“Popular female celebrity has gone into rehab. She expects to make a full recovery and return to her tour and her fans by next month, says the publicist.” How many times have we read this in the news?

Justin BieberAs I write, I am thinking of Justin Biebers recent DUI arrest, and I can only help but heave a big sigh, as I am sure, he too, will become another alumnus of “Hollywood Rehab.”

Don’t get me wrong – I love the newest edition of People magazine as much as the next person. Yes, I do think that the disclosures of pop stars and actors such as Demi Lovato and Kesha seeking treatment for eating disorders and addiction issues can minimize stigma around these problems. (Thank you, ladies.) But I also wonder how this portrayal of mental illness and treatment impacts the public.

My concerns as both a mental health provider and a social scientist are the concepts of “drive thru” treatment and the glamorization of specific mental illnesses that are being molded by the media.

Quick fix

An astute and humorous colleague of mine actually coined this term – “grab and go” treatment – as a way of explaining the influx of clients who are looking for a quick fix to mental health issues. Many individuals seeking diagnoses and professional advice are astounded when they are told that progress will take time, energy and money, thus creating an inconvenience and the need for reassessment of one’s lifestyle.

It can be frustrating to report the same explanation of quality treatment and the trajectory of most mental illness, yet I can understand how this inaccurate perception of psychiatric illness and “rehab” developed.

If you look at “TMZ” posts, rehab is this soothing place where one can “center” his/her self.  In reality, impactful treatment for a disorder will require more sweat and time than a Bikram yoga class. Of course many people are shocked and upset to find out that the stay at the “spa” turns out to be a crash course in their mental make-up and die-hard habits. If only the mental health problems of the world could be solved so simply.

Become an educated consumer

So what is a conscientious individual to do? Well, for starters, become educated consumers of the media and news. If you want to know more about mental health, research a treatment facility or talk to a provider. Read articles written by mental health professionals and researchers.

Also, a word to the writers, journalists and those who are in recovery – be careful about romanticizing mental health disorders. As blogger Alice Gregory of the New Yorker recently wrote in response to a memoir on anorexia nervosa:

It is the survivors’ responsibility to not inadvertently write ‘how to’ manuals on disorders in their accounts or to make their darkest moments sound angsty, sexy, and deeply creative.”

These styles of writing sell more books, but the consequences of these messages to readers who are struggling are not so benign. I agree with Ms. Gregory: It is time that someone wrote about the exhaustive, restrictive, antagonistic elements of living with a disorder and the hard work and commitment needed to heal.

Regardless, I still may order a copy of the Biebs’ future memoir on his rise above the “bad boy” years, but, of course, only for research purposes….

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marijuana legalizationFor the first time in history more than 50 percent of Americans support the legalization of marijuana. Those of us in the addiction field are faced with new attitudes about a substance that is not as innocent and harmless as many of its proponents would like us to believe.

Contributing to the confusion about the effects of marijuana use is a history of scare tactics, incomplete research and a lack of facts. Indeed, much has been written about the harmful effects of marijuana that has not stood the test of time and scientific scrutiny. It is, however, dangerous and irresponsible to think that marijuana is a welcoming and wonderful gift free of potential consequences.

The “less harmful” debate

One of the most common arguments is that it is “less harmful than alcohol; therefore, it isn’t harmful.” This argument does not make sense. Saying something is less harmful than the most destructive, addictive substance on the planet does not somehow validate consuming a “lesser” drug. Being bitten by a less poisonous snake is not a comfort to the person who was bitten.

If anyone is to argue the merits of marijuana use, those arguments must be supported by significant, valid research. Gone are the days when addiction counselors could use scare tactics to try and shake people into better decisions about substance use. Now, people have access to a constant flow of information, and with more sophisticated consumers comes the need to carefully understand the various points of contention within the marijuana debate. Make no mistake: It is a contentious debate with considerable passion. And the debate is necessary in order to help people make decisions about starting, stopping or considering marijuana use.

It appears that many people have stopped listening to addictions professionals and have made up their minds that marijuana is “just no big deal.” Evidence of this is often found in the comments of online articles suggesting that marijuana use may harm the brain, cause more traffic fatalities or contribute to academic failings. If you were to talk with an average teenager, they would most likely tell you that marijuana use is no big deal, is better than drinking and is now legal in a number of states, which makes it even more okay.

