Sharing my journey through the mental health system, and especially my successful withdrawal from psychiatric medications, seems to have struck a chord with readers. Many have left comments stating their own desire to break free of pharmaceuticals. A few visitors have expressed reservations about my stance on these issues, because they have found psychiatric drugs helpful and life-enhancing.

The two positions (a belief in the value of medications and a desire to break free of them) are not mutually exclusive. There is no reason a person couldn’t credit drugs with saving his or her life, and still hope to someday be liberated from taking them. But there is obviously a tension between faith in pharmaceuticals and the desire to live without drugs.

The following text was cobbled together from my replies to the desires and concerns of readers. It explains at some length the fallacy in believing pharmaceuticals to be potent weapons against mental chaos. The next post will argue against long-term use of medications without trials of drug reduction, and also offer some suggestions for tapering off pharmaceuticals.

If ‘mental illness’ has failed as a metaphor for psychic distress, as I’ve argued, how do we explain the obvious fact that some people have so much trouble with their minds? Whether we speak of an adolescent hearing voices and drifting out of touch, or a young woman paralyzed by anxiety, or an older man with no desire to live, we see mental problems all around us. Why raise a fuss and argue against the widely accepted notion that these are illnesses?

The problem is perception. If by ‘illness’ the psychiatric world meant something akin to a cold or flu, something transient and healable, I would raise no objection. But instead the authorities speak of ‘brain disease,’ which invokes comparison to progressive disorders like Alzheimer’s dementia and Huntington’s chorea. They insist that expensive psychiatric medications are needed by the ‘mentally ill’ the way insulin is needed by diabetes. And everyone understands diabetes to be a lifelong condition once acquired.

The ‘illness’ metaphor as currently used robs hope from those suffering mental distress. And if there is one thing we need when our minds are in turmoil, it’s a sense that things can get better. The expectation of a little improvement at the cost of drug dependence and awful side effects will not suffice. We need to believe in the possibility of a grand and glorious transformation from constricted misery to expansive joy. The ‘brain disease’ metaphor rules out such optimism.

For most of my life, the idea that people could suffer diseases of the mind seemed obvious. As a young boy I’d watched my mother cycle through many psychiatric hospitalizations and rounds of shock treatment. Although she never seemed any less miserable upon returning from these confinements, I accepted that she needed them.

After she eventually killed herself, I concluded that the treatments hadn’t worked, not that she’d been misdiagnosed.

During my first year at junior high school, my sister lost touch with ordinary reality after months of heavy LSD use. Weeks after her last dose of the drug, she continued to speak of forces and beings I couldn’t see. She also seemed unable to resist staring at the sun. It became my job to protect her from this and other dangers in the days leading up to her psychiatric hospitalization at UCLA medical center. That something had gone wrong with her mind seemed obvious, and I never doubted that she needed the powerful antipsychotic drugs she hated.

Although psychotherapists long shied away from discussing spirituality, people suffering from depression and the clinicians who treat them are learning that symptoms diminish with spiritual practice. Many mental health clinics now offer meditation classes along with cognitive behavioral training, and therapists have begun to ask clients about transcendent beliefs.

These developments promise to advance the struggle against depression, which until recently was treated in purely “mental” terms. By including the soul as a participant in our pursuit of mental wellness, we humanize psychiatric care.

Spirituality and soulfulness can be very helpful in recovering from depression, but not everyone feels comfortable with them. For one thing, scientific institutions have cast doubt on mystical beliefs in general, and on the existence of soul in particular. Furthermore, spiritual growth gets confused with traditional religion, which many perceive to be out of touch with modern life. Can those leery of mysticism and/or religion still enjoy the benefits of spiritual practice?

Twelve Step programs tell addicts to make amends. Many religious traditions admonish adherents in the same vein. Good parents and judges recognize that justice is better served with restitution and pleas for forgiveness than mere retribution. With so much wisdom advising us to clean up the past, pay for our mistakes, and ask forgiveness, we can be sure there is something healing about doing so.

But it’s not always easy. The Twelve Steps of Alcoholics Anonymous tell us to “make direct amends [to those we've harmed], except when to do so would injure them or others.” AA literature discusses touchy situations, like whether to tell a spouse about infidelity long after the affair has ended, or to reveal financial irregularities to an employer knowing that the resultant job loss will damage one’s children.

These issues need to be decided on a case-by-case basis according to what’s best for all the affected parties. I am not about to take on these complexities.

But there is another kind of dilemma that often arises: What about all those people we’ve harmed in the past who can no longer be reached? Many have died, others have changed names, moved away, or can’t be found. How do we make amends without talking to the injured party?

My last essay attracted more attention than any of my others. A number of fellow bloggers posted links to it, and a couple of mental health activist sites picked it up. This was very gratifying, but in reading the comments here and elsewhere, I see that more must be said about “mental illness” as a dead concept. In particular, I should propose alternative ways of viewing conduct problems.

