Trigger warning: This Post might be triggering for some, please do not continue if you are very upset at the moment.
As a therapist. I want to help others, ultimately healing wounds. But, healing isn’t always easy. Getting better is complicated and sometimes scary. To look back at what caused the hurt, means going there again, risking the old feelings flooding you.
For that reason, it can help to prepare as much as possible. Before going back, it’s necessary to be sure that the memories won’t overwhelm you . When fear arises, there are ways to make going back safer:
First: The body and mind does everything it can to protect itself, and no matter the circumstances, you have survived so far . Second: You do not have to face the past all at once: it’s possible to work with some things and see how that goes before digging deeper. For example, if you have several traumatic memories you might start with a memory you’re aware of, that is unpleasant to think about, but not so much so that you can’t imagine thinking about it. In some cases it is recommended to think about the worse scenario, like when someone with OCD thinks about touching a dirty toilet, but with complex PTSD there is usually several traumas that hasn’t been integrated yet, and therefore taking it slowly might be wiser.
Third: It is possible to learn tools and test if they will help you cope with challenges in the now. Every time you use a new coping mechanism, it will be easier to use it next time, so by practicing new skills again and again, it can feels safer to work with underlying issues. Also: fear is normal, it wants to protect us. It’s good to know that something inside of you only wants the best for you, that fear has had its function and still will be there to protect you. It is no shame in withdrawing every now and again, sometimes it’s okay to rest and not do everything at once.
Finding an accurate representation of mental illness on TV is no small feat. When the media we consume seems to always depict people with mental illness as “dangerous” or “scary,” it can be easy to wonder if compassionate depictions of mental illness exist on TV.
Luckily, a lot of newer shows have been making an effort to “get it right” and show mental illness in a realistic and humanizing way. These shows can evoke some powerful responses in viewers who may be seeing their own struggles accurately represented on screen for the first time. With recommendations from our mental health community, we analyzed eight shows to see how they portrayed mental illness — and included where you can watch them!
1. “This Is Us”
“This Is Us” is an emotional drama that shows how the lives of the Pearson family intersect in unexpected ways. The show has long been praised for the way it has handled anxiety. Most notably was the scene in season one when Randall had a panic attack. Of this scene, community member Sharon E. wrote, “I felt this so much. His performance and the writer’s portrayal of a panic disorder brought on by stress was spot on.”
Even some mental health professionals agree. In an interview with Health magazine, Dr. James Murrough, assistant professor of psychiatry and neuroscience at the Mount Sinai Hospital in New York City, said, “This was a pretty accurate portrayal. When you’re experiencing a panic attack, it can feel like you’re dying or losing your mind,” he said. “The blurring of his vision gave the feeling of detachment or unreality. Depersonalization or feeling disconnected from your body is another common symptom of a panic attack.”
And while most agree the panic attack scene is accurate, some have taken issue with the way Randall’s brother dropped everything he was doing to support him — not because it wasn’t great, but because it wasn’t altogether realistic. In his piece, My One Reservation About the Panic Attack Scene in ‘This Is Us,’ Mighty contributor Matthew Martin-Ellis wrote
I hate to be the guy who takes issue with a well-meaning (and in many ways progressive) television scene, especially one that sheds light on a character struggling with mental illness. But… My concern is with the selfless and beautiful, yet ultimately unrealistic and unfeasible response of the character’s brother… The responses of allies we see in the realm of fiction seem increasingly idealized and impractical.
And while it’s unfortunate that we can’t always expect perfect responses like these from our loved ones, it is nice to see a model for a good way to respond. Additionally, from a representation standpoint, it’s also important the show depicts the mental health struggles of a black man. According to Mental Health America, black men are 20 percent more likely to report serious psychological distress than white men, but are consistently more apprehensive about seeking professional help.
Where you can watch: streaming on Hulu.
2. “BoJack Horseman”
“BoJack Horseman,” follows the washed-up 90s TV star (BoJack) and his struggles with addiction, relationships and maintaining his celebrity status, all the while satirizing the entertainment industry and current events. The Netflix show has gained a cult following but is perhaps best known for its accurate portrayal of depression. But the show didn’t necessarily intend for it to be that way. In an interview with The Huffington Post, the show’s creator Raphael Bob-Waksberg said, “It was never our top priority to be the voice of depression.” He explained they were just trying to capture who the character was.
But regardless of intent, “BoJack Horseman” resonates with many folks who struggle with depression. As Mighty community member Ximena P. commented, “‘BoJack Horseman’ is honestly one of the most realistic depictions of living with anxiety and depression. I love that it shows the ugly sides of depression rather than painting the typical ‘beautiful and tragically sad life.’ It shows the side of feeling numb and empty and honestly not caring about anyone or anything for long periods of time, while having other moments where you care so much it becomes hard to function.”
Though I completely agree that the show does a great job of showing the struggles of depression, I’ll admit, as someone with depression, it was hard for me to watch at times when things hit close to home. Ximena echoed this feeling when she said, “I should probably say that a lot of people find it triggering or depressing. It features alcoholism and other types of substance abuse so, it isn’t always an easy watch.”
Where you can watch: streaming on Netflix.
