved mental/emotional strategy that can also both cause and solve problems. Anxiety can disrupt our life and narrow our focus, making us hyper-vigilant for certain stimuli while oblivious to others; yet under some circumstances, such hyper-vigilance and narrow focus can be life saving. People who tend to be more anxious than others may have many problems due to the anxiety, but they are also less likely for example to die in accidents. So while there is a particular biological way anxiety manifests in our bodies and brains, this biological process itself cannot be called a “dysfunction.” Instead, to determine whether a given level and type of anxiety is doing more harm than good, one would need to analyze the exact level and type of threat in the person’s life. And since no one’s viewpoint on this is completely objective, no clear line can be drawn between “helpful” anxiety and “disorder.”
While many people would recognize anxiety as evolutionarily important, it is much less common in our culture to recognize the potential value of depression, or depressed mood. This partly accounts for the high rate of use of anti-depressants, thought by our culture to be useful in eliminating a pesky “bio-chemical imbalance. Yet, a great deal of evidence suggests that depressed mood is objectively helpful to people in carefully reviewing complex problems, and that our ability to be depressed, just like our ability to be anxious, has evolved for a purpose. That is, just like fever or anxiety, depression has high costs to an individual, but despite this it is often more helpful than not, and so the biological process that gets activated in depression cannot in itself be called a “dysfunction.” (For a brief review of the evidence for this, see here. For online access to a more in depth look at the subject, see here)
Again, since no one’s viewpoint is completely objective, no clear line can be drawn between a potentially “helpful” depression, and one that is in excess of that which might be helpful in a given circumstance, and so might deserve to be called a “disorder.”
If we really “get it” that anxiety and depression should not automatically be thought of as disorders, then we might instead talk to people in a more open-minded way about what is going on. We might help them identify the original problem that prompted their anxious and/or depressed mental states, and perhaps help them as best we can find solutions to those problems, or at least ways to work around the problems, so that further anxiety or depression is less likely to be triggered and is also less necessary. We might do this all without ever being able to clearly define whether any amounts of anxiety or depression the person might have been experiencing were in “excess” of that which was helpful in the situation; rather, this would be an open question during the discussion, a question to explore rather than one to answer with a formula or a DSM.
But what about other serious mental health issues, such as mania and psychosis? What possible use might exist for mental states that cause these sorts of problems?
The story at this point becomes more complex.
Let’s start with mania. Richard Bentall, in his excellent summary of a lot of mental health research titled Madness Explained discusses evidence that mania is a way of defending against depression. It is interesting to note that most of the strategies used to fight depression, if used to excess or if used by people over-sensitive to the methods, can result in mania. For example, even a simple strategy like avoiding thinking critical thoughts about oneself can contribute to mania, and anti-depressant medications also frequently cause mania.
So, if depression is evolutionarily useful, why might we, or at least some people, have evolved a tendency to fight depression by becoming manic? I would suggest that, just as depression is a way to address complex problems by slowing down and thinking through problems in a slow and analytical way, mania is a way to experiment with the opposite strategy, to shut out negative information, to speed up & play around with creative possibilities that might not be seen when looking at a problem in an analytical way. Also, experimenting with mania might allow a person to escape from some life problems caused by depressed mood itself.
While mania may at times result in solutions to life problems, it is clearly a high-risk strategy. Many people have no inclination to try it at all. This may be because they don’t have the right genes for it, or just because they have not yet become desperate enough for it to seem, to their deeper self if not their conscious self, to be a strategy worth attempting. To other people however such a strategy seems a natural inclination for them. Again, rather than define it as clearly a “disorder” we might take a less certain stance, helping people look at their place in life and at how various strategies they may be inclined to try may be helping in some ways but also causing destruction in other ways, and then helping people explore options about what to do next and how to do it.
So, what about psychosis? Does it have an evolved role in solving life problems, and if so, what sorts of problems is it meant to solve? The answer in that case is even more complex.
“Psychosis” may be loosely defined as being out of touch with reality and/or disorganized in a way that causes serious problems, and it can occur both as part of an extreme mood state such as depression or mania, and apparently independently of a mood state or when a person appears to be in a neutral mood. When it appears as part of a mood state, it is often just an extreme manifestation of that mood state, as in the manic person who believes he or she has been given special powers by God, or the depressed person who feels that his or her flesh may be rotting.
When psychosis appears outside of a specific mood state, it is often thought by psychiatry to be independent of mood, or to be a “thought disorder” rather than a “mood disorder.” But this notion is contradicted by an extensive body of evidence showing close inter-relationships between “bipolar disorder” which is seen to be a mood disorder, and “schizophrenia” which is seen to be a “thought disorder.” To the extent there is a genetic vulnerability, for example, the vulnerability seems to be to both of these disorders, and many people experience a mix of both.