Is it not worth considering that perhaps we are moving too quickly in adopting an attitude that marijuana is “no big deal?” For those of us who have teenagers or young adults at home, shouldn’t we be concerned about the emerging evidence that early marijuana use may have profound implications for brain development? Are we ready to dismiss the possibility that marijuana use can play a role in driving fatalities, academic success and mental health outcomes?

Marijuana research

My chief concern is helping young people make good decisions about drug use. As an addiction counselor and a parent, I pay close attention to new research that reveals the possibility that there are problems with early use of marijuana. Some recent examples have caught my attention:

  • 2012 – A New Zealand IQ study found that after following 1,000 people from age 13 to 38, those classified as marijuana dependent lost six to eight IQ points.
  • 2014 – A University of Maryland study found that cannabinoids were the most prevalent other drug detected in fatal driving accidents.
  • 2013 – Northwestern University research found that the earlier marijuana is used, the worse the effect is on the brain, leading to memory and cognitive problems.
  • 2014 - The National Institute on Drug Abuse indicated that “research shows that heavy users generally report lower life satisfaction, poorer mental health and physical health, less academic success and is associated with a higher likelihood of dropping out of school.”
  • 2013 – In the Netherlands researchers found that young people with a genetic vulnerability to mental illness have an increased risk of depression when smoking marijuana.
  • 2014 – In Colorado, arrests for driving under the influence of marijuana have increased 50 percent since the start of legal marijuana use for those over age 21.

Of course this research is not perfect. All research is subject to limitations and problems due to additional variables. We know that marijuana stays in the system longer than other substances; so it is difficult to determine if using it causes more accidents. But, it is pretty clear that using a psychoactive substance while driving is probably not the best idea, even if it is safer than driving drunk (see previous point about less harmful does not equal non-harmful).

That is true for arguments on both sides of the debate. People who use marijuana to cope with anxiety often argue that it is the only way they cope, yet there is insufficient research to support marijuana use as a primary anxiety treatment. In fact, there is some research that suggests marijuana use can create more anxiety in people with certain genetic predispositions.

The real debate

I am writing this blog post knowing full well that many will react with anger and will think that, once again, here is an addiction counselor who just does not understand the “truth” about marijuana. I say we should all work together to really understand the truth. We should open our minds to the possibilities that there is more to understand before we place a universal “stamp of approval” on marijuana use.

I believe we owe careful thought, intelligent debate and considerable research to the young people who are right now considering using marijuana. If you are 40 and smoking marijuana, you might argue that you work, are successful and have no consequences to your use. But this debate is not about you and your belief that you have a right to do what you please.

This debate is about the health and welfare of our adolescents and young adults who at this very moment are becoming more likely to dismiss any possibility that marijuana may not be the answer to their problems.

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mental illness stigmaI do not know the answer to this question, but I have some thoughts about one aspect of it.

A significant public education effort has been mounted to decrease the stigma associated with mental illnesses by emphasizing their neurobiological basis. We can rightly think of psychiatric conditions as brain disorders with a partly genetic basis. As I have described in “Does reframing mental illnesses as brain disorders reduce stigma?” and “Is psychiatry’s drug addiction increasing the stigma of mental illness?,” this new understanding, assisted by drug companies’ advertising, gradually has taken hold in the public mind.

Yet this hard-won knowledge has not decreased the stigma associated with psychiatric disorders. Although it has ameliorated blame of the individual to some extent, the biological view also has led to more pessimistic prognoses in the public mind and may be fueling perceptions of dangerousness.

These research findings on stigma are especially disconcerting to me; when I educate patients and families, I make the point that psychiatric disorders are “illnesses” in every sense of the word. I make this point – for example, with depression – to help patients be more understanding and less critical of the sheer difficulty they face in recovering. Force of will is not enough; if you’re mentally ill, you cannot just change your mind and be well.

Our emphasis on the biological basis of psychiatric disorders appears to be backfiring. So what do we do? “Sorry, they’re not biological after all.” We cannot go backward; biological treatments are essential for many patients and, with burgeoning knowledge in neuroscience, these treatments hold promise of becoming increasingly effective over the coming years.