3. “United States of Tara”
“United States of Tara” follows suburban mother Tara through her journey with dissociative identity disorder (DID) and how it affects all aspects of her life — including her marriage, family and career. Unlike other depictions of DID, “United States of Tara” does not show DID as inherently dangerous, and according to Mighty community member, Astrid N. the show is an “amazing depiction of dissociative identity disorder.”
The show did make efforts to portray DID in an informative an accurate way. As the International Society for the Study of Trauma and Dissociation noted, “the producers and scriptwriters sought extensive consultation on DID from some of the world’s most prominent experts on DID, and interviewed and consulted DID patients as well.”
Though the show represents DID fairly in many ways, it isn’t without flaws. For example, each of Tara’s alters is fairly “extreme” in being noticeably distinctive from the other alters, and each of her “transitions” is very apparent. This choice was likely made so viewers could follow the plot visually, but nonetheless, it still doesn’t represent the condition as many people with DID experience it.
Often switches between alters are not obvious… When DID develops in childhood, it is to protect the child from trauma and allow them to have as normal a childhood as possible. It is meant to go unnoticed.
Where you can watch: streaming on Hulu.
4. “Parks and Recreation”
Though “Parks and Recreation” is primarily known for its funny characters and moments, some applaud the show for how it depicted depression through the notoriously “happy” character, Chris Traeger. Mighty community member Kari O. said, “The way they show how Chris spirals into depressive episodes was so relatable for me. Because I can be so happy, but one little thing can send me into a complete downhill spiral in minutes.” — Kari O.
This kind of character is so important to show because oftentimes depression doesn’t “look” like what we think it does. While we often generalize depression as being “sad,” the reality is it can sometimes look like the exact opposite. In her piece, 19 Problems Only Happy People With Depression Understand, Mighty contributor Jill Alexandra wrote,
My biggest fear is usually that someone can see right through me. As a result, I sometimes force myself to put on an unnaturally enthusiastic and upbeat persona when I am really in a bad place, out of fear that people will be able to see the truth if I don’t.
Where you can watch: streaming on Netflix.
The show is a comedy-drama that centers on Frank Gallagher, a single father of six children. “Shameless” is also a fan-favorite in the mental health community for its depiction of bipolar disorder, specifically through Ian’s character. As Mighty community member Casey R. said, “I was just diagnosed when I started watching the show. It was comforting to see Ian go through his ups and downs and survive.”
The representation of bipolar disorder and how taking medication can be helpful in recovery has resonated with many viewers. In a HelloFlo blog about “Shameless,” Sebastian Zulch wrote:
Watching Ian’s journey has always been heart wrenching for me because I could relate so much. But I appreciated the show’s positive portrayal of mental illness and medicine, which helped normalize my own experiences a little more. As someone who hasn’t been able to hold down a full time job yet, Ian showed me that it’s possible to get to a point where you can thrive in the workplace and properly advocate for yourself when you’re bipolar and on meds.
Where you can watch: streaming on Netflix.
6. “Please Like Me”
“Please Like Me” is an Australian show based on the real-life experiences of show’s star and director Josh Thomas. Perhaps most notable about the show is that it has brought mental health to the forefront by showing depictions of psychiatric hospitalization, panic attacks and depression.
In an interview with Pivot, Thomas said his goal was “doing mental health in a way that I thought was sort of honest and a bit true to life.”
Mighty community member Lisa K. seems to agree. She wrote, “[Josh Thomas’s] mother has bipolar disorder and he later befriends a woman with depression and dates a guy with severe anxiety. They do a great job of portraying the realities of these illnesses. It’s really relatable and real, but also just a really funny show.”
Where you can watch: streaming on Hulu
7. “Jessica Jones”
The Netflix original series “Jessica Jones” was based on a Marvel comic of the same name. The show has been praised for the way it handles post-traumatic stress disorder. Describing the show, Mighty community member Burrow K. wrote:
Jessica Jones’ is hands down the best representation of PTSD I have ever seen. I seriously cried seeing my struggle depicted so accurately on TV. She wasn’t perfect, she wasn’t depicted in the way society has deemed “acceptable.” She wasn’t the strong, silent survivor: her survival was messy, her flashbacks unpredictable, her coping mechanisms possibly less than ideal… I could go on and on and on.
The show’s focus on trauma and mental illness was intentional. When asked about the way the show dealt with abuse, rape and PTSD, showrunner Melissa Rosenberg told the Los Angeles Times:
Playing them as honestly as possible was very much the objective from the beginning. The tone is meant to be very grounded and real, so you have to be very grounded and real with whatever subjects you’re dealing with. So there was no glossing this over. It was really an exploration of a survivor and her healing, to the degree that she does, in facing those demons quite literally.
Where you can watch: streaming on Netflix.
8. “Lady Dynamite”
“Lady Dynamite,” tells the loosely-based real-life story of stand-up comedian and actress Maria Bamford, and her experience being hospitalized for bipolar disorder. The show has been lauded for its realistic and comedic portrayal of mental illness.
Instead of treating mental illness as an obstacle for a character to overcome, or a device to explain otherwise nonsensical actions, ‘Lady Dynamite’builds it into the very fabric of its world. It mines tragedy for comedy, showing us a character who is herself struggling to find the humor within her own terrible pain. It’s the rare comedy that shows us that the reality of mental illness is that darkness can coexist with creativity and fun and hope.
