Wednesday, February 17, 2016

Disordered Thinking – STOP IT!

There’s a Bob Newhart clip.  The client worries about being buried alive.  The clinician’s solution: “STOP IT!”

What if it were that simple? You only had to change your mind. Exercise your option to do something different.  This is the second of a series of articles that makes the case for a 100% voluntary approach to mental health. If you want to start at the beginning, you can do that here:  Rethinking Public Safety – The Case for 100% Voluntary,

In this second essay, we take a look at trauma, and propose an end to ‘disordered’ thinking.  By the end of this article, we will be asking everyone – clinicians, politicians, law enforcement, emergency responders, families, friends, the general public – even those of us with labels – to ‘STOP IT!’ 

1.    Human needs are not disorders

For years now, the behavioral health community has maintained a ‘disordered’ perspective.  The idea is that people have pre-existing genetic, biochemical, mental or behavioral abnormalities. Those affected are irrational and susceptible to acting without regard to personal welfare or that of others. Aggressive treatment is required to correct or mitigate deficiencies, including psychoactive drugging and psychotherapy.

In 2011, however, the National Council for Behavioral Health blew the lid off this theory. In a special publication - nearly 100 pages in all – they ‘broke the silence’ on the impact of trauma in behavioral health.  They called on behavioral health professionals nationwide to recognize and address the prevalence of trauma in mental health, substance use, criminal justice and shelter settings.  They called attention to the fact that ninety (90!) percent or more of service users across these domains are ‘trauma’ survivors. Notably, A. Kathryn Power, then-Director of the Center for Mental Health Services (a division of SAMHSA) wrote: “Interpersonal violence … is widely accepted to be a near universal experience of individuals with mental and substance use disorders and those involved in the criminal justice system.” Other kinds of ‘trauma’ including lack of access to basic human needs, widespread poverty and social marginalization were also noted.  

You can read the entire National Council publication here:  Breaking the Silence: Trauma-Informed Behavioral Healthcare (National Council Magazine: 2011:2),  Another excellent resources is the 2014 TED Talk by Nadine Harris, MD: ‘How Childhood Trauma Affects Health Across a Lifetime,’

2.    This is a social justice issue.

You may wonder why the word ‘trauma’ was put in quotes.  In recent times, the idea of trauma has been medicalized. It is now seen as a disorder -  something to be treated, even medicated away.  In actual fact, however, trauma is a social justice issue, not a medical one.  Vast numbers of behavioral health clients grow up without a way to meet basic human needs. Things like:

  • reliable access to food and habitable shelter
  • safety of person and property
  • dignity, respect and fair treatment
  • meaningful participation and voice
  • the family means to make a living
  • opportunities for development across major life domains
  • human support to make sense of experience in their own way

These are people’s actual, life circumstances.  They would be matters of concern for anyone.  They represent core dimensions of existence.  Universal Declaration of Human Rights  Yet, many, many people feel insecure, ignored or even totally trampled on  - and with good reason - physically, emotionally, socially, economically, existentially.

Labeling trauma a ‘disorder’ in these circumstances is problematic to say the least.  Any conscious, reality-based human being should be distressed by these conditions.  The distress is a message.  It is like your hand burning on a hot stove.  The feeling of pain tells you to move your hand.  This prevents further damage.  If you just rationalize or drug that sensation away, there is no telling how bad you’ll end up.  

The painful thing is that we live in a society where many hands are currently burning.  The stove is on high, so to speak, on a massive scale.  The medical model solution is to blame and ‘treat’ (drugs, CBT, electroshock), the victims when they cry out too loud and make others uncomfortable.  We lock them up, silo them away – and not for their own sake I would argue.  Speaking for myself, there is nothing quite as devastating as realizing that you live in a world that – despite many good intentions – has somehow gone drastically off course.  Frankly, it can be a relief to know that crisis is someone else’s job and to not have to feel so unbearably helpless. 

3.    FFamilies are not the problem here

Families have been given a bad rap in popular psychology.  For many, families are our most valued allies and supports. Even where that is not the case, the social injustices of the modern world affect families just as much as anyone. 

The fact of the matter is that life is hard on its own.  There is trauma-a-plenty to go around.  Opportunities abound for poverty, discrimination, bullying, bad grades, bad judgment, job or home loss, failure, rejection, break ups, tragedy, bankruptcy, grief, regrets, humiliation, sickness, injury, accidents, threats, rape, harassment, stalking, deception, scandal, swindles, slander, targeting, insecurity, crime, worries, disaster – it’s an endless list.  

