Fighting the stigma of mental illness is a difficult and never-ending process, despite the great progress we have made in the last few decades. Unfortunately, the recent shooting in Aurora, Colorado, will likely add to the difficulty.

Misperceptions fuel stigma

Tragic events like these often fuel the misperception that anyone with a mental illness could be violent and dangerous. It is a natural assumption to make with the pain and shock of the murders fresh in our minds. However, such assumptions are inaccurate, and they unfairly stigmatize people with mental illness. The fact is, people with mental illness are not more likely to engage in violent behavior than the general public.

Defeating fiction with facts is one way One Mind for Research is tackling the stigma of mental illness. Led by former congressman Patrick J. Kennedy and businessman Garen Staglin, One Mind for Research is a bold initiative bringing together renowned neuroscientists, advocates, policy makers and others to cure diseases of the brain within the next 10 years. Kennedy compares their plan to the ambitious goal of his late uncle, President John F. Kennedy, to land a man on the moon, and the slogan for the current effort is “a moonshot to inner space.” It’s a huge goal, they admit, but they are committed.

Focus on stigma

I attended their first annual meeting in May — a dazzling event featuring sessions on the latest research and treatments for brain disorders and attended by mental health professionals from across the country. But what set the conference apart was its emphasis on stigma, most notably a panel on “The Science of Stigma,” moderated by actress Glenn Close, who has family members with mental illness. The panel featured Elyn Saks, PhD, a law professor at The University of Southern California, recipient of a 2009 MacArthur Foundation “genius” grant and author of The Center Will Not Hold, Saks’ bestselling, brave memoir of her struggles with schizophrenia.

I say brave, because schizophrenia is still one of the most misunderstood and “scary” types of mental illness, and the people who have it are often shunned. Saks, who is a leader in her field, is a great example of how a person with a brain disorder can lead a successful life with the right treatment and medication.

Financial burden

One Mind for Research is partnering with high profile people like Saks to underscore its message: Mental illnesses are brain disorders and should be treated like any other disorder or disease of the body, like diabetes or heart disease. They also cost our country a fortune.

At the conference, Michael Thompson, a principal at PricewaterhouseCoopers, presented new data showing that the annual cost of treatment and long-term care for brain disorders in 2010 was $476.1 billion and is estimated to be $515 billion in 2012 (19 percent of the United States’ total national health expenditure). If we include the indirect cost of treating brain disorders, such as missed work days and lost jobs, that cost estimate increases to $934 billion.

That’s a staggering amount of money, and it shows just how prevalent and widespread brain disorders are. We shouldn’t treat brain disorders as shameful secrets or as signs of “weakness.” Instead, we should help reduce the stigma of mental illness that prevents many people from getting treatment.

Helping veterans

In particular, One Mind for Research is focusing on members of military with brain disorders such as posttraumatic stress disorder (PTSD). Some members of the military and veterans view seeking help from a mental health professional as a “career killer,” and they don’t get the help they so desperately need. With General Peter Chiarelli (ret.) on board as chief executive officer, I have high hopes that they will break down some of the barriers to treatment for our deserving military.

Reducing stigma

Thanks to collaborations like One Mind for Research, we are getting people to take mental illness seriously — and we are making some good progress reducing stigma. Many people now think of alcoholism, anxiety, depression and PTSD as treatable conditions, rather than personal weaknesses.

Fighting stigma remains a difficult challenge, however, and each tragic news story linking a mentally ill person with a violent act increases that challenge. Eradicating stigma will take time and persistent effort, on the part of mental health professionals, advocates, patients and members of our community. We still have work to do.

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

We’re all familiar with the expression “the straw that broke the camel’s back,” which Charles Dickens coined in Dombey and Son. Humans are resilient creatures, but we all have limits to our ability to endure under pressure.

In the past, we thought resilience was a product of a strong will. However, neuroscience and other areas of research have provided us with a fresh new lens through which we are able to better understand our limits. This knowledge is freeing–it allows us to be free from the self-imposed stigma Tom Ellis, PsyD, ABPP, referred to in an earlier post.

This self-imposed stigma can be the result of our internal narrative that speaks about the need to be stoic and shoulder all adversity that comes our way. When we find that we are not able to hold true to this narrative, we often believe that we have failed. In thinking this way we relegate ourselves to the margins of society and fulfill the new narrative of “being less than.”

Allostatic overload

The scientific term for “the straw that broke the camel’s back” is “allostatic overload.” This refers to one becoming ill as a result of the chronic over activation of the body’s regulating systems–some of which are voluntary, and some of which are not.

We have often thought of the human physiological regulatory systems (the body’s components for keeping us healthy) as being somewhat independent. For example, we might have focused on the health of the heart and not realized the interplay of the cardiovascular system with the other systems in the body.