Mighty community member Emily B. agreed, adding, “It’s funny and relatable, but at the same time consistently deals with how difficult it is for someone to manage bipolar symptoms, especially working in a field like the entertainment industry that really promotes a more ‘manic’ performance style and schedule. Huge thank you to Maria Bamford for putting herself out there like that.”
Where you can watch: streaming on Netflix.
Did we miss a show? Share your favorites the comments below.
Photos via “BoJack Horseman” and Marvel’s “Jessica Jones” Facebook pages
In my mid-20s, at the beginning of my training as a clinical psychologist, I was placed on a psychiatric day treatment ward in one of the poorer parts of Boston. One day, the experienced therapist with whom I led a men’s group was sick, and I was called on to do the group by myself. A ball of nerves, I decided to ask the men about their ancestry (with the helpful presence of a globe in the room) rather than risk silence. I briefly spoke of my Russian and Eastern European great-grandparents to set the tone and then spoke with each man in turn. After a few minutes of this exercise, there was a pause. A fellow from across the room looked at me and said softly, “You think you’re better than us, don’t you? You think this could never happen to you.”
I was stunned. Somehow I stammered a denial, but of course he was right. Perhaps I didn’t think I was better than them, but I certainly thought I was different from them. Like most of us in Western societies, I had grown up believing that psychiatric disorders were illnesses—diseases like any other—and there had been nothing in my training until then to convince me otherwise.
But learning about trauma, dissociation, and attachment in the ensuing decades has changed my mind. And I am not the only one.
PARADIGMS IN CONFLICT
Over the past several decades, the study of schizophrenia and the study of the dissociative disorders have been dominated by opposing paradigms. For schizophrenia, the assumption of a genetic basis and biological causation has reigned supreme. Adverse childhood experiences are viewed as irrelevant at best and adult stressful or traumatic experiences as only “releasing” underlying disease mechanisms. Symptoms are considered meaningless—unrelated to a person’s life circumstances—and psychotherapeutic approaches, when used at all, are limited to supporting medical interventions. In diagnosing schizophrenia for clinical or research purposes, posttraumatic and dissociative disorders are rarely considered or ruled out; indeed, in adherents to this paradigm, posttraumatic disorders are frequently disdained, discredited, or simply ignored.
In contrast, the overriding paradigm for the study of dissociative disorders has focused almost exclusively on life events—traumatic or otherwise—that are assumed to be meaningfully related to the symptoms a person experiences. A wide range of psychotherapeutic approaches to treatment are supported and advocated, whereas most medical interventions are viewed as anathema. At the same time, many trauma-oriented clinicians and researchers think of schizophrenia only as something dissociative disorders are not—but are often confused with; schizophrenia’s validity as a biologically based entity is rarely questioned.
Consider how these two paradigms deal with auditory verbal hallucinations. To persons adhering to the dominant biological paradigm (or “medical model”), voices are psychotic symptoms to be treated with medications or coped with using distraction techniques. As Colin Ross (2008Ross, C. A.2008. “Dissociative schizophrenia”. In Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Edited by: Moskowitz, A., Schäfer, I. and Dorahy, M. J.281–294. London, , England: Wiley.[Google Scholar]) put it, from this perspective the notion of talking with someone’s voices would be as absurd as “asking a patient’s knee a question” (p. 284). In contrast, in a trauma/dissociation paradigm, voices are split-off parts of the personality that are ignored at one’s own peril—acknowledging and engaging these disowned parts, though often challenging, is typically advocated. The schizophrenia field views voices as biologically generated indications of a brain disorder, whereas the dissociation field views them as psychological indications of unresolved trauma or loss. Two more disparate perspectives cannot be imagined. Currently, these fields eye each other with considerable suspicion and, to a large extent, do not speak the same language or experience the world in the same way.
EUGEN BLEULER: THE MARRIAGE OF DISSOCIATION AND SCHIZOPHRENIA
But it was not always this way. When Eugen Bleuler published his Dementia Praecox oder Gruppe der Schizophrenien (Dementia Praecox or the Group of Schizophrenias) 100 years ago, the construct of schizophrenia was infused with dissociative concepts (Moskowitz, 2008Moskowitz, A.2008. “Association and dissociation in the historical concept of schizophrenia”. In Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Edited by: Moskowitz, A., Schäfer, I. and Dorahy, M. J.35–49. London, , England: Wiley.[Google Scholar]; Moskowitz & Heim, 2011Moskowitz, A. and Heim, G.in press. “Affect, dissociation, psychosis: Essential components of the historical concept of schizophrenia”. In Psychosis and emotion: The role of emotions in understanding psychosis, therapy and recovery, Edited by: Gumley, A., Gilham, A., Taylor, K. and Schwannauer, M.London, , England: Routledge.[Google Scholar]). While insisting on an organic basis for the disorder, Bleuler recognized the symptoms his patients described as meaningfully related to their life experiences and used hypnotherapy and psychotherapy in his clinical work. He justified changing the name of the disorder largely on the basis that the “splitting” of the “different psychic functions” was central to its pathology (Bleuler, 1911/1950Bleuler, E.1950. Dementia praecox or the group of schizophrenias, Edited by: Zinkin, J.New York, NY: International Universities Press. Original work published 1911[Google Scholar], p. 8). Bleuler’s 1911Moskowitz, A. and Heim, G.2011. Eugen Bleuler’s Dementia praecox or the group of schizophrenias (1911): A centenary appreciation and reconsideration. Schizophrenia Bulletin, 37(3): 471–479.[Google Scholar]“definition” of schizophrenia reads almost as a calling card for dissociative disorders:
If the disease is marked, the personality loses its unity; at different times different psychic complexes seem to represent the personality … one set of complexes dominates the personality for a time, while other groups of ideas or drives are “split off” and seem either partly or completely impotent. (p. 9)
The profoundly dissociative nature of Bleuler’s concept of schizophrenia has been ignored for many decades but should be apparent to any unbiased reader, as has been recognized by Colin Ross (2004Ross, C. A.2004. Schizophrenia: Innovations in diagnosis and treatment, New York, NY: Haworth Press.[Google Scholar]) and myself (Moskowitz, 2008Moskowitz, A.2008. “Association and dissociation in the historical concept of schizophrenia”. In Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Edited by: Moskowitz, A., Schäfer, I. and Dorahy, M. J.35–49. London, , England: Wiley.[Google Scholar]; Moskowitz & Heim, in press).