As The Death of Mental Illness made clear, I’m well aware that speech and behavior can sometimes appear so out of control as to demand assistance. Some commentators have opined that whether we call these tendencies “illnesses” or not is merely a question of semantics. No doubt there is some truth to that, but because of stigma and damaging effects on self-image, the words we choose have important implications for human life.

In summary, here are my reasons for doubting the disease paradigm: 1) It is difficult to draw a line between “mental illness” and normal variance. 2) Which disruptive behaviors get labelled as “mental illness” reflects cultural bias and not medical science. 3) The medicalized diagnostic system is supposed to guide the prescribing of pharmaceuticals, but psychiatric drugs are neither specific to particular diagnoses nor very effective. 4) Although brain alterations occur with longstanding behavioral disorders, there is no evidence of causative organic pathology to explain any “mental illness.” (This last point was not included in the essay, but was outlined in my response to one of the comments.)

In writing this post, I may be crashing the American Psychological Association’s annual blog party. Naturally, I’m in favor of joining others to increase awareness and reduce stigma around psychiatric problems. But despite the spirit of solidarity, I’m perhaps an outsider, because I no longer believe ‘mental illness’ serves as a helpful concept.

In this era of burgeoning diagnoses, it’s a bit awkward to declare our great emperor, the Diagnostic and Statistical Manual of Mental Disorders (DSM), naked and unfleshed. Especially at a party.

Let me be clear: people sometimes behave in ways that look incomprehensible or even insane. Suicidal behavior, profoundly delusional speech, and irresistible compulsions represent severe behavioral problems for individuals and society. No doubt they stem from cognitive activity and emotional tones that differ from average day-to-day awareness. These sorts of disordered conduct do indeed derive from ‘mental’ processes, but do they qualify as ‘illnesses?’

Withdrawing from my last psychiatric medication has reminded me how much the pills taught me. Until recently, I believed their tutorage instructed me only about dreadful side effects, about feelings of dependence, and about the sad fact that pharmaceuticals couldn’t save me. But now I see how they also enhanced my understanding of the mind and its sensitivity.

A little over two weeks ago I took my final buproprion dose. I had already tapered my intake down to a quarter tablet a day. The painlessness of my slow reduction had lulled me into imagining that complete cessation would go unnoticed by my nervous system. Wishful thinking. The withdrawal symptoms have been mild compared to previous drug tapers, but they’re strongly affecting me.

By now, most of us have heard of the triune brain concept. Proposed by neuroscientist Paul D. MaClean, it provides a straightforward way of viewing the mind’s function and evolution.

MacLean divides the brain into three levels, which can roughly be described as cognitive, emotional, and instinctual. Because of its simplicity, the model has been criticized by some experts, but it has become quite popular just the same. I bring it up because it relates to my prior discussion about how I first learned to embrace emotions, but now feel it necessary to release them.

Every person’s development is unique, but there are common themes that repeat in the lives of many. In my case I started from the rather typical modern stance of deifying rational thought. Raised by a scientist, and then trained as one, I valued the mind’s ability to figure things out. It never occurred to me that such mentation could lead to problems. Thinking seemed perfectly reasonable.

The first fault line developed in that surety when I started to see my thoughts as obsessional. My difficulty never heightened to the level of diagnosable obsessive compulsive disorder (OCD), thank heaven, but a tendency toward repetitive and self-exacerbating negative thinking became obvious. At first, I worried about my future. When in college, fears about my grades kept me awake at night, even though I earned nearly all A’s. In medical school I obsessed about getting “the best” residency, even though there is no such thing. As my career fell apart in midlife I started panicking at the prospect of running out of money.

These obsessions were all different in substance, but identical in flavor. They combined with profound regrets about the past and fantasies about what might have been. This ‘woulda, coulda, shoulda‘ mentality turned into a kind of magical thinking: it almost felt like wishing hard enough would make things change.

Did I protest too much?

In a recent comment exchange with a reader, I found myself arguing a position that once felt important to me. Namely, I insisted that emotions constitute a central and vital feature of human life. Although on some level this is obviously true, I took it further and stated, in essence, that a life with less feeling is a life less lived. However, as I thought about the conversation afterward, it became clear that my attitude has changed.

As it should. No one committed to growth should feel locked into any belief, because as we mature our views broaden and our opinions change. A year or so ago it felt important to embrace my emotions. Throughout my entire life I’d been scared of my intense feelings. They seemed dangerous and (of course) irrational.

The fear bore its fruit of avoidance. My desire to sidestep pain grew so great that I accepted antidepressants and many other psychiatric drugs in an effort to keep a lid on my experiences. This strategy proved disastrous. Side effects mounted, my productivity declined, and I felt a chronic low grade misery in place of the intense mood swings of earlier years.