12 Jan Evident(ce)
I’m struggling to write about an excerpt from Johann Hari’s book “Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions” that appeared in The Guardian yesterday. So much of what he writes dovetails with what we tried to communicate in “All The Rage”, our film about the mindbody focused work of Dr John Sarno. One of the struggles in writing about it is that there are so many direct connections between our film and Bari’s piece that it is difficult to find the foundation to build on. You want to make every connection – where do you start?
In my work, I often start by illuminating the hidden frames that shape our expectations. For the most part, these frames are “hidden” because acknowledging them causes cognitive dissonance. For example, almost no one wants be called a Racist, so we are blind to examples of our own implicit bias. When confronted with the possibility that wading into the muck of our own emotions might help relieve physical pain, very few people want that level of responsibility. So even when given the possibility of pain relief, we often react with anger. When one is dealing with things that people actively don’t want to see (even if this force is unconscious)- and doing so in a manner that doesn’t conform to an expected form, there’s often powerful resistance to the ideas being expressed. The rejector of those ideas might say things like, “this is badly written” or “self-indulgent”, or it doesn’t follow “scientific protocol” or “there’s no randomized control trial to prove this is true”. If the piece you are writing challenges people because it subtly exposes the existence of these frames and expectations, the interaction gets even more obtuse and complex. The paradox of trying to clarify complexity is that the strands of ideas can become overwhelming, causing the information to get caught up like so many baby wipes in a sewage system. Each idea seems to add clarity in itself but quickly gums up the works.
Having said all that, I’ll try to tease out some of the ways our film and Hari’s book are connected. Hari’s take on how the medical system often defaults to a diagnosis based on very thin scientific evidence is completely in line with Sarno’s observations with back pain. In Bari’s research, he found that evidence supporting the theory that depression is caused by low levels of serotonin is extremely weak. Yet this theory has led to the construction of a whole system of thought in regards to the treatment of depression that largely relies on pharmacological solutions. In the case of Dr. Sarno and back pain, so many studies have disproved any correlation between damaged herniated discs and pain that the American College of Physicians and the American Pain Society guidelines now strongly discourage MRI in diagnosing low back pain. Yet the theory of herniated discs causing back pain still persists and MRI’s still are prescribed with fervor, however faulty the science may be. In both cases, the foundation for the diagnosis has been invalidated. A discussion of serotonin and depression can be found here. Here is something I wrote covering Gina Kolata’s series of New York Times articles over the past 15 years that ask, how come study after study shows that the theory that herniated discs cause pain doesn’t hold up, yet practice doesn’t change?
Both Hari and Sarno have found evidence for the causes of pain and depression being connected to much broader social and emotional factors. Following that line of thinking, a cure might be based on recognizing the power of our emotional response to the world: how both external and internal pressures – and especially our emotional reactions to these pressures – affect us physically. Hari’s book points out that in the past 30 years, psychiatry has increasingly focused on chemical antidepressants that address a chemical imbalance in the brain. He writes that when he went to the doctor in his teens complaining of pain and depression, his doctor told him,
“There is a chemical called serotonin that makes people feel good…and some people are naturally lacking it in their brains. You are clearly one of those people. There are now, thankfully, new drugs that will restore your serotonin level to that of a normal person. Take them, and you will be well.”
Like so many others, Hari was thankful, and felt a great sense of relief knowing that he finally had a story to explain his symptoms. Unfortunately, while the drugs worked at first, they quickly diminished in their power and his dosage was consistently increased. Fifteen years later, as he went on a journey to find out more about the problem of depression, he quickly uncovered some inconvenient truths about the evidence behind the efficacy of the drugs. It turns out that they don’t really work for somewhere between 65 and 80 percent of the people who take them. As stated above, he also found that the causal correlation between a lack of serotonin and depression is exceedingly weak. Under close scrutiny, the chemical aberration theory simply doesn’t hold up. In fact, this British Medical Journal piece argues that the serotonin story has more to do with marketing than with healing.
Dr. Sarno might not have known about this data on depression, but understood the context of it when spoke about this idea in relation to the historical continuum. As he states in an outtake from our film, “In the 19th Century, before Freud came along, psychiatry blamed mental illness on mental diseases, on diseases of the brain. In other words the explanation for aberrant behavior was there was something wrong with the brain. I’m pointing out in the new book that 21st Century medicine is doing exactly the same thing again. Only this time they’re more sophisticated about what’s wrong with the brain. They don’t say it’s a disease. They say it’s a chemical aberration. Ok, so here we are back where they were in the 19th Century. Amazing. plus ça change, plus c’est la même chose… The more things change, the more they stay the same.”
In other words, Dr Sarno understood that the focus on physical causes often serves to blind people to the power of emotional phenomenon. In other words, if they aren’t looking for it, they aren’t going to find it. While almost all of his colleagues focused on physical causes for back an neck pain like herniated discs and pinched nerves, Sarno came to see that this physical diagnosis didn’t make sense. Like those that Hari interviewed, when Sarno looked for data to support the standard care he’d been taught, he found that there wasn’t any. There was no solid evidence to support the use of physical therapy, bed rest, heat and icing, electrical stimulation or any of the other things he’d been taught. It was just “standard practice”, and for the most part, it didn’t seem to help in any solid or repeatable way. He also found that the structural diagnoses that people were given often didn’t make sense. For example, a patient might be diagnosed with a herniated disc for a pain in their neck, but they also had pain in several other body parts to which this herniation didn’t apply. Yet there was no attempt to explain why this might be the case, or why the pain might migrate around the body. As Gina Kolata found out years later, when people actually did randomized control trials to determine once and for all that herniated discs were the cause of pain, they found just the opposite: just as many people with “terrible” herniations had no pain as had pain, and that many people without any herniation or other structural abnormality had horrific pain. In other words, the causal story fell apart. Dozens of similar studies later led the American College of Physicians to advise against using MRI’s to diagnose back pain – yet this guidance is largely ignored.