However, Bleuler’s ideas about schizophrenia have little currency in today’s nosological world; all but the name has been jettisoned, and even that has been retained with considerable squeamishness—requiring constant vigilance against its interpretation as “split personality.” Instead, the architects of our current diagnostic system harked back to Bleuler’s predecessor, Emil Kraepelin, for inspiration.
EMIL KRAEPELIN, TAXONOMIES, AND GENERAL PARESIS
Despite Kraepelin’s experimental psychology pedigree (he studied with Wilhelm Wundt early in his career), his ideas on Dementia Praecox were far less informed by psychology than those of Bleuler (who used Jung’s word association experiments to aid his understanding), and he saw concepts of dissociation as irrelevant to diagnostic conceptualization. Rather, Kraepelin’s approach to parsing mental disorders was strongly influenced by biological classifications, such as Linnæus’s taxonomy of plants and the system developed by his own esteemed older brother, the biologist Karl Kraepelin (Weber & Engstrom, 1997Weber, M. M. and Engstrom, E. J.1997. Kraepelin’s “diagnostic cards”: The confluence of clinical research and preconceived categories. History of Psychiatry, 8: 375–385.[Google Scholar]). In addition, the model on which Kraepelin based his concept of Dementia Praecox was General Paresis of the Insane—sometimes called Dementia Paralytica. General Paresis was a terminal condition that combined psychotic symptoms with paralysis and ultimately death and was widespread in Europe during the early part of the 19th century. The triumphant linking of its symptoms with a brain disorder caused by late-stage syphilitic infections in the mid-19th century clearly provided Kraepelin with a template or paradigm—a “model disease entity”—for mental disorders in general and dementia praecox in particular (Jablensky, 1995Jablensky, A.1995. Kraepelin’s legacy: Paradigm or pitfall for modern psychiatry?. European Archives of Psychiatry and Clinical Neuroscience, 245: 186–188.[Google Scholar], p. 186).
THE NEO-KRAEPELINIAN PARADIGM OF MENTAL DISORDERS
The example of General Paresis, mental disorders were brain disorders but that any classification of psychopathology was best pursued through identifying brain pathology, not only drove Kraepelin’s typology but also still underpins that of the current diagnostic systems influenced by his thinking—the Diagnostic and Statistical Manual of Mental Disorders(3rd ed. [DSM–III]), the International Classification of Diseases–9, and their related progeny (Jablensky, 2007Jablensky, A.2007. Living in a Kraepelinian world: Kraepelin’s impact on modern psychiatry. History of Psychiatry, 18: 381–388.[Google Scholar]). For the past three or four decades, the classification of mental disorders has been dominated by this approach, which came out of a group of primarily American psychiatrists self-identified as neo-Kraepelinian (frequently referred to as a movement or even a revolution).
As the neo-Kraepelinians set about revising the psychiatric diagnostic system in the 1970s, and reached their goal with the 1980 publication of the DSM–III, they were ostensibly creating an atheoretical system with improved reliability over its precursors. But in reality, they were clearly motivated by the belief that these conditions were medical disorders like any other; indeed, in a publication from that time, two prominent researchers spoke of “coveting” for schizophrenia the solid genetic grounding of “pellagra, paresis, tuberculosis, polio, and PKU [phenylketonuria]” (Gottesman & Shields, 1973Gottesman, I. I. and Shields, J.1973. Genetic theorizing and schizophrenia. British Journal of Psychiatry, 122: 15–30.[Google Scholar], p. 15).
A fundamental task for the neo-Kraepelinians was to shore up the distinction between schizophrenia and manic depression, a distinction that had been blurred by Bleuler’s broad category. They accomplished this primarily by strongly emphasizing specific psychotic symptoms in the diagnostic criteria for schizophrenia (particular auditory hallucinations and delusions proposed by Kurt Schneider—so-called first rank symptoms) and by undermining the validity of the schizoaffective disorder category in a number of ways (Moskowitz & Heim, in press-a). The Kraepelinian dichotomy of schizophrenia and bipolar disorder has been explicitly seen as providing the foundation for a biologically based nosology; indeed, challenges to the clear differentiation of schizophrenia and bipolar disorder are often viewed as undermining the validity of the entire diagnostic system (Kendell, 1987Kendell, R. E.1987. Diagnosis and classification of functional psychoses. British Medical Bulletin, 43: 499–513.[Google Scholar]). In addition, the neo-Kraepelinians have articulated a number of more general assumptions, including (a) that mental disorders are discrete from one another and from “normality” and (b) that advances in understanding mental disorders will come primarily from focusing on neurobiology (Klerman, 1978Klerman, G. L.1978. “The evolution of a scientific nosology”. In Schizophrenia: science and practice, Edited by: Shersow, J. C.91–121. Cambridge, MA: Harvard University Press.[Google Scholar]). This level of domination over research and practice (for example, DSM–IV diagnoses are required for insurance payments and frequently for journal article acceptance) clearly constitutes what Thomas Kuhn termed a scientific paradigm.