A practical way of understanding why some people may have “psychotic” experiences and perceptions independently of extreme mood states, may be the notion that these experiences and perceptions are often developed to defend against extreme mood states, and so while they are active, the person’s mood state becomes neutral. Evidence for this notion comes from the fact that when people become aware that they have been deluded or psychotic, they often become depressed. Al Galves, in a recent blog post, explores some of the ways psychotic experience may protect people from the sorts of extreme emotional states they might otherwise experience would they face their world more directly. (For example, a person who feels depressed and useless may develop a belief that he or she has been chosen by the president to carry out a special mission: protected by such a belief, the person’s mood may become neutral.)
I believe the story may be even more complex than Al suggests however. Evidence existsthat when it seems important to a person to control a particular situation, and yet the person has no definite idea about how to control it, that person is much more likely to begin thinking in ways that break conventional rules, in ways which consider less likely possibilities. This results in increased perceptions of patterns where no patterns exist, belief in conspiracies, etc. It also would appear that this sort of thinking, despite its risks, would be more likely to result in thinking “outside the box” and in perceiving patterns which others, due to their more conventional thinking, might have missed. Some people may be genetically more prone to this sort of thinking than others (which might help explain why the risk for psychosis, and creativity, appear to run in the same families.) But others may be prone to this sort of thinking only because the circumstances of their lives caused them to focus on trying to control more situations that could not be controlled in any straightforward way, and so they consciously or unconsciously shifted into a style of thinking more likely to result in psychotic experiences, yet also more likely to result in creative solutions.
I was recently reading how in people diagnosed with schizophrenia, there is often a very serious loss of a sense of context, or a loss of the “common sense” of the culture of the person. This is often seen as just a “biological deficit” of the person, part of the “disease process.” Yet, thinking creatively, as well as spiritual opening, often involves dumping what we think we know, so we can think of things in a fresh way. People who do this to an extreme, and especially people who do it instinctively without making a conscious decision to do so, may be at risk of making a mess of their lives, and of getting diagnosed, and of getting stuck in this style of thinking, but that doesn’t mean that there isn’t also possible benefits to that style of thinking or reasons why we have evolved to be capable of thinking that way.
According to this line of thinking, there is a biological process (much more complex than the formerly hypothesized “excess of dopamine” which appears not to exist in reality) that underlies psychotic thinking – however, like anxiety and depression etc., it is a biological capacity that has evolved for a reason, and so it is sometimes helpful despite the high risks associated with the process. If the capacity to shift into such “outside the box” thinking has evolved for a reason, then this suggests that a culture that managed to chemically suppress all manifestations of such states of mind would ultimately be crippling itself, rather than becoming more “healthy.” It might lose the capacity to think outside of its own usual assumptions, and so lose the flexibility necessary to meet new evolutionary challenges.
A better approach would be to approach individuals experiencing “psychotic” states in a more open-minded kind of way, being unsure of what might be helpful or not, and being open to exploring that with the person. Such an approach would include being curious about the life dilemma that originally triggered the psychotic thinking, and being open to the notion that the psychotic thinking may actually be helpful at some stage in coming up with solutions to that dilemma, rather than just being an “illness.” This doesn’t mean failing to recognize the high risks associated with psychosis, or refusing to ever do things that might directly reduce the psychosis if that seems necessary, because after all, recognizing the potential benefits of a fever does not mean that we would never take direct action to control it if it seems to be “too much.” However, it does mean that mental health care for psychosis should become much more collaborative, much more “pro-person” and less “anti-psychotic” since after all the psychosis may actually in some ways be serving the person, even while hurting the person in other ways.
One reason I am a proponent of cognitive therapy for psychosis is that, at least for those in its more humanistic wing, there is recognition that work with psychosis should be “radically collaborative” and should recognize that there may be value in psychotic experiences, even ones which otherwise cause problems. Such therapists approach their work with an open mind, and can help clients invent their own approaches to the future, seeing that they have options to take elements of their own visionary experience while also having the capacity to step back from this visionary or psychotic experience and back into more conventional views when that makes sense.
I believe that people experiencing psychosis deserve to be helped, both because the experiences which drove them to psychosis were often very difficult and confusing, and because the experience of being psychotic in itself can be very destructive and confusing. Yet, I also believe that those who tend to get diagnosed with psychosis have the capacity to help the rest of us as well, because they are the ones who tend to think outside of our cultural “box.” Ideally, we will find a way of interacting with these people which helps both them, and us, have both the capacity to think in a conventional way when that is helpful, yet also experiment with thinking outside of conventions so we can make progress as a culture in dealing with our blind spots.