4.   A closer look at human needs and ‘trauma’

The implications of the trauma/ human needs perspective are pressing and are vast.   They provide a widely applicable, independent framework for understanding human behavior. No pathology, no chemical imbalances, no genetic markers are needed. 

Sound unbelievable?  It’s not.  All you need is an integrated understanding of the human stress response and then to connect the dots from there.

The two nervous systems

We have two basic nervous systems:

(1)    ‘All-is-well’ (parasympathetic) for everyday routines.  This is for stuff like eating, sleeping, relaxing, small talk, hobbies, tinkering around…


(2)    ‘High-stakes’ (sympathetic/ ‘survival response’/ fight-flight-freeze)  This is our ‘get your butt in gear’ system.  It’s our rapid response system for things that are a big deal – essentially threats or opportunities.  This includes all kinds of stuff - both ‘good’ and ‘bad’ – where the stakes are high: 

·         Discovering a new friend, new gossip, twenty dollars or your toddler in the road
·         Taking tests, exams, someone’s wallet or advantage of a child
·         Scoring a point, contract, victory or high
·         Getting laid, married, yelled at, ripped off, assaulted or stopped by police
·         Going on first dates, adventures, job interviews or a rampage with your partner
·         Getting through performance reviews, competitions, college, police interrogations or psychiatric exams
·         Resisting temptation, peer pressure, arrest or psychiatric drugs

The high stakes system is the key

If you want to make sense of so-called ‘psychopathology’, the high stakes system is the key.  If you know what to look for, you potentially can explain all the so-called major disorders - anxiety, depression, bipolar, OCD, borderline, substance use, anti-social, addictions, dependency, paraphilias, etc.  You just need to know the person’s story, their perceived needs, and their default responses when the ‘stakes are high’. 

How the high stakes system works

The high stakes system spurs the body to initiate dramatic physical and mental changes.

On a physical level:

  • Blood and resources go to the muscles (tense, achy, shaky, trembling, agitated), heart (pounding), and lungs (heavy breathing, hyperventilating, out of breath).
  • Energy production (digestion, swallowing, bladder, bowel) are triaged or shut down.  This leads to things like nausea, vomiting, lump in throat, urge to urinate, incontinence, cramping, diarrhea, light-headedness.
On a mental level:

  • Focus narrows to the source of concern (tunnel vision, hyperfocus, losing the forest for the trees)
  • Rapid response feels urgent (hair trigger, impulsive, reactive)
  • High-level thinking is largely triaged out (stammering, stuttering, losing words, mind going blank). 
  • Gone are the capacities needed to think ahead, remember consequences, learn new information, weigh costs and benefits, assess impact on others, defer gratification and solve complex issues.

How high-stakes and all-is-well interact

Here is how these two systems interact:

Phase 1: Initial activation (High-stakes revs up)

1. We see (perceive, experience) a threat or opportunity
2. The high-stakes response kicks in
3. Resources shift automatically from brain (rational thought) to brawn (taking action)
4. Strong effects (fight, flight, freeze) occur.

It’s important to note that fight, flight and freeze are more like tendencies than fixed forms of expression. The effects are unique to individuals.  They represent an amalgam of personal strengths, past experiences and familiar ‘tried and true’ behaviors.  Thus, different people ‘fight, flight. freeze’ on different levels and in very different ways.

Here are some things I have done:
  • Physical (strike out, yell, swear, damage property, run, drink or take drugs, go limp, hide in bed)
  • Emotional (rage, seethe, envy, hate, worry, dread, cower, cry, space out)
  • Social (complain, humiliate, beg, apologize, withdraw),
  • Intellectual (argue, distract, forget, go blank)
  • Spiritually (pray, leave body, become a deity, feel empty or dead,).      


Phase 2: Prolonged activation (If high-stakes stays turned on)

Sometimes the high stakes circumstances go on and on…. When things stay unresolved, the high-stakes system keeps at it, with the following effects:
  •  Resources keep going to brawn not brain
  •  Mental capabilities progressively break down
  •  Bodies break down too

If concerns stay unresolved for weeks, months or even years, this can take a heavy toll.  Our brains and bodies need sleep and resources to repair, restore and learn.  If they don’t get that, we might end up:

  •         Physically sick, injured, exhausted, attacking
  •          Emotionally despondent, erratic, raging, burned out
  •       Socially withdrawing, ranting, verbally attacking, totally depending on others
  •       Intellectually zoning out, disorganized, losing time or memories, missing the forest for the trees
  •       Spiritually visiting other realms, hearing or seeing things, feeling worthless or empty, wanting to die. 

