Explanations and unexplanations: Restoring meaning to psychiatry

Reasons to be sick

First, much of our community misunderstands and is intolerant of healthy emotional feelings of sadness, anger and fear; to be distressed or worried is to be ‘not myself’. Only two weeks of significant distress attracts the diagnosis of depression, and it is regarded as irresponsible and dangerous not to be happy (Ehrenreich, 2009). But happiness is a marker of well-being experienced in certain life circumstances, and not a suitable goal to pursue directly. What can be sought is a good life, something that, although difficult to define, is fairly easy to recognise. With luck and opportunity, there will be significant periods of happiness, but misery, fear and anger are also part of a good life. What should be promoted is openness to and acceptance of uncomfortable feelings, rather than ‘rushing past pain and unease toward comfort and stability’ (Mariotti, 2009).

Second, many psychiatrists seem to wish that the suffering presented to them was more like heart attacks or cancer, where getting appropriate and specific treatment saves lives. There is a precedent within psychiatry: syphilis filled psychiatric hospitals 100 years ago. Finding a biological explanation (the syphilis spirochete), and later a treatment (antibiotics), eliminated these psychiatric illnesses. Enthusiasm in psychiatry for finding similar explanations and cures leads to an overinvestment in making sense of suffering in terms of disease.

Third, healthy individuals experience a plethora of symptoms in any given week. Ill-defined headaches, nausea or back pain, and bodily manifestations of emotions (churning stomachs, racing pulse, fatigue) come and go, and are given more or less attention according to circumstances. Most symptoms and emotional feelings pass without any substantial sustained effect on well-being. However, when someone is made susceptible by tiredness, intoxication, or circumstances in the family or broader environment, those bodily feelings can become a focus for attention and pre-occupation that facilitates their persistence. A child who cannot say to his parents ‘I can’t bear your fighting, please stop’ might attend more than is helpful to his painful tummy. If the cards fall in a certain way, he can be diagnosed with and treated for a gastrointestinal illness or anxiety. But neither physical nor mental illness labels for his bodily experience constitute explanations; his symptoms would be better thought of as arising from his predicament (Taylor, 1979). Only when it is understood that his complaints of gut ache are a response to his parents fighting will it be recognised that intervention needs to be with his parents.

Psychiatric diagnoses as unexplanations

Co-opting bodily, emotional and mental experiences into the domain of Western medicine can be traced back at least to the Victorian concept of neurasthenia. New diseases have become available, often under influence from the pharmaceutical industry – for example, the conversion of the intense somatic and mental experience of severe shyness into the disease of social phobia (Moynihan and Cassels, 2005). Across the lifespan, there are gastro-oesophageal reflux disease in infancy, attention deficit disorder in children (and increasingly adults), irritable bowel syndrome, and chronic fatigue syndrome.

The most prevalent current unexplanatory label is depression, as it is now understood. As psychiatry has become more biological in recent decades, more human experience has been reduced to simplistic unexplanations like ‘chemical imbalance’, exposing distressed individuals to psychotropic medications. In one year, 6.8% of Australians aged 16–85 years took antidepressants. Half of them did not report symptoms consistent with 12-month affective or anxiety disorder, and 30% had never had an affective or anxiety disorder (Harris et al., 2011).

Until 50 years ago, depression as a medical diagnosis was uncommon and severe, frequently requiring hospitalisation. In English, ‘depression’ was used to describe ordinary dejection 200 years before it was used as an illness label. So it could easily be expanded from its restrictive medical use to encompass all of those who would have been diagnosed with anxiety in the benzodiazepine era, and many more besides. What was masked in English-speaking cultures – the distinction between these two meanings of the term depression – was overt in Japan, where the term used for that severe form of depression (utsubyo) could not be applied to the lower level feelings of distress and suffering that are now labelled depression in our society (Watters, 2010). Antidepressants didn’t take off in Japan until the creation of the term kokoro no kaze (cold of the soul), which Japanese society could embrace in much the same way that our society embraces the concept of depression.