PARADIGMS AND SCIENTIFIC REVOLUTIONS
According to Kuhn (1970Kuhn, T. S.1970. The structure of scientific revolutions, 2nd, Chicago, IL: University of Chicago Press.[Google Scholar]), in The Structure of Scientific Revolutions, the idea that science advances in a linear fashion with knowledge continually accruing so that “reality” or “truth” is more and more closely approximated over time is a myth. Rather, he argued, a field advances under the influence of a dominant paradigm, meaning both a particular past scientific achievement held up as a model or exemplar (as in the case of General Paresis and psychopathology) and the generally accepted beliefs and attitudes of a particular scientific community. A paradigm exerts an organizing influence on a field and guides research, determining to a large extent what types of research questions are considered legitimate and what sorts of answers are considered acceptable.
Kuhn (1970Kuhn, T. S.1970. The structure of scientific revolutions, 2nd, Chicago, IL: University of Chicago Press.[Google Scholar]) argued that paradigms change and a scientific revolution ensues when three conditions are met: (a) a period of crisis develops in which the paradigm fails to adequately answer questions considered fundamental; (b) serious “anomalies” occur in which phenomena not clearly compatible with the paradigm are observed; and, importantly (c) a suitable alternative paradigm that explains many of the previous findings and at least some of the observed anomalies comes to light. Kuhn saw scientific revolutions as taking time to resolve; he argued that changing such strongly held beliefs involved a process of persuasion and fundamental reorganization not unlike that of religious conversion: “Conversions will occur a few at a time until, after the last holdouts have died, the whole profession will again be practicing under a single, but now different paradigm” (Kuhn, 1970Kuhn, T. S.1970. The structure of scientific revolutions, 2nd, Chicago, IL: University of Chicago Press.[Google Scholar], p. 152).
Since the publication of the DSM–III in 1980, the ascendance of the neo-Kraepelinianparadigm in the psychiatric world has been paramount. It has driven our view of schizophrenia and marginalized acceptance of the dissociative disorders and posttraumatic stress disorder (PTSD). However, this paradigm is now under threat from many quarters—from within its ranks as well as from outside—and there is good reason to view it as a paradigm in crisis.
FAILURES OF THE NEO-KRAEPELINIAN PARADIGM
Evidence for fundamental tenets of the neo-Kraepelinian paradigm—that there are clear genetic or biological bases for schizophrenia and other mental disorders and that mental disorders are discrete from one another and from normal experiences—have not been supported.
Comorbidity of diagnoses, incompatible with viewing diagnoses as discrete categories, is rampant in the DSM–IV system and typically viewed as a major problem. Psychotic symptoms are now recognized as common to many disorders other than schizophrenia, and their presence in a significant portion of the community with no diagnosed mental disorder firmly suggests that the line between “normality” and “pathology” is not hard and fast (Van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2008Van Os, J., Linscott, R. J., Myin-Germeys, I., Delespaul, P. and Krabbendam, L.2008. A systematic review and meta-analysis of the psychosis continuum: Evidence for a psychosis proneness—persistence—impairment model of psychotic disorder. Psychological Medicine, 39: 179–195.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). In addition, evidence for the validity of schizoaffective disorder, a fundamental challenge to the Kraepelinian dichotomy, has accumulated over the years. The demonstrated existence of persons with prominent schizophrenic and affective symptoms undermines the core distinction between schizophrenia and bipolar disorder and provides an argument for viewing even severe psychopathology as a dimension or series of dimensions instead of as categories. Finally, the abject failure of genetic-based research to find any strong link with schizophrenia or bipolar disorder provides a further anomaly for the neo-Kraepelinianparadigm to explain or attempt to ignore (if anything, the genetic evidence points to a “shared neurobiology across the two disorders,” Thaker, 2008Thaker, G.2008. Psychosis endophenotypes in schizophrenia and bipolar disorder. Schizophrenia Bulletin, 34: 720–721.[Google Scholar], p. 720).
All of this is taking its toll on the medical model. As the neo-Kraepelinian edifice begins to crumble, adherents resort to stronger and stronger biological language, as though words such as neuropsychiatry and endophenotypes have the power to restore its once shining façade. The emphasis on endophenotypes is particularly telling, as this concept involves exploring putative underlying biological variables that may have only an indirectrelationship to the signs and symptoms of mental disorders. For example, a recent large-scale twin and family study focused on apparent genetic impairments in memory and intelligence as conveying liability for schizophrenia (Toulopoulou et al., 2010Toulopoulou, T., Goldberg, T. E., Mesa, I. R., Picchioni, M., Rijsdijk, F., Stahl, D.and … Murray, R. M.2010. Impaired intellect and memory: A missing link between genetic risk and schizophrenia?. Archives of General Psychiatry, 67: 905–913.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). The strong emphasis on endophenotypes, arising from a failure to find clear connections between genetic makeup and psychiatric diagnoses or symptoms, suggests that the neo-Kraepelinianstalwarts have beaten a strategic retreat; at the same time that psychological approaches to treating and understanding psychiatric symptoms, including delusions and hallucinations, have made great strides, the dominant paradigm has given up the traditional territory of mental disorders—the signs and symptoms that people suffer from and that treatments target.