The possibilities are endless.  That’s just some of what has happened for me.

Phase 3: Resolution (Return to ‘all-is-well’ baseline)

To stop decline, we need to feel some resolution. We need to be able to trust that things will be ok.  Otherwise, the high-stakes system will keep doing its job – which is to stay on alert and protect us from potential danger.    

The moment things start to feel resolved, however, something magical happens.  The effect is dramatic:

  •       The high-stakes response turns off
  •       The all-is-well system takes over automatically
  •       We are able to rest, relax, digest food, sleep
  •       Our bodies replenish, our brains repair and heal
  •       Extremes and intensity tend to quiet down

5.    Threatening people is dangerous

The high-stakes system it is binary and reactive.  You are either friend or foe, for me or against me.  This is not a disorder, it’s basic survival.

Imagine you are in the wild.  You catch a glimpse of something out of the corner of your eye.  Is it a bear or just a tree?  Is there a stick or a rattlesnake in the path?  The high-stakes system does not take chances.  It reacts and asks questions later. 

Whether you are police, clinician, psych tech, family member, friend or the person of concern, this is the frame of mind that leads to everyone’s worst nightmare.  But, once you understand how high-stakes works, it’s pretty clear what to do.

In high-stakes times, people trust their guts (that’s where the resources are).  Talk is cheap, roles are cheap.  It’s all in how you come across.  If the right feeling happens (respect, dignity, shared humanity, genuine caring about my concerns), then the stakes go down and all-is-well kicks in. Blood returns to the brain, along with the ability to think, communicate and heal.  We all go home tonight.
It’s also relatively easy to see the problem with coercive, confrontational approaches. A show of force tends to destroy the very rapport that could be life-saving. To be sure, risk is ever present.  But, in a very real way, the odds shift with how you play your hand. (For a sterling example of this, listen to the 911 recording involving Michael Hill, a would-be school shooter and school office worker, Antoinette Tuff,

It’s also easy to see why reasoning and logic don’t usually work.  This is not a reasoning frame of mind.  Literally, the brain capacity is not there.  That doesn’t mean rational capacity is gone forever.  It just means the stakes are too high for now. 

This is good news.  It is often a solvable problem. It means that we both can get to a reasoning place if one of us can make the stakes go down. 

How to do this is the million-dollar question.  But, at core, it’s really simple.  There’s a golden rule that cuts all ways:

                            If you want to make things safer,                        start looking safer to those you want to reach. 

When you scare someone, the high-stakes nervous system literally starts pumping the blood away from their brain. The more you threaten them, the less their brain has to work with.  Thus, the less rational they physically are able to become. This is dangerous for everyone!

6.    A better nosology for behavioral health…?

So where does all this leave us?

The DSM (psychiatric) model of ‘mental disorders’

On the one hand, the DSM (Diagnostic and Statistical Manual published by American Psychiatric Association) is quite frank.  It has no opinion about the root causes of ‘disorders’; it is simply a system of classification and labels. In no small part, the DSM is also the product of insider turf wars, political compromise, industry needs and billing concerns.  Caplan, PJ (1995) They Say You're Crazy: How The World's Most Powerful Psychiatrists Decide Who's Normal  (Perseus Books:

One noteworthy consideration for our purposes is that insurance companies pay for ‘mental disorders’ – but not to help normal people who are struggling with a difficult life.  The result is a ‘don’t ask, don’t tell’ (garbage in – garbage out) approach to assessment. Rote symptom checklists determine whether your anxiety, mood, grief, trauma, substance use, sexuality is ‘normal’ or ‘disordered.’  Real life facts, like a growing up in shelter housing getting routinely abused in the group showers, are frequently ignored as irrelevant, or not even asked about. It’s like your teacher pronouncing you ‘learning disordered’ without ever considering whether you study. 