Given the research findings on stigma, we cannot make do with a sound bite: “It’s a brain disorder,” implying, it’s not your fault, or your parents’ fault. Blaming the genes or the brain is not helping. We need to understand, not blame.

I see no alternative to aiming for more sophisticated education (one reason why I decided to write a whole book on depression). For starters, we need to make four basic points:

  1. Brain changes associated with psychiatric disorders are reversible.
  2. Heredity is not destiny.
  3. Psychiatric disorders are associated with problems in living.
  4. Medication is not enough.

Brain disorders

One adverse side effect of the “brain disorders” perspective is the (false) implication that the prognosis for recovery is thereby more grim. Of course there are brain changes with psychiatric disorders, just as there are brain changes with college educations. Neuroscience is demonstrating remarkable brain plasticity, not only early in development but also throughout life. Research shows changes in brain functioning associated with medication and with psychotherapy.

Here I am stating the obvious: If brains didn’t change, no one would develop psychiatric disorders, and no one would recover from them; experience would never change. Now we have rapidly developing science and technology to help us understand the neurobiological processes associated with these changes, and this knowledge will help us influence the changes for the better.

Genetics

Unfortunately, Jo Phelan’s research with a national U.S. sample shows that a genetic explanation for mental illness increases its perceived seriousness and persistence. Moreover, the genetic view extends the stigma from the ill person to the family. Hence, as is true for the brain-disorder view, a genetic explanation increases pessimism about prognosis.

But our fates are not cast in our genes. Research shows that we can rightly speak of genetic “risk” or “vulnerability” for the development of psychiatric disorders. Yet, just as we are learning about brain plasticity, we are appreciating the dynamic nature of genetic influences.

You don’t develop depression because you have “the depression gene.” Multiple genes in interaction – complex networks – are associated with a given psychiatric disorder. Moreover, environmental factors influence gene expression; broadly speaking, for example, early stress can influence the likelihood that genes associated with depression are activated. Thus genes do not act in isolation; they act in concert with other genes and with the environment, including the social environment. To repeat: Heredity is not destiny.

Problems in living

Psychiatric disorders are brain disorders. But how does brain functioning become disordered? Heart disease is a biological illness. How does heart disease develop? We need to think about problems in living. Plainly, health-related behavior plays a significant role in heart disease (e.g., diet and exercise). Stress plays a role in the development of heart disease and psychiatric disorders. Stress is associated with problems in living, including health-related behavior (e.g., being a workaholic, failing to maintain a regular sleep schedule).

Research shows that depression is associated with two kinds of stress: fateful stress (e.g., accidents, victimization) and self-generated stress, which includes stress associated with interpersonal relationships (often mutually generated). Self-generated stress also includes alcohol and drug abuse, which contribute significantly to depression and other psychiatric disorders.

Taking problems in living into account offers hope: We can address these problems and thereby influence our brain functioning.

More than medication

One result of the recent emphasis on “brain disorders” is patients’ increasing reliance on medication and decreasing use of psychotherapy. No doubt, medication can be sufficient for many persons. Yet, if we consider environmental influences over gene expression and the fact that problems in living contribute to brain disorders, we can see that medication is likely to be only part of the solution. For complex and severe psychiatric disorders – for example, developing in the context of a history of problematic relationships – medication alone is likely to be insufficient.

I hold a simple view: Medication relieves symptoms, but psychotherapy promotes new learning. For lasting change, you must learn ways to alleviate and cope with the stress that evokes the symptoms. Moreover, when psychiatric disorders are associated with interpersonal problems, couples and family therapy may be especially important.

As a psychotherapist, my clinical experience convinces me that symptom relief through medication often is essential to enable the patient to benefit from any form of psychotherapy. Moreover, when the psychiatric disorders are especially severe, hospital treatment may be necessary to enable change with medication and psychotherapy.

Can public education reduce stigma?

I have not answered this question. Given the persistence of stigma in the face of massive efforts to increase public knowledge, it is hard to be sanguine about our educational prospects. I am merely addressing the adverse side effects associated with our ill-fated attempt to alleviate stigma by recasting mental illnesses as brain disorders. Perhaps with a bit more complex thinking, we would not translate brain disorders into irreversible conditions.