So, the neo-Kraepelinian, categorical, medically based diagnostic system clearly seems to be in a state of crisis. But, as Kuhn has noted, a discipline such as psychopathology will not loosen its grip on a paradigm unless a suitable alternative is available to take its place. What is the evidence that one is appearing?
THE EMERGING TRAUMA/DISSOCIATION PARADIGM
In recent years, evidence has accumulated that traumatizing events are strongly linked to psychopathology in general and psychotic symptoms in particular. Kenneth Kendler, a prominent psychiatric geneticist, concluded from a carefully designed large-scale twin study that childhood sexual abuse was “causally related” to the development of psychiatric and substance abuse disorders (Kendler et al., 2000Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M., Myers, J. and Prescott, C. A.2000. Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and cotwin control analysis. Archives of General Psychiatry, 57: 953–959.[Crossref], [PubMed], [Web of Science ®], [Google Scholar], p. 953). In a subsequent commentary, he noted that the more than threefold increase in major depression attributable to severe sexual abuse was “much greater” than the odds ratios associated with any gene putatively linked to schizophrenia or bipolar disorder (Kendler, 2006Kendler, K. S.2006. Reflections on the relationship between psychiatric genetics and psychiatric nosology. American Journal of Psychiatry, 163: 1138–1146.[Crossref], [PubMed], [Web of Science ®], [Google Scholar], p. 1140); he soberly concluded, “The project to ground our messy psychiatric categories in genes … may be in fundamental trouble” (Kendler, 2006Kendler, K. S.2006. Reflections on the relationship between psychiatric genetics and psychiatric nosology. American Journal of Psychiatry, 163: 1138–1146.[Crossref], [PubMed], [Web of Science ®], [Google Scholar], p. 1145). Psychotic symptoms in particular appear to be strongly linked to trauma, both adult trauma (particularly when associated with PTSD; e.g., Scott, Chant, Andrews, Martin, & McGrath, 2007Scott, J., Chant, D., Andrews, G., Martin, G. and McGrath, J.2007. Association between trauma exposure and delusional experiences in a large community-based sample. British Journal of Psychiatry, 190: 339–343.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]) and childhood interpersonal traumas (including in longitudinal studies such as Arseneault et al., 2011Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moffitt, T. E. and Caspi, A.2011. Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. American Journal of Psychiatry, 168: 65–72.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). These studies are becoming increasingly well designed, typically controlling for many potentially confounding variables, even apparently genetic ones. Furthermore, psychological trauma has been strongly linked to the development of delusions and hallucinations (Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009Moskowitz, A., Read, J., Farrelly, S., Rudegeair, T. and Williams, O.2009. “Are psychotic symptoms traumatic in origin and dissociative in kind?”. In Dissociation and the dissociative disorders: DSM–V and beyond, Edited by: Dell, P. and ’Neil, J. O. 521–533. New York, NY: Routledge.[Google Scholar]), and dissociation has been found to consistently and powerfully predict auditory hallucinations (but not delusions) in a range of populations (Moskowitz & Corstens, 2007Moskowitz, A. and Corstens, D.2007. “Auditory hallucinations: Psychotic symptom or dissociative experience?”. In Trauma and serious mental illness, Edited by: Gold, S. N. and Elhai, J. D.35–63. Binghamton, NY: Haworth Press.[Google Scholar]; several recently published studies have supported this relationship). Finally, brain changes long assumed to indicate a core genetic or biological neurodevelopmental disturbance in schizophrenia have been linked with chronic stressful or traumatic childhood experiences (Read, Perry, Moskowitz, & Connolly, 2001Read, J., Perry, B., Moskowitz, A. and Connolly, J.2001. The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry: Interpersonal and Biological Processes, 64: 319–345.[Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Teicher et al., 2003Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., Navalta, C. P. and Kim, D. M.2003. The neurobiological consequences of early stress and childhood maltreatment. Neuroscience and Biobehavioral Reviews, 27: 33–44.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). And these trauma-based brain changes are entirely consistent with emerging evolutionary-based explanations for psychotic symptoms (Grace, 2010Grace, A. A.2010. Ventral hippocampus, interneurons, and schizophrenia: A new understanding of the pathophysiology of schizophrenia and its implications for treatment and prevention. Current Directions in Psychological Science, 19: 232–237.[Google Scholar]; Moskowitz, 2004Moskowitz, A.2004. “Scared stiff”: Catatonia as an evolutionary-based fear response. Psychological Review, 111: 984–1002.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]).
IS THERE A SCIENTIFIC REVOLUTION IN THE HOUSE?
