The opinions included in this article belong to the writer and do not represent those held by the Herald Editorial Board. Resources and support for those experiencing mental illness are available at The SHARE Center, Walden Peer Counseling, and Yale Mental Health and Counseling. Explore Yale’s wellness resources at Being Well at Yale.
About half of all Yale undergraduates will, at some point, enter the hallowed halls of Yale’s Mental Health & Counseling department. Roughly the same proportion of students have dropped by the Good Life Center, Yale’s wellness organization, for a cup of tea or a slice of avocado toast. And a full quarter of the student body took “Psychology and the Good Life”—Yale’s “happiness class”—when it was offered three years ago. Yale students, like many other people, are concerned with living our best lives. But unlike most Americans, for this fleeting moment of college, we have many institutional options at our fingertips.
The aesthetic appeal of wellness is undeniable: everyone loves golden retrievers, stickers, and golden retriever stickers. The spaces dedicated to wellness at Yale are much prettier than the duller Yale Health building. And at least before COVID, the Good Life Center flavor of wellness was aggressively available: there were endless meditation sessions, teatimes, student-led hikes, and therapy dogs in the library.
As much as the idea of ‘wellness’ bothers me on a personal level—it feels naggy, like someone’s mom telling me to work out—there is a lot of evidence that some of these initiatives work. The building blocks of wellness at the Good Life Center include the imperatives to Eat Well, Move Well, Love Well, and Rest Well, among others; all of them seem to be backed by a substantial body of positive psychology research. Most people report an increase in general well-being when they work out, when they make healthy connections, when they eat fresh fruit and vegetables. The ability to do all of these things at once might rely on a great deal of luck, but for some they seem to offer a path towards fulfillment.
Mostly, students complain that wellness initiatives do not take the gravity of the mental health crisis—in America, on college campuses, for individual students—seriously enough. The inexplicably euphemistic Yale Wellness Leaders send us emails that read “it’s okay not to be okay,” which feels like an insufficient response to this ongoing global trauma. The solutions that wellness offers really do work for some, but not for everyone.
Susan Sontag’s Illness as Metaphor is an oblique masterpiece in part about how we understand cancer and tuberculosis. But it also offers clues about the most mysterious of afflictions: insanity. I was shocked by her descriptions of the mental institutions of the seventies. “Once put away,” she writes, “the patient enters a duplicate world with special rules…. The metaphor of the psychic voyage is an extension of the romantic idea of travel that was associated with tuberculosis. To be cured, the patient has to be taken out of his or her daily routine.” Those designated ‘insane’ faced a difficult trade-off: you could finally have a drastic change of environment, but it might look like exile.
We are now worlds away from the old model of insanity as exile, not least because of the sheer numbers: 50% of Americans will have some form of mental illness in their lifetime. Many people have accepted that somewhere, their own brains and bodies have gone wrong. Discussions of mental health as a larger psychic voyage have been supplanted with insistences that it is biological, the same as any other clinical illness. In my experience of conversations with Yale students, and indeed with the general public, the only complaints about psychiatric healthcare seem to center on stigma and access. There are fights to be won—but they’re mostly about ensuring access to mental healthcare, and that the stigma of mental illness is erased, so that everyone feels comfortable going to therapy and seeing a psychiatrist.
The biological explanation has gained traction in the last ten years. These days, my friends joke about their “fucked-up brains” running on their last molecules of serotonin. Many people trust the idea that depression and anxiety (both rampant among college students) and many other mental illnesses are caused by the subject possessing an abnormal number of neurotransmitters—a chemical imbalance.
Because psychiatry is so well-trusted even among the generally skeptical, the problems with it managed, for a while, to escape my notice. I complained about the golden-retriever wellness industry in lieu of really thinking about the larger healthcare system, even though I learned back in high school history class that larger systems are where the diseased roots always lie. Although the police should be defunded and capitalism destroyed, I thought, somehow, psychiatry might still save us; the sole institution upon which we feel comfortable resting our hope for repair.
Destabilizing this framework feels dangerous. We frame mental illnesses such as depression and anxiety as purely biological because we’re nervous about the nuance required to discuss the ways in which mental illness is related to individual experience, the ways in which it is socially constructed. We’re afraid that if we allowed this nuance, someone might take away our ability to get help. People rely on the comparison to physical illness in order to confirm their experience of the very real symptoms from which they suffer. The benefit of exclusively using the language of biology is that it allows people to feel validated in the reality of what is happening to them. But it is an enormous trade-off to make.
