Alien-Nation

I did an assessment intake the other day with a teenage boy (call him Tommy)* and his mother that captured so many themes I see as a clinician that I decided to share it here. First, it was the usual referral question—does the child have ADHD? After a warming-up period in the interview (he was quite guarded and reserved initially), we got to the crux of the issues. Tommy shared that he wasn’t feeling so hot, that he felt alone, uncertain and isolated, and that he struggled to concentrate on his academics. He had few friends, no romantic prospects, and was clearly both worried and hopeful about making the transition to college. Although he did not use any illicit substances, he was fifty pounds overweight and took refuge in both eating and reading. His mother was caring, but, in my opinion, she was understandably misguided about the situation. “We saw a psychiatrist several years ago,” she told me after he shared his ‘symptoms’. “They diagnosed him with depression, anxiety and they wondered if it might also be ADHD”. He had clearly been given a diagnostic check-list type interview and had been placed on an antidepressant and given some anti-anxiety meds to take as needed and was told he might need medication for his ADHD. “I had depression,” the mother told me knowingly, “so it runs in my family.”

I nodded, knowingly. And, inwardly, I felt the familiar frustration I feel when people (and perhaps parents especially) are taught to medicalize negative feelings. So I turned to Tommy and said, “You told me you feel isolated from your peers, you feel self-conscious at school because you were teased as a kid for being overweight, that you read and eat to escape into other worlds, and that you basically never talk to anyone about what is really going on inside of you.”

He nodded.

“Well,” I said, “from my perspective at least, it doesn’t seem to me that you have ‘depression’, ‘anxiety’ or ‘ADHD’, at least not in the sense that such things are ‘diseases’ that arise from something broken in your brain. Tommy, I see you as being scared, down, and uncertain. And the reason seems pretty straightforward to me. Deep inside you feel like you have a lot of potential; at times, sitting alone, maybe through relating to the characters in all those books you read, you are able to see that you are a smart and caring person. Yes, maybe a little quirky, but that basically translates into being funny and interesting when looked at the right way. In other words, a part of you senses that you are potentially a very lovable and admirable person. But people rarely, if ever, see you that way. Instead, they see a lonely, shy, fat kid who used to be teased and now just keeps to himself. And your parents, although very concerned, caring and well-intentioned, don’t really know you, or at least they don’t know what is going on inside, do they? They have shown their concern by explaining that you have this thing called “depression” and they took you to a doctor who "diagnosed" you and put you on some pills to make your negative feelings go away. And, so, you are super confused. For example, you probably wonder if you really do have a lot of potential, or if you just tell yourself that to make yourself feel better. You hope that college will be better, but fear it will not. Indeed, you probably worry you are going to end up isolated and alone, living with your parents for the rest of your life. And that thought leaves you sometimes feeling miserable and wondering, “What is the point of my life?” Does that description sound right?”

“Yes,” Tommy said, now with tears streaming down his face. “That is exactly it. Nobody knows me. I feel shitty because I am all alone and am afraid I will always be alone.”

“That is right,” I said. Then, after a time of sitting with and honoring his pain, I said, “But now that we know that, we might be able to take some steps that really help turn things around.”

The themes of this exchange happen day in and day out at our clinic. One patient after another comes in feeling miserable and trying to place their “symptoms” in a medical box that leads to some pill that will take the pain away. Yet, of course, the emotional pain is just that—a symptom. But it is NOT a symptom of broken neurobiology. It is a symptom of the individual’s core psychosocial needs not being met. Thus, the emotional pain is not really the problem. Like the pain one might experience from a broken arm, Tommy's emotional pain is telling him his life is not going well and thus it is functioning exactly like it should.

If we take a step back and look at society at large, it seems to me that the classic line from Dickens is apt, “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness”. By making this point, I am attempting to note, as the NY Times columnist David Brooks did recently, that in many ways we are living in a wonderful time. In particular, I would venture that those individuals who have the right combination of talents and gifts and beliefs and visions for their environmental niche are flourishing today more than at any time in our past. In other words, the best are getting better. Yet, at the same time, it seems that there are more and bigger “cracks” in our confusing, disconnected, disjointed society than ever before. As such, more people are falling into those cracks than ever before, such that now a very large minority of the population (upwards of a quarter to a third?) are struggling with serious psychological problems and feeling isolated, discouraged, confused and struggling with what they fear is a meaningless, painful existence. That is, they are suffering from a deep sense of alienation.