The failures of the current dominant medically based neo-Kraepelinian paradigm, coupled with the successes of an alternative paradigm focusing on adverse life experiences (including attachment disturbances) and dissociation, could herald the approach of a scientific revolution. Evidence that this may be occurring includes the increased willingness of prominent medical journals such as the American Journal of Psychiatry and Archives of General Psychiatry to publish studies supportive of this view (e.g., Arseneault et al., 2011Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moffitt, T. E. and Caspi, A.2011. Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. American Journal of Psychiatry, 168: 65–72.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Kendler et al., 2000Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M., Myers, J. and Prescott, C. A.2000. Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and cotwin control analysis. Archives of General Psychiatry, 57: 953–959.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Scott et al., 2007Scott, J., Chant, D., Andrews, G., Martin, G. and McGrath, J.2007. Association between trauma exposure and delusional experiences in a large community-based sample. British Journal of Psychiatry, 190: 339–343.[Crossref], [PubMed], [Web of Science ®], [Google Scholar]). As more and more psychiatrists are shifting paradigms, it must be recognized that many medically trained individuals within the trauma and dissociative disorders field have long championed this perspective (of course, there are psychologists and other non-physicians who continue to firmly embrace the “medical model” as well, but these paradigms to a large extent do map onto disciplinary distinctions and tensions).
Should a new paradigm emerge, it will be a genuine biopsychosocial one, recognizing that genetics plays a role in psychopathology, likely in providing vulnerability to certain broad forms of mental disorders or to mental disorders in general. It will also recognize that life experiences from gestation on play a major role not only in the expression of psychiatric symptoms but also in the expression of the genes that underlie vulnerability to mental disorders. This new paradigm must also recognize some form of dimension or dimensions across apparently different types of mental disorders (evaporating the comorbidity “problem”) and between pathology and so-called normality. It will require recognition of the extent and severity of childhood trauma, a reality that has long faced considerable resistance from adherents to the medical model. Finally, the presence of dissociative conditions, with the corollary that such individuals are radically different at different times, must be taken into account not only clinically but also in the design of research—something to which the current paradigm has been blind.
The DSM–5 committees appear to have some awareness of these challenges. Dimensional perspectives are being considered for personality disorders and possibly as an axis alongside other categories. What is striking is that the schizophrenia committee is recommending the elimination of the (currently pathognomic) first rank symptoms (voices conversing or commenting, delusions involving intrusions or withdrawals of thoughts or behavior), belatedly recognizing that they have “no unique diagnostic specificity” for schizophrenia (American Psychiatric Association, 2011American Psychiatric Association. (2011). Schizophrenia.http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=411# (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=411#)[Google Scholar]). This is obviously welcome news (an early indication of a paradigm shift?), as the association of these clearly dissociative symptoms with schizophrenia has led to substantial misdiagnosis of dissociative identity disorder patients. But it also reminds us of the enigma that practically every attempt to define schizophrenia, from Bleuler to the present day, has invariably called forth dissociative identity disorder. That the paradigmatic biological disorder can be so easily confused with the paradigmatic environmental disorder should already be shaking the rafters of this house (but of course, as the dominant paradigm does not recognize dissociative identity disorder, it does not recognize this enigma!). The explanation for this puzzle should help us to understand the nature of schizophrenia—until then, we can firmly state that whatever schizophrenia is, it is not psychotic symptoms and certainly not auditory hallucinations. Unfortunately, the DSM–5 schizophrenia committee has not gone this far and continues to emphasize psychotic symptoms, even as the head of that committee, William Carpenter, warns against this approach (“Psychotic experience is to the diagnosis of mental illness as fever is to the diagnosis of infection—important, but non-decisive in differential diagnosis,” Fischer & Carpenter, 2009Fischer, B. A. and Carpenter, W. T.2009. Will the Kraepelinian dichotomy survive DSM–V?. Neuropsychopharmacology, 34: 2081–2087.[Crossref], [PubMed], [Web of Science ®], [Google Scholar], p. 2081).
If a new paradigm does emerge, we can be sure that Kraepelin’s paradigmatic disease entity—General Paresis of the Insane—will be replaced. Perhaps it may not be possible to find a new exemplar for mental disorders in general, but PTSD would seem a worthwhile candidate for at least some of them—those clearly linked to trauma and characterized by dissociation (as, for example, has been proposed by Van der Hart, Nijenhuis, & Steele, 2006Van der Hart, O., Nijenhuis, E. and Steele, K.2006. The haunted self: Structural dissociation and the treatment of chronic traumatization, New York, NY: Norton.[Google Scholar], in their structural dissociation model). And the possibility that schizophrenia, or at least some form of psychotic disorder, could fit this model should not be rejected outright. Even Bleuler, the progenitor of schizophrenia, despite his commitment to an organic etiology, seemed to recognize this. A growing appreciation of this possibility could, quite literally, trigger a scientific revolution in our view of mental disorders altogether.
The stronger the affects, the less pronounced the dissociative tendencies need to be in order to produce the emotional desolation. Thus, in many cases of severe disease, we find that only quite ordinary everyday conflicts of life have caused the marked mental impairment; but in milder cases, the acute episodes may have been released by powerful affects. And not infrequently, after a careful analysis, we had to pose the question whether we are not merely dealing with the effect of a particularly powerful psychological trauma on a very sensitive person, rather than with a disease in the narrow sense of the word. (Bleuler, 1911/1950Bleuler, E.1950. Dementia praecox or the group of schizophrenias, Edited by: Zinkin, J.New York, NY: International Universities Press. Original work published 1911[Google Scholar], p. 300; Sünje Matthiesen, translation)
Some stories bury themselves deep into your soul, leaving marks and holes. When the marks are gone, scars appear to remind you not to forget. This story did that to me. From now on, I will not forget. I will not forget that there is always hope, no matter how terrible your life was. Because this book is about extreme abuse. This post might be triggering, so refrain from reading further if you can be triggered.