Medical scientists who study allostatic overload understand that the human body is much more complex. This new way of thinking is based on a “whole body” view about health. Our own unique genetic and biological makeup interacts with the biology and minds of other people and with the external environment in often fairly unpredictable unique ways.

Understanding stress

When our narrative speaks about the need to be stoic and “hold up” under pressure, we are basically saying that there is only one answer to handling our stress, and that if we do not rise up over adversity, we have failed. In doing so, we do not recognize that our physiology also plays a role in how we manage stress.

While some medical professionals overemphasize the biological aspects of stress, others tend to focus only on the psychological aspects of “the mind.” We have all heard people say, “It’s all in your head.” Instead, it would be more helpful to remember that the “whole body” is made up of both body and mind and that these are not separate parts of the whole.

The whole body can only take so much pressure before it gives out, regardless of how “strong” we are psychologically or physically.

Stress and mental illness

The concept of allostatic overload gives us a new approach to thinking about the complexity of stress which is often manifested as mental illness. It helps us realize that internal body mechanisms beyond our complete control are also at play in our reactions to events that cause us stress. Furthermore, this way of thinking helps us understand the importance of interacting with others in a healing environment.

When we develop this awareness, we can see the importance of reaching out to mental health professionals who have experience in helping shape new healthy narratives, ones that can influence body functions in a positive way. This can result in a shift from a self-imposed state of stigma to one that helps us interpret a situation without guilt and failing. The new narrative has the potential for placing us more fully in healing relationships with others, rather than isolated on the margins. Being in healing relationships provides a person with added support to carry the “last straw.”

From Hollywood movies and media reports dating back to the late 1970s, you may have formed the impression that posttraumatic stress disorder (PTSD) is rampant among men and women who have been deployed to war zones.

Remember Bruce Dern’s character in Coming Home?  Or characters in The Deer Hunter, Rambo: First Blood, or more recently Jarhead and In the Valley of Elah? All of us can probably conjure up an image of the archetypal dysfunctional combat veteran: emotionally volatile, paranoid, socially isolated, angry, violent, drug-dependent and plagued by vivid flashbacks to brutal combat experiences.

Yet, how true to life is this image? It may come as a surprise to you, but this question is harder to answer than you might think.

Prevalence rates

In studies of U.S. military veterans, the prevalence of combat-related PTSD ranges from about two to 17 percent.  This is a wide range.  Here are some reasons why there’s such considerable variability in rates of prevalence:

• scientific and technical differences in sampling strategies;
• measurement strategies (e.g., use of structured psychiatric interviews versus self-report measures);
• inclusion and measurement of the Diagnostic and Statistical Manual’s “clinically significant impairment” criterion;
• latency of assessment and potential for recall bias;
• various features of the combat experience itself

Prevalence rates are also likely affected by issues related to a range of sociopolitical and cultural factors.  For example, PTSD rates in the U.S. military are often a bit higher than they are for other Western nations.  Media reports, societal expectations and even various system incentives (e.g., disability payments) or disincentives (e.g., stigma) can influence symptom reports and affect perceptions of combat and emotional problems.  The same is often true for many reported physical symptoms as well.

Is it possible to narrow the range of PTSD prevalence with any precision?  Despite a significant body of scientific literature on PTSD, a lack of clarity remains regarding the prevalence of the disorder among military personnel and veterans.  In 2007, a debate in Science demonstrated an interesting variety of perspectives that experts in the field hold. This debate followed Bruce Dohrenwend and colleagues’ excellent re–evaluation of PTSD prevalence among Vietnam veterans from data collected in the late 1980s by the National Vietnam Veterans Readjustment Survey. Data from this one study have been interpreted to indicate a 15.2%, 9.1% and 5.4% prevalence of PTSD among Vietnam veterans.

More recently, an article last year by David Dobbs in Scientific American and highlighted in numerous print, radio and television stories and blogs further reinforced the fact that PTSD prevalence remains hotly debated.  This is partly because the stakes are large: major decisions about VA funding, research allocations, veteran disability payments and even society’s perspective on war itself may hinge on the answer to this question.

My own interpretation of the scientific literature is that the best prevalence estimates are in the five to nine percent range.  This is undoubtedly a meaningful percentage, but it also means that, by any estimate, the vast majority of combat veterans DO NOT have PTSD.

What’s the bottom line?

Regardless of the “true” prevalence of combat-related PTSD, the disorder as we currently define it is present in a substantial number of veterans and is associated with severe impairment in daily functioning, the presence of other psychiatric disorders, other medical problems and reduced quality of life.  Thus, it represents a significant and costly illness to veterans, their families and our society as a whole.  Certainly we need more research to help us better understand the prevalence, course, phenomenology, protective factors, effective treatments and costs associated with combat-related PTSD.