Beyond that, even the categories themselves are questionable. Experienced clinicians disagree frequently.  Individual suicide and violence aren’t predicted much better than flipping a coin.  In 2012, concerns like these led whistleblower Paula Caplan, Ph.D., to report to the Washington Post:  "Psychiatry’s bible, the DSM, is doing more harm than good."  A year later, the National Institute of Mental Health literally threw out the DSM and decided to start over.  Insel, T (Apr. 29, 2013) Transforming Diagnosis, Director’s Blog (CMS),

The Medical Model of ‘mental illness’

The medical model hasn’t fared much better.  Despite billions of research dollars, there is no demonstrable ‘chemical imbalance’ and no compelling genetic or biological markers.  During the past several decades of increasing ‘drug therapy’, disability rates have sky-rocketed.  Long-term outcomes and relapse rates have worsened overall. There are countless reports of drugs increasing or even creating urges to violence or suicide.  Due at least in part to treatment effects, the ‘mentally ill’ lose 15-25 years (on average!) off the normal life span.  Whitaker, RH (2010).  Anatomy of an Epidemic.  New York: Random House

The social justice model of trauma and human needs

On the other hand, when you look at trauma and its effects, a different picture arises.  Much of what has been baffling about human behavior and symptoms becomes understandable:

  • Resources are seemingly scarce
  • People have basic needs
  • They see a threat or opportunity
  • The high stakes system kicks in
  • Predictable physical, mental and social effects occur.

Equally important, this is not a disorder.  High-stakes reactivity is supposed to happen in high-stakes situations.  The problem is not that people are maladaptive.  The problem is that some 90% of behavioral health service users are going without basic life necessities – things that everyone needs to live and be well. 

The impact of diversity

When you put the above factors together in varying combinations, you can pretty much cover the DSM. If you factor in the survival function of high-stakes responses, it gets even more convincing.
The wide variability of high stakes responses is not an accident.  To the contrary, our natural human diversity in times of need is a tremendous asset to our species.  When an entire community is facing a threat, this ensures that people will respond in numerous rich and creative ways. 

This promotes community resilience and survival overall.  If we all responded the same way to danger or opportunity, a single threat (predator, disease, disaster) could wipe us out.  We actually need the creative solutions that people come up with under duress to ensure our collective survival.       

On the other hand, when the stakes are more individual, the virtue of diversity can get obscured.  Only one of us – not the whole group - appears to be affected.  So, the way a person responds can look pretty strange to everyone around them.   

This explains why so-called 'mental illness' is so hard to diagnose and categorize.  We're not seeing an actual 'thing' in and of itself (e.g., depression, bipolar, panic disorder).  We're seeing the response to an actual thing – for example, feeling sick to your stomach before an important test at school. 

 At this point, you can also see the futility of trying to classify so-called ‘mental disorders.’ Just look at a group of kids before a high school math test.  They are all facing the same core stressor, but there are almost as many responses as students.  (This same scenario highlights the problem with adrugs-first approach.  Very few students will do better on the test, if say, the moment someone sees you puking, the school injects you with Zyprexa.)

So let’s take this one step further.  Imagine you are having the worst day of your life.  You have been waiting for hours, naked, hungry, cold and alone, in a barely furnished room. You have never met the doctor who shows up and claims to be here to help you. After five minutes, the doctor cuts you off, then proceeds to tell you what your problem is and what you need to do about it.  A prescription is written, given to a nurse.  Your entire fate from that point on depends on what you do next.   

There is hardly a better way to exacerbate, instead of lessen, high-stakes responses.  This is true even if you come into the system as a lucky one-in-ten with no prior trauma.  On its face, such arbitrary exercise of authority is traumatizing in and of itself.  It is unilateral, frightening, insensitive, confusing and grossly uninformed.  There is no meaningful discussion, no apparent recourse, no one on your side.  Experientially, it’s much more like being a prisoner of war than a recipient of actual care. 

This kind of ‘treatment’ causes the very ‘illnesses’ that experts claim to see.  High-stakes responses are unique and extreme by design. They make look strange to onlookers, but this is a good thing overall.  Predators/ competitors are unable to anticipate or plan for what we’ll do – which promotes both individual and species survival.

On the other hand, it’s not hard to connect the dots with common ER ‘outcomes.’  People are seen at their worst, treated badly, diagnosed based on their worst possible performance and then detained and drugged accordingly.  Needless to say, this is not a particularly fair or ‘professional’ way to assess someone’s capacity to survive safely in freedom. 

The moral of the story:
            If you want to be as safe, rational and helpful               as possible, but you’re still hanging on to disordered thinking…

No comments:

Post a Comment