I have just read Scared Selfless by Michelle Stevens. It is hard to describe how important this book was to me. Working as a psychologist myself, this was like finding the famous needle in the haystack. When I stumbled upon it on audible, i knew it was about trauma, but I had no idea that it also was about multiple personality disorder and that the author (a psychotherapist) was the one sharing her story. When I first listened to it, my boyfriend heard the first chapter too. Unfortunately, he couldn’t stomach the horrible abuse Stevens has experienced as he started to think about his own daughters. For me, it was impossible to stop listening. It was such an emotional journey, taking me from despair to horror and then hope. There has been such a long time since a book managed to evoke these feelings in me, and I realized one thing: Humans must keep searching for stories like these, that reminds us there’s always hope; That we truly are survivors, no matter what we’ve experienced. I will take this book with me in all conversations with my lovely clients from now on. And if I ever feel hopelessness, or that I can’t offer anything more, I shall remember that is just not true. By loving what you do and remembering why you do it, we can all change lives. Ourselves and others.
“A riveting memoir that takes readers on a roller coaster ride from the depths of hell to triumphant success.”—Dave Pelzer, author of A Child Called “It”
Michelle Stevens has a photo of the exact moment her childhood was stolen from her: She’s only eight years old, posing for her mother’s boyfriend, Gary Lundquist—an elementary school teacher, neighborhood stalwart, and brutal pedophile. Later that night, Gary locks Michelle in a cage, tortures her repeatedly, and uses her to quench his voracious and deviant sexual whims. Little does she know that this will become her new reality for the next six years.
Michelle can also pinpoint the moment she reconstituted the splintered pieces of her life: She’s in cap and gown, receiving her PhD in psychology—and the university’s award for best dissertation.
The distance between these two points is the improbable journey from torture, loss, and mental illness to healing, recovery, and triumph that is Michelle’s powerful memoir, Scared Selfless.
Michelle suffered from post‐traumatic stress disorder, anxiety, and depression, and made multiple suicide attempts. She also developed multiple personalities. There was “Chelsey,” the rebellious teenager; “Viscous,” a tween with homicidal rage; and “Sarah,” a sweet little girl who brought her teddy bear on a first date.
In this harrowing tale, Michelle, who was inspired to help others heal by becoming a psychotherapist, sheds light on the all-too-real threat of child sexual abuse, its subsequent psychological effects, and the best methods for victims to overcome their ordeals and, ultimately, thrive. Scared Selfless is both an examination of the extraordinary feats of the mind that are possible in the face of horrific trauma as well as Michelle’s courageous testament to their power.
Thank you Stevens, for sharing your story.
If you are a survivor of abuse yourself this homepage might be of help. Finding a good therapist can help too. Don’t be afraid of trying to find help, it can help you to heal.
Many people enter the therapy process with minimal awareness of their trauma history. When the trauma survivors are dissociative, they have the ability to block out an awareness of their trauma. They may know that their family had problems, or that their family was dysfunctional, etc, but they may believe they were never abused.
However, blocking out conscious awareness of trauma does not mean that the survivors have no effects of that trauma. Using denial and dissociative skills does not mean that the abuse did not happen. Denial means that the person simply is refusing to acknowledge or accept the fact that they were traumatized. They are pretending they were not hurt, when they were actually hurt very badly.
Even if the memories of abuse are hidden from the survivor’s awareness, blocked trauma / unresolved trauma creates very noticeable and obvious symptoms that can be easily seen in their every day lives.
People will enter therapy aware of some of the following symptoms, but they may not realize these complications are suggestive of unresolved trauma issues:
.1. Addictive behaviors – excessively turning to drugs, alcohol, sex, shopping, gambling as a way to push difficult emotions and upsetting trauma content further away.
2. An inability to tolerate conflicts with others – having a fear of conflict, running from conflict, avoiding conflict, maintaining skewed perceptions of conflict
3. An inability to tolerate intense feelings, preferring to avoid feeling by any number of ways
4. An innate belief that they are bad, worthless, without value or importance
18. Suicidal actions and behaviors, failed attempts to suicide
19. Taking the perpetrator role / angry aggressor in relationships
20. Unexplained but intense fears of people, places, things
These same symptoms can be applied for survivors already working in therapy. Attending regular therapy does not mean the clients have resolved their trauma issues or that they are even working in that general direction. Many therapy clients will continue to deny, dissociate, and refuse to look at their trauma even if they are aware of their daily struggles.
If you are experiencing a number of the symptoms listed above, ask yourself if you are truly ready to address your trauma issues, or if you find it more comfortable to continue living with these struggles.
Is it harder to face how you were abused and who abused you? Or is it harder to live a life full of depression, anxiety, thoughts of suicide, troubled relationships, extreme fears, physical pain, and addictions?
Running from your trauma history will not help you feel better. In the short-run, you might not have to face the issues, but the cost in the long-run of unresolved trauma weighs more heavily than you might suspect.