The chemical imbalance theory began with an exploration of treatment. By figuring out how to cure—or, at least, mitigate—the symptoms of mental illness, scientists could conceivably find the cause of the distress. Scientists have experimented with drugs, and sometimes these drugs work: by increasing a person’s levels of serotonin you can sometimes reduce certain symptoms of depression. From that understanding, we’ve extrapolated the idea that low serotonin causes depression.
The problem is that this chemical imbalance theory is not true, or at the very least, we do not know if it is true. Daniel Carlot, a professor of psychiatry at Tufts and a medical journalist, sums it up: “There is no direct evidence that a serotonin or norepinephrine deficiency is involved [as a cause of depression], despite thousands of studies attempted to demonstrate such a deficiency.” It is just as inaccurate an assumption to say that, because opiates are used to treat back pain, that back pain is caused by a deficiency of opiates in your system.
There’s also no evidence for a serotonin genotype link to depression. A recent meta-analysis—an enormous study to synthesize many studies on the subject—yielded absolutely no evidence that the serotonin genotype even predisposes people to sad feelings.
The majority of psychiatrists are aware of how little progress we have made in determining the causes of mental illness. They know that sometimes the drugs work—but they’re aware that we still don’t know why the drugs work. One psychiatrist notes: “[W]hen I find myself using phrases like ‘chemical imbalance’ and ‘serotonin deficiency,’ it is usually because I’m trying to convince a reluctant patient to take medication.”
And that is certainly not where the problems with psychiatry end; pharmaceutical companies and their interests are so deeply enmeshed with the professions of therapy and psychiatry that it feels impossible to extricate one from the other. Psychiatry has developed a symbiotic relationship with drug companies. When a new category of mental illness is created, “Psychiatrists flock to treat new customers. Drug companies promote new conditions in advertising.” For example, the bulk of the medical literature from the early days of Zoloft, a popular antidepressant, was “literally written by the drug company that manufactured the drug.”(They hire medical ‘ghostwriters’—writing the papers themselves, and then paying a psychiatrist to sign off.)
Sometimes, when I talk about mental illness, I feel like a conspiracy theorist. The frightening thing is that no one seems to have the answers, but many in the industry pretend that they do. Ideas like the chemical imbalance theory have become so embedded in our understanding of existence that they feel impossible to challenge. However, in the initial trials for FDA approval of most antidepressants we currently use, drugs showed better results compared to the placebo only about 51% of the time.
I was hoping I would come away from my exploration of psychiatry with renewed faith in our healthcare system. Instead, I find I have increased faith in the placebo effect.
In the interest of full disclosure, this is not a purely academic question for me. While in college, to try to be a more functional human being, I have begun to dip my toe into some of the solutions on offer. I have tried developing a very elaborate narrative about how my life is going (is it really that simple?), having tea with Tracy George and talking about my problems in her stunning Good Life Center office (helpful), going to group therapy (I sat at Yale Health once a week with students I didn’t know feeling just like I do in class: am I talking too much? Is the discussion leader impressed with my contributions?), journaling (self-indulgent), changing my diet (I have not done this consistently nor have I done it based on any research), working out more often (this brought me a lot of joy, but only from the bouncy thrill of taking a dance class with all of my friends, which became immediately unreplicable after we went home for quarantine), getting dressed up every day (a suggestion from my mom), falling in still-unrequited love with my best friend (a suggestion from no one and yet inescapable), one-on-one therapy (over phone call during quarantine while I walked in the dog park), time, placebo effect, and buying an eyelash curler. I am very tempted by LSD and not very tempted by Xanax; I have supported many industries and left others disappointed. I wonder if I think of myself as a project.
Carlot, the critical psychiatrist, wrote: “As much as it may be convenient and intuitive for us to use the language of dualism [with regards to mental illness], in fact psychopharmacologists and psychotherapists are both treating the same thing—what we might call the mind/brain. One can change the processes of one’s mind just through talking, just as one can through pills, or through exercise and teatime. And they all work at about the same rate of empirical success. We’re all trying to treat the mind/brain: Tracy at the Good Life Center, and the smug, well-exercised meditators, and me, and everybody else on earth.
Life is a sweaty and glittery mess. I’m trying to accept that no one has the answers—or that, more accurately, all of us have some of the answers. Psychiatry is not a clear good or evil; neither is the wellness industry. Many of my peers have taken the initiative to criticize various institutions for the way they tell us to live. I am only asking that psychiatry is not spared that fate of college discourse.
Endnotes:
If you’re interested in learning more, I made a critical syllabus to introduce you to some resources, art, and theory about psychiatry. Check it out here: Hero’s Psychiatry-Critical Syllabus
Sources:
Clare Wilson, “Nobody can agree about antidepressants. Here’s what you need to know,” New Scientist, October 2, 2018.