But it is not just mental problems that are socially determined; so too are physical disorders. Type 2 diabetes is caused by obesity, itself strongly correlated with poverty. These social factors urgently need to be addressed, but diabetes must still be treated. So it might be argued that mental illness should be treated medically, independent of its social causes. The difference is that, unlike ‘depression’, ‘diabetes’ straightforwardly explains each of the patient’s symptoms. Depression on the other hand explains nothing; at best it describes. Depression as a description can be benign: a GP can tell a patient who meets the criteria for depression, without making any explanatory claims, ‘I think what you are experiencing could be described as depression. This is quite common in our society and it tends to last weeks rather than months, and you’ve had it for several weeks now, so it is likely that it will go away relatively soon. Why don’t you come back in a couple of weeks and let me know how you are going with it’

But more often descriptions masquerade as explanations (Frankel, citing Lewis, 1996), and ‘depression’ is pressed into service as unexplanation. Unexplanation, like bullshit (Frankfurt, 2005), shies away from uncertainty, and is not benign. Autonomy is eroded by labels like depression which distract from identifying authentic predicaments, thereby compromising their resolution. Unexplanatory labels lead to engagement in systems that locate problems within the individual and deflect attention from social context. Once in those systems, failure to respond can lead to an escalation of potentially harmful ‘treatments’.

They fuck you up, your mum and dad.

They may not mean to, but they do.

The crude term ‘fucked up’ gives a better broad explanation than sickness for young people’s distress. It captures two apparently contradictory processes. The first sense is Larkin’s, being fucked up not just by ‘mum and dad’, but by the whole range of life circumstances and physical influences like habitual intoxication or head injury that can have a spoiling influence on life and development. The second sense is of having fucked up, of having done things that ought not to have been done and not having done things that ought to have been done.

In making sense of patients’ suffering, distress and unhappiness, it is essential to sort out the interplay between what life has done to them and what they have done with their opportunities. Often patients and those around them get the balance wrong, undermining understanding of their predicament. For example, it is common in those young people with ‘externalising disorders’ to focus on their fuck ups rather than appreciating that their unacceptable behaviour can be understood as a legitimate protest against circumstances that leave them feeling frightened and hopeless.

Implications for psychiatric interventions

There are good arguments for aiming to deal with young people’s distress outside the health system. Young people’s distress must be taken seriously, but does not necessarily constitute an emergency. So the parental response might be, ‘It is frightening and I’m probably not going to sleep tonight, but I will sit with this, and tolerate that everybody feels really bad’ or ‘There is somebody in my family or community who can talk my son through this’, rather than immediately deciding that the situation exceeds the capacity of extended family, friends and community, and requires professional help.

But once young people cross the threshold into psychiatric care, there is a responsibility to help. Psychiatrists can offer some combination of:

Contemporary psychiatric training and practice focuses its attention on pain and functioning at the expense of relationship and meaning, but this approach risks providing analgesia at the expense of understanding.

Psychotropic drugs, whether prescribed, bought on the street, or imbibed in a bar, often succeed short-term in taking away pain and enhancing functioning; for example, alcohol appears to attenuate social phobia. What is more uncertain is their long-term harm–benefit ratio, with the possibility that, for example, treating depression earlier and more frequently with antidepressants may increase the risk of further episodes of depression (Patten, 2004). In any event, success with distressed people is determined mostly by a combination of non-specific factors and natural recovery rather than the direct effects of any specific treatment, pharmacological or otherwise (Bentall, 2009). If the benefits of the therapeutic relationship between prescriber and patient are ignored, most drugs do little more than take the edge off suffering. Whilst this reduction in pain is a benefit, it is not enough. More attention should be paid to the relationship within which the psychiatrist prescribes or administers therapies. And more respect should be given to ‘watchful waiting’ – providing a careful assessment to exclude anything acutely dangerous, then monitoring the patient’s well-being without applying a specific intervention (Meredith et al., 2007). Watchful waiting is different from doing nothing, with which it is often confused. It can be supplemented by a rehabilitation approach, with prescriptions for graded resumption of activities, exercise, healthy eating and other non-specific health-enhancing interventions.