Coinciding with this human reality has been the emergence of Big Pharma and the disease-pill model of human suffering, resulting in the narrative that those isolated, disenfranchised, despondent individuals have “diseases” of depression, anxiety, attention, or whatever and the correct fix is a pill that will magically restore the mythical “chemical imbalance”. A powerful 2013 article in Clinical Psychology Review by Dr. Brett Deacon shows how incredibly misguided this model of human suffering is.

Alienation is a psychosocial phenomenon. It is mediated by bio-physiological-mechanical processes; however, it is not reducible to them, any more than your understanding of this blog is reducible to them. The biological reductionists, like the head of National Institute of Mental Health, Dr. Thomas Insel, don’t comprehend this simple fact and because they carry real power and influence the consequences for society are tragic.

So what causes alienation? Although each individual struggling with it feels it in a unique combination of ways, the broad picture of it is not really all that complicated. We just need to understand two things. First, we need to understand the core human psychosocial need. Second, we need to understand the three domains of human consciousness and the filtering that takes place between these domains. Meeting the core psychosocial need results in feelings of fulfillment, purpose, and harmony between the three domains of human consciousness. That state can be characterized as a state of deep psychological well-being, which is the antithesis of alienation. In contrast, failing to meet the core need results in maladaptive defenses, vicious interpersonal cycles, cognitive rigidity, confusion, anxious uncertainty, and ultimately, if it persists, psychological shutdown (AKA depression, which is more or less the opposite state of psychological wellness).

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But what, exactly, is the core psychosocial need? As articulated here, I call it the need for relational value, which is defined as need to be known and valued by self and important others. I contend that, fundamentally, the root cause of most neurotic conditions (described here) stems from the failure to meet this need.

What, then, are the three domains of human consciousness? As articulated here, the first domain is the experiential core. This refers to the embodied, intuitive, perceptual, affective feeling of being in the world. It is a pre-verbal system that infants are born with and guides action toward benefits (the function of positive emotions) and away from costs (the function of negative emotions). The core need for relational value is imbedded in this system. Work on attachment in children can be considered work on exploring how this need starts out, how it develops, and the problems that emerge if there is a lack of attunement with important others in meeting this need.

The second domain is the verbal, private self-consciousness system, which, in adults, closely overlaps with the term “identity” or “ego” (see here for a blog on understanding ego functioning). This is the network of linguistic beliefs and values that represents who you are, who you should be, how the world works, why other people are the way they are, and the reasons for your actions. It is a unique part of your mind that can be directly shared with others, as I am doing with you now via this blog.

The third domain is the public self-consciousness system, which is the “persona” or image we attempt to project and share with others. This domain interacts with how other people see and treat us, which then feeds back on the other domains.

Now, let’s think about a situation where someone is flourishing. Usually, that individual has beliefs, feelings, talents and attributes that they themselves value and that are also valued by important others. Because this attunement and valuing meets the core need for relational value, the person feels positive, motivated, curious, and growth oriented. Their affirmation from others, so long as it is attuned with how they truly see themselves, allows them to feel pride in self and love for others and usually results in them narrating their life story in a way that is relatively free of deep confusion and conflict.

Now consider what happens when someone is languishing. Like Tommy, such individuals are much more likely to not be valued by their peers, but instead are seen as lesser, weaker, ineffective, undesirable and/or unworthy. Not only does this result in emotional pain, it creates an enormous dilemma for the emerging identity, which has the task of narrating the reasons for what is happening and why. Are important others correct in their negative assessment of the self? In other words, "Am I really unworthy?" If so, if follows that the individual should either hide completely or at least hide the part of the self that important others don’t value. Indeed, this motive can be so strong it results in people repressing and denying key aspects of their emotional self even to themselves (see here). Another competing explanation for such a state of affairs is that others are being unfair, mean, insensitive, etc and thus they are to blame. This justification legitimizes feelings of resentment and orients folks to separate from important others, and go at it on their own, or to seek out different folks who will value them. To the extent that these questions and related conflicts are pervasive for the individual, the problem of being valued by self and important others goes unresolved and a vicious spiral of alienation—from both self and other—ensues.

Given all the data on a deepening crisis of mental health, coupled with what I am seeing at the clinic, it seems to me that this spiral is happening to more people than ever before. But, as was the case with Tommy, if we are clear about its nature and causes, we might be able to turn our Alien-Nation around.

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*This case is an amalgamation of several similar cases and all identifying information has been altered