From the origins of psychiatry to the present, there have been two distinct paths one could walk toward the understanding and the treatment of mental illness.  These paths are the neuro-biological path, and the environment path, or nature vs. nuture.  Although most scientists of any notoriety would purport that genes, neuro-biologcal structure and environment are all implicated in the development of what we call mental illness, only recently have these paths begun to converge when it comes to treating it.

An important lag in our public perception is found with the understanding of epi-genetics, or the notion that genes are turned on or off by environment (and are even impacted by the environments of our progenitors several generations back).  For some reason, epi-genetics has largely been left out of the public discourse on mental illness.  One possible reason for this is because this wide array of possible influences over our mental states may appear threatening.  Just when we thought we had it figured out, it appears a lot more complicated and at least partially out of our hands.  Thinking we can map the brain and therefore understand and prevent mental illness is perhaps not as direct a goal as we had once hoped.

And in the meantime, when it comes to treatment, we risk getting knocked over by the massive pendulum swinging between the worlds of psychotropic medication, and psychotherapeutic and psychosocial efforts.  At this point, most practitioners only practice delivering care from one end of this spectrum or the other.  Our opportunities to visit a practitioner trained in dispensing and monitoring medication AND administering psychotherapy are few and far between. We are indeed more likely to come across individuals with strong biases in either direction, thereby potentially leading people in need of complex care interventions, toward lopsided and incomplete recovery outcomes.  And as most schools of thought uphold the covert ideal that IT is the preeminent path toward mental wellness, even when we have care teams composed of professionals with varied training, they often fall short of being able to cooperate and collaborate to the best of their abilities.

Why in the midst of this massive mental health crisis are we still fighting over our own piece of the pie?  Well, for many of us, our livelihood depends on it.  We are set up to prove through evidenced-based studies that what we are doing is valuable, and essential.  And those of us whose practice is better suited to qualitative analysis, or who are not represented in the current discourse on recovery-oriented interventions –  well, I’m afraid that for now, we’re mostly out of luck.

Even with several studies on the remarkably small difference between antidepressants and placebo for moderate depression, not to mention the question of long-term impact and the possible contribution to chronicity of depressive states, we still dole out pills faster than we can read the literature on them.  But it’s not only pharmaceutical money that drives the system.  Several reputable meta-analyses reveal that only a small percentage of therapeutic impact of Cognitive Behavioural Therapy(CBT) and other psychotherapies (15% of the total impact) is due to specific technique, while readiness of a client for change, their other supports, empathy from and rapport with the therapist, account for the majority of therapeutic change.  Yet, CBT techniques are seen as the gold standard, and today’s therapists are counseled to uphold firm boundaries, focus principally on technique, and hope for the best, leaving their basic human impulse to connect at the door.

It is clear to me that when massive amounts of funding are involved, when you have professionals with varying expertise pitted against each other for research money, when the popular discourse on mental health is years behind the research, you have a recipe for a less than ideal situation.

What can we do?  Educate ourselves.  Dare to be critical of the care we receive and the rationale behind it.  Stand up to the system that tells us there are only one or two options for any mental health problem.  Treatment plans should be client-centered, involve a choice of interventions, and clients should be trusted to take a principal collaborative role with providers.  When there is a medication with fewer side effects you have researched and would like to try, advocate for yourself.  When you come across a therapist with poor bedside manner and you know that empathy and rapport create the foundations for a healing relationship, ask for someone else.  Trust yourself if you come across an alternative treatment that seems to work for you.  It’s time to remember who is serving whom, and take some of the power out of the hands of clinicians and researchers, and place it in the hands of service users and advocates.  It’s time to realize that although most clinicians have our best interests in mind, their systems of learning are as human and as fallible as the people who create them.  As long as mental health care is fighting for the same small scraps of government funding, we are bound to place jobs, survival, and ideology over individualized care.   In my opinion, although I hope for the best, I think we just might be decades (or a massive federal government shift) away from anything we might dare to call “best practice.”

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