Aaron Carroll, “Do Antidepressants Work,” The New York Times, March 12, 2018.
Daniel Carlat, Unhinged: The Trouble with Psychiatry— A Doctor’s Revelations about a Profession in Crisis (New York: Simon & Schuster, 2010).
Susan Sontag, Illness as Metaphor (New York: Farrar, Straus and Giroux, 2010).
Devin O’Banion, “This is not happiness!,” Yale Daily News, October 13, 2019.
“Learn About Mental Health,” Centers for Disease Control and Prevention, January 26, 2018. Laurie Santos, “The Happiness Lab,” 2019 Pushkin Industries. https://www.happinesslab.fm/
The opinions included in this article belong to the writer and do not represent those held by the Herald Editorial Board. Resources and support for those experiencing mental illness are available at The SHARE Center, Walden Peer Counseling, and Yale Mental Health and Counseling. Explore Yale’s wellness resources at Being Well at Yale.
About half of all Yale undergraduates will, at some point, enter the hallowed halls of Yale’s Mental Health & Counseling department. Roughly the same proportion of students have dropped by the Good Life Center, Yale’s wellness organization, for a cup of tea or a slice of avocado toast. And a full quarter of the student body took “Psychology and the Good Life”—Yale’s “happiness class”—when it was offered three years ago. Yale students, like many other people, are concerned with living our best lives. But unlike most Americans, for this fleeting moment of college, we have many institutional options at our fingertips.
The aesthetic appeal of wellness is undeniable: everyone loves golden retrievers, stickers, and golden retriever stickers. The spaces dedicated to wellness at Yale are much prettier than the duller Yale Health building. And at least before COVID, the Good Life Center flavor of wellness was aggressively available: there were endless meditation sessions, teatimes, student-led hikes, and therapy dogs in the library.
As much as the idea of ‘wellness’ bothers me on a personal level—it feels naggy, like someone’s mom telling me to work out—there is a lot of evidence that some of these initiatives work. The building blocks of wellness at the Good Life Center include the imperatives to Eat Well, Move Well, Love Well, and Rest Well, among others; all of them seem to be backed by a substantial body of positive psychology research. Most people report an increase in general well-being when they work out, when they make healthy connections, when they eat fresh fruit and vegetables. The ability to do all of these things at once might rely on a great deal of luck, but for some they seem to offer a path towards fulfillment.
Mostly, students complain that wellness initiatives do not take the gravity of the mental health crisis—in America, on college campuses, for individual students—seriously enough. The inexplicably euphemistic Yale Wellness Leaders send us emails that read “it’s okay not to be okay,” which feels like an insufficient response to this ongoing global trauma. The solutions that wellness offers really do work for some, but not for everyone.
Susan Sontag’s Illness as Metaphor is an oblique masterpiece in part about how we understand cancer and tuberculosis. But it also offers clues about the most mysterious of afflictions: insanity. I was shocked by her descriptions of the mental institutions of the seventies. “Once put away,” she writes, “the patient enters a duplicate world with special rules…. The metaphor of the psychic voyage is an extension of the romantic idea of travel that was associated with tuberculosis. To be cured, the patient has to be taken out of his or her daily routine.” Those designated ‘insane’ faced a difficult trade-off: you could finally have a drastic change of environment, but it might look like exile.
We are now worlds away from the old model of insanity as exile, not least because of the sheer numbers: 50% of Americans will have some form of mental illness in their lifetime. Many people have accepted that somewhere, their own brains and bodies have gone wrong. Discussions of mental health as a larger psychic voyage have been supplanted with insistences that it is biological, the same as any other clinical illness. In my experience of conversations with Yale students, and indeed with the general public, the only complaints about psychiatric healthcare seem to center on stigma and access. There are fights to be won—but they’re mostly about ensuring access to mental healthcare, and that the stigma of mental illness is erased, so that everyone feels comfortable going to therapy and seeing a psychiatrist.
The biological explanation has gained traction in the last ten years. These days, my friends joke about their “fucked-up brains” running on their last molecules of serotonin. Many people trust the idea that depression and anxiety (both rampant among college students) and many other mental illnesses are caused by the subject possessing an abnormal number of neurotransmitters—a chemical imbalance.