The bottom line is that veterans with PTSD or any other difficulties readjusting to civilian life need and deserve compassion, understanding and the very best healthcare and mental health services that we as a society can provide.  We owe them that much, don’t you think?

A national expert on PTSD research, Dr. Frueh is the director of Clinical Research at The Menninger Clinic and a professor at the University of Hawaii at Hilo.

I’ve adopted the term biomania to refer to what I see as excessive enthusiasm for an exclusively biological approach to understanding and treating psychiatric disorders. As a psychologist who practices psychotherapy, I share enthusiasm for neurobiological understanding, and I am grateful for effective biological treatments that help patients make good use of psychotherapy. I am hopeful that neurobiological research will contribute to the development of increasingly effective uses of psychiatric medications as well as novel biological treatments. Moreover, I believe we can help ameliorate stigma associated with mental illness through recognition that, like other medical conditions, psychiatric disorders have a biological basis. My objection relates to an exclusive emphasis on biology that leaves the person out of the picture.

Notoriously, decades ago psychiatrist Thomas Szasz went too far in the opposite direction from biomania, as captured in the title of his 1974 book The Myth of Mental Illness, in which he proclaimed that psychiatry deals with problems in living, not illnesses. As decades of neurobiological research amply demonstrates, psychiatric disorders are physical illnesses: many have a genetic basis, and neuroimaging research shows alterations in brain functioning associated with these illnesses.

Problems in living

I think Szasz was obviously wrong in failing to acknowledge psychiatric illness, but he was right in drawing attention to problems in living. Let me use major depression—a well defined, common, and serious psychiatric disorder—to illustrate my point. Major depression is a state of high physiological stress, and functional neuroimaging studies typically show high emotional arousal in conjunction with impairment in the prefrontal cortex, an “executive” area of the brain that is active in planning and organizing activity, thus pivotal in complex problem solving.

Seriously depressed persons have no doubt that they are ill, and they are not surprised to learn that their brain is not functioning optimally. In his brilliant memoir Darkness Visible, author William Styron noted how depression resulted from an “aberrant biochemical process.” Here is how he experienced the altered biochemistry:

“With all of this upheaval in the brain tissues, the alternate drenching and deprivation, it is no wonder that the mind begins to feel aggrieved, stricken, and the muddied thought processes register the distress of an organ in convulsion.”

He concluded, “It is a storm indeed, but a storm of murk.”

Stress pileup

What is the basis of these adverse brain changes? We know that episodes of depression stem from a combination of genetic vulnerability and psychological stress. I have used the idea of “stress pileup” to characterize the psychological stress that builds up over a person’s lifetime. Not uncommonly, an interaction of genetic risk with childhood adversity such as loss and trauma sets the stage for adulthood stress to trigger a depressive episode. Often enough, stressful events that can trigger episodes are completely beyond the individual’s control: death of a loved one, natural disasters, general medical illnesses, accidents. Yet much of the time, the stress that contributes to depression is partly self-generated: overwork, perfectionism and the self-criticism that goes with it and—most prominently—interpersonal conflicts. These latter sources of stress can be viewed as problems in living; they are psychological and interpersonal.

I remember one day in a patient education group explaining the stress pileup view of depression and going through a cascade of psychological and interpersonal stressors that can ensue over time. A patient piped up and said, “But my doctor says I have a chemical-imbalance depression.” I replied that all depression is biochemical. The question is: What causes these biochemical changes (and alterations in patterns of brain activity)? An important part of the answer is psychological stress. The stress pileup view and chemical imbalance view are complementary, not mutually exclusive.

In need of something more

The field of mental health needs neuroscientists who are biomanics, that is, passionately excited about researching the biology of psychiatric disorders. But there is a danger of clinicians and patients becoming biomanics, as biomania can be associated with an exclusive focus on biological treatments. Many patients become demoralized after trying multiple medications and combinations with limited benefit; they need something more. Szasz was half-right: to the extent that stress plays a role in the development, perpetuation and recurrence of psychiatric disorders, we must pay attention to problems in living—that is, problems in thinking, feeling, behaving and relating. No doubt, effective psychiatric medication can help enormously with problems in living that stem from psychiatric disorders. But we also know that many forms of psychotherapy are highly effective in treating psychiatric disorders insofar as they directly address problems in living and promote new learning. Hence psychotherapy and medication can complement each other, and research suggests that combining the two is most effective for severe depression.

Psychology and biology are thoroughly intertwined. We know that the quality of early relationships influences brain development; moreover, the quality of the patient-therapist relationship plays a central role in the effectiveness of psychotherapy. Furthermore, psychotherapy, like medication, has been shown to affect patterns of brain functioning. Yet we still have much to learn about all these matters, and we can count on biomanics along with psychotherapy researchers to bring continuing progress in our efforts to treat more than the illness, namely, the person who is ill.