With respect to understanding meaning, although each young person comes to psychiatry with a different story, there is a limited repertoire of themes – fear, pain, loss or hunger (usually for relationships of some sort) – so that the seminal story, though not immediately apparent, can often be found. Setting and patient characteristics will mean that it is not always timely to pursue narratives, but they remain central to the psychiatric enterprise. In developing a narrative about how the patient got to be where they are in life, the aspiration is an authentic story, rich in emotional and interpersonal detail (rather than a glib and stereotyped script; see Henderson-Brooks, 2010). This is achieved by following a procedure close to the scientific process: bringing experience together into a coherent/cohesive and meaningful story, then testing and improving that story, always trying to make better sense of the circumstances (Rivers, 1918).

Seventeen-year-old Zoe was admitted to hospital having taken 24 paracetamol. The psychiatric registrar noted that she lived with her mother and younger brother in what appeared to be a well-functioning family. He assessed the suicide attempt as having been of moderate intent and lethality. When asked why she took the overdose, Zoe replied ‘I broke up with my boyfriend’, but the registrar recognised that this attribution falls short of an explanation because very few of hundreds of adolescents who break up daily take serious overdoses.

The registrar competently established that Zoe met criteria for moderately severe depression, but felt unsatisfied that this explained her behaviour, and went on to establish the story of the break-up. This turned out to have been relatively benign; they had been together for 6 months in a warm relationship, and he ended it politely. So by now the registrar had excluded many potentially relevant issues, but an explanation for why Zoe attempted suicide only emerged when he explored where her father fit into the story. It turned out that when Zoe was a toddler, her parents divorced and her father disappeared from her life until she was 12, when he contacted Zoe and they tentatively built up a relationship. Then, about when Zoe began her relationship with her boyfriend, her father transferred interstate, again interrupting their relationship.

So now there was an explanation: the break-up resonated with Zoe’s abandonment by her father, turning a troubling but relatively benign process into a life-threatening one. A conventional psychiatric formulation would be that Zoe was depressed and depressed people often make suicide attempts. It would note that Zoe’s abandonment by her father was recapitulated in the relationship with her boyfriend, helping to make sense of why Zoe had become depressed. But the approach advocated here makes redundant, rather than makes sense of, the depression diagnosis; Zoe suffers from paternal abandonment, not depression brought on by paternal abandonment. Explaining Zoe’s behaviour to her and her mother in this way led to her mother tearfully saying ‘I always thought you were better off without your deadbeat father, but now I can see how difficult his going again was for you.’ Mother and daughter were thereby able to exploit the crisis of Zoe’s overdose to grow and develop.

This narrative task must be treated with the same kind of scepticism that should be directed towards other drug and non-drug treatments. The story developed with the patient needs to be interrogated and re-examined to ensure that it is not avoidant, that it is the most authentic and helpful story that can be developed for that person at that time.

Ethical choice of psychiatric intervention

Because there is little evidence to favour one psychiatric intervention over another, even for severe disturbance, there is often limited scientific guidance for choosing between plausible alternatives (though implausible ones like homeopathy can be excluded). It is not good science to blindly choose a treatment that scores a few points better on a 100-point scale when the clinical significance of that advantage is dubious. That statistical advantage should be taken into account, but the decision should be guided more by ethical considerations: avoiding doing harm, enhancing autonomy. This dictates that, in the absence of a clear, clinically significant advantage for medication over watchful waiting, the first choice is watchful waiting.

I propose that the most ethical interpretation of the psychiatric task is to provide a safe, validating (and therefore potentially transformative; see Porges, 2009) environment in which patients can, with our help, come to an authentic account of where they are, how they got there, what needs to be accepted and what must be changed. This approach might prolong pain but it has the benefit of strengthening people in the face of subsequent difficulties and distress. Sickness is unexplanatory for most suffering. Much of contemporary psychiatric practice robs actions and experiences of meaning by applying simplistic labels and glib biological unexplanations that pathologise and erode autonomy. Good stories can be ethically and clinically superior to diagnoses and drugs in supporting suffering individuals.