Because psychiatry is so well-trusted even among the generally skeptical, the problems with it managed, for a while, to escape my notice. I complained about the golden-retriever wellness industry in lieu of really thinking about the larger healthcare system, even though I learned back in high school history class that larger systems are where the diseased roots always lie. Although the police should be defunded and capitalism destroyed, I thought, somehow, psychiatry might still save us; the sole institution upon which we feel comfortable resting our hope for repair.
Destabilizing this framework feels dangerous. We frame mental illnesses such as depression and anxiety as purely biological because we’re nervous about the nuance required to discuss the ways in which mental illness is related to individual experience, the ways in which it is socially constructed. We’re afraid that if we allowed this nuance, someone might take away our ability to get help. People rely on the comparison to physical illness in order to confirm their experience of the very real symptoms from which they suffer. The benefit of exclusively using the language of biology is that it allows people to feel validated in the reality of what is happening to them. But it is an enormous trade-off to make.
The chemical imbalance theory began with an exploration of treatment. By figuring out how to cure—or, at least, mitigate—the symptoms of mental illness, scientists could conceivably find the cause of the distress. Scientists have experimented with drugs, and sometimes these drugs work: by increasing a person’s levels of serotonin you can sometimes reduce certain symptoms of depression. From that understanding, we’ve extrapolated the idea that low serotonin causes depression.
The problem is that this chemical imbalance theory is not true, or at the very least, we do not know if it is true. Daniel Carlot, a professor of psychiatry at Tufts and a medical journalist, sums it up: “There is no direct evidence that a serotonin or norepinephrine deficiency is involved [as a cause of depression], despite thousands of studies attempted to demonstrate such a deficiency.” It is just as inaccurate an assumption to say that, because opiates are used to treat back pain, that back pain is caused by a deficiency of opiates in your system.
There’s also no evidence for a serotonin genotype link to depression. A recent meta-analysis—an enormous study to synthesize many studies on the subject—yielded absolutely no evidence that the serotonin genotype even predisposes people to sad feelings.
The majority of psychiatrists are aware of how little progress we have made in determining the causes of mental illness. They know that sometimes the drugs work—but they’re aware that we still don’t know why the drugs work. One psychiatrist notes: “[W]hen I find myself using phrases like ‘chemical imbalance’ and ‘serotonin deficiency,’ it is usually because I’m trying to convince a reluctant patient to take medication.”
And that is certainly not where the problems with psychiatry end; pharmaceutical companies and their interests are so deeply enmeshed with the professions of therapy and psychiatry that it feels impossible to extricate one from the other. Psychiatry has developed a symbiotic relationship with drug companies. When a new category of mental illness is created, “Psychiatrists flock to treat new customers. Drug companies promote new conditions in advertising.” For example, the bulk of the medical literature from the early days of Zoloft, a popular antidepressant, was “literally written by the drug company that manufactured the drug.”(They hire medical ‘ghostwriters’—writing the papers themselves, and then paying a psychiatrist to sign off.)
Sometimes, when I talk about mental illness, I feel like a conspiracy theorist. The frightening thing is that no one seems to have the answers, but many in the industry pretend that they do. Ideas like the chemical imbalance theory have become so embedded in our understanding of existence that they feel impossible to challenge. However, in the initial trials for FDA approval of most antidepressants we currently use, drugs showed better results compared to the placebo only about 51% of the time.
I was hoping I would come away from my exploration of psychiatry with renewed faith in our healthcare system. Instead, I find I have increased faith in the placebo effect.
In the interest of full disclosure, this is not a purely academic question for me. While in college, to try to be a more functional human being, I have begun to dip my toe into some of the solutions on offer. I have tried developing a very elaborate narrative about how my life is going (is it really that simple?), having tea with Tracy George and talking about my problems in her stunning Good Life Center office (helpful), going to group therapy (I sat at Yale Health once a week with students I didn’t know feeling just like I do in class: am I talking too much? Is the discussion leader impressed with my contributions?), journaling (self-indulgent), changing my diet (I have not done this consistently nor have I done it based on any research), working out more often (this brought me a lot of joy, but only from the bouncy thrill of taking a dance class with all of my friends, which became immediately unreplicable after we went home for quarantine), getting dressed up every day (a suggestion from my mom), falling in still-unrequited love with my best friend (a suggestion from no one and yet inescapable), one-on-one therapy (over phone call during quarantine while I walked in the dog park), time, placebo effect, and buying an eyelash curler. I am very tempted by LSD and not very tempted by Xanax; I have supported many industries and left others disappointed. I wonder if I think of myself as a project.
Carlot, the critical psychiatrist, wrote: “As much as it may be convenient and intuitive for us to use the language of dualism [with regards to mental illness], in fact psychopharmacologists and psychotherapists are both treating the same