To reiterate, in educating patients and families, I intend to help them appreciate fully the seriousness of the problems: You cannot simply will yourself out of them or rely on any simple solution. In so doing, I hope to inspire compassion while also emphasizing the capacity for change and recovery.

To me, neuroscience is hopeful: Better understanding will lead to better treatment. But I also protest what I call “biomania,” that is, exclusive reliance on biological understanding to the detriment of appreciating the contribution of problems in living and treatments that address these problems directly. Karl Menninger and his colleagues defined hope as “the positive expectations in a studied situation which go beyond the visible facts.” Perhaps more realistic hope will be one antidote to stigma. But the “studied situation” requires more knowledge than can be contained in a sound bite or a tweet.

Editor’s note: Check out these other posts about brain disorders and stigma by Dr. Allen:

  1. Is psychiatry’s drug addiction increasing the stigma of mental illness?
  2. Does reframing mental illnesses as brain disorders reduce stigma?

References

Allen, J.G. (in press). Biomania: Benefits, risks, and challenges. Smith College Studies in Social Work.

Allen, J.G. (2006). Coping with depression: From catch-22 to hope. Washington, DC: American Psychiatric Publishing.

Menninger, K.A., Mayman, M., & Pruyser, P.W. (1964). The vital balance. New York: Viking.

Phelan, J.C. (2005). Geneticization of deviant behavior and consequences for stigma. Journal of Health and Social Behavior, 46, 307-322.

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Is psychiatry’s drug addiction increasing the stigma of mental illness?

by Jon G. Allen, PhD March 11, 2014

I deliberately chose a tendentious title for this essay – misleadingly metaphorical rather than literal – to highlight, as one of my recent posts outlines, my alarm stemming from reading research on stigma. With many others, I had assumed that treating psychiatric disorders as “a disease like any other” (i.e., like any other general medical […]

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I’m a registered dietitian, and I don’t like “The Biggest Loser”

by Kim Morgan, RD March 7, 2014

Rachel Frederickson, (right), the most recent winner of The Biggest Loser, lost 60 percent of her body weight on the show. The “winner’s” initial weight of 260 pounds made her BMI a health risk at 44.2, while her new weight of 105 pounds also has her BMI a health risk at 18.1. Is she healthier […]

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It’s time to arm teenagers with knowledge of psychology

by Michele Arnold March 4, 2014

The American Psychological Association (APA) has a psychology course for high school students. All the lesson plans, except “Emotion,” are locked because only Teachers of Psychology in Secondary School (TOPSS) can open them. The “Emotion” lesson looks comprehensive (it includes a section on neuroscience); I just hope the teachers who use the APA course infuse […]

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What if we REALLY got rid of shame about suicide?

by Thomas Ellis, PsyD, ABPP March 1, 2014

De-stigmatization seems like such a no-brainer. Stigma, whether associated with an affliction like AIDS, or (in our case) mental illness, is a bad thing. It brings suffering to victims above and beyond that inflicted by their illness. At its worst, it brings with it such shame that people often don’t obtain the care they need. […]

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Does reframing mental illnesses as brain disorders reduce stigma?

by Jon G. Allen, PhD February 26, 2014

Psychiatry is moving gradually toward characterizing “mental illnesses” as “brain disorders.” This movement is consistent with increasing understanding of the contribution of brain functioning to psychiatric disorders. This biological contribution includes genetic factors as well as alterations in brain chemistry, activity and structure. But research in neuroscience also shows that genetic makeup is not destiny: […]

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Are the best days in mental health services behind us?

by Thomas Ellis, PsyD, ABPP January 30, 2014

In a compelling story in a recent episode of CBS’s 60 Minutes, Virginia state Senator Creigh Deeds tells the wrenching story of losing his 24-year old son to suicide, shortly after his son had attacked him with a knife. This occurred the day after Deeds had taken his son to an emergency room, only to be […]

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It’s Good to be Good: Love Your Neighbor

by Stephen G. Post, PhD January 17, 2014

So long as you draw some boundaries and don’t get overwhelmed, it’s good to be good and science says it’s so. Basically, love your neighbor and be a bit happier and healthier. Is there a definition of love that pretty much everyone out on an American highway can connect with from experience? I found one […]

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