As Hari went around the world looking for answers he found;
… from São Paulo to Sydney, from Los Angeles to London – I started to see an unexpected picture emerge. We all know that every human being has basic physical needs: for food, for water, for shelter, for clean air. It turns out that, in the same way, all humans have certain basic psychological needs. We need to feel we belong. We need to feel valued. We need to feel we’re good at something. We need to feel we have a secure future. And there is growing evidence that our culture isn’t meeting those psychological needs for many – perhaps most – people. I kept learning that, in very different ways, we have become disconnected from things we really need, and this deep disconnection is driving this epidemic of depression and anxiety all around us.
This is the kind of statement that makes data scientists reach for their guns, or their Lexis Nexis account. As Gabor Mate often points out there is a lot of data that supports the idea that social and emotional pressures can wreak havoc on our health, but most people ignore the studies. However the more Hari, and Dr. Sarno in his work, and Gabor Mate in his, looked for connections the more clearly the story came into focus. As we looked into it for our film it became so clear to us that people’s stories about their own lives had a deep impact on their health that for a while our working title for the film was “The Story of Pain”.
With each of the nine causes of depression and anxiety I learned about, I kept being taught startling facts and arguments like this that forced me to think differently. Professor John Cacioppo of Chicago University taught me that being acutely lonely is as stressful as being punched in the face by a stranger – and massively increases your risk of depression. Dr Vincent Felitti in San Diego showed me that surviving severe childhood trauma makes you 3,100% more likely to attempt suicide as an adult. Professor Michael Chandler in Vancouver explained to me that if a community feels it has no control over the big decisions affecting it, the suicide rate will shoot up.
For those who focus on randomized control trials as being the gold standard of evidence, these studies might not be all that persuasive. From this viewpoint this data “suggests” a connection but it doesn’t prove it. However, when one starts to look at the problem from a truly biopsychosocial perspective it becomes impossible to ignore the tidal wave of evidence that points to a connection between mind and body in regards to health. Unfortunately, because so few people understand the problem from a truly holistic perspective, the bio – psycho – social approach is often applied in a deeply disjointed way. Physically focused medical doctors, often general practitioners, often don’t have the training to understand how stress or emotions might be the cause of physical symptoms. Whey they find that their tests that reveal “evidence” they declare the person to be healthy despite their symptoms- or seemingly dismiss the symptoms as “psychosomatic”. The patient hears that they are making it up, it’s all in their head, and or they are crazy. These doctors don’t have the social/interactive skills to discuss it. In order for a biopsychosocial model to work those who look at the physical symptoms have to understand they psychology of what is going on and the psychologists who are working with the problem have to have some insight into the physical aspects of the problem. If not, then it isn’t an integrated bio-psycho-social model.
Further, an understanding of how our social and economic structures contribute to the problem is necessary. Currently, there’s not a lot of interest in western industrialized nations in radically reforming our economies. In fact, if one believes, based on the data, that the increasing wealth gap is a driver of these problems, then the recent tax bill in the United States will only exacerbate this problem in extreme ways.
As Hari points out, the relief that many people feel from being told a clear story, that makes sense, can be profound. So if a patient is told, you have a chemical imbalance and this little pill will set it right, then a sugar pill (ie.a placebo) might work just as well as Zoloft at first. However, if the real cause isn’t chemical, but instead emotional, the pill, or the placebo often won’t work for long. As Dr. Sarno found, the real power of healing comes from truly understanding the cause of the problem and addressing it. Hari takes on the larger social structures that contribute to the problem. I think Dr. Sarno acknowledged them and often found that if he simply explained to people what was going on in terms of the repression of their emotions and their pain, they often got better right away. “Knowledge is my penicillin. I tell them what’s go on and lo and behold, they get better.” Not everyone who say Dr. Sarno got better, but a search on twitter or Amazon will reveal reams of devoted followers who found relief from looking inward after all other methods had failed them.
I spent the last year hustling around the country, and the globe, in order to raise awareness of our film about Dr Sarno. As I look back I’m a bit stunned by how much resistance we faced. In large part that resistance was subtle and unconscious, which makes it even harder to address. Not only did we have trouble getting the film screened, we couldn’t get it written about in substantive ways, and when we did get it reviewed, the film was largely dismissed as one-sided propaganda. Very few people want to examine the role of their emotions, nor how their worldview might be connected to their illness. There’s a tendency to dismiss the messenger rather than accept the message.
Frankly, It’s been a bit of a hard landing. Our last blast of screenings were in November and it’s been difficult for me to focus on my work since then. I haven’t been “depressed”, but I do have to contend with the sense that our culture doesn’t value our work. Reading Hari’s excerpt reminded me how important this work is, but also sparked a connection to the frustration that I feel after this long year. I take great solace in the fact that so many people have been helped by the film. When we do get it screened the response is tremendous. However, it can be hard to make work that not only isn’t supported by any institutions, but that also subtly challenges them. Without the support of some kind of system, it can be difficult to continually push forward. Reading Hari’s work gives me some hope that consciousness of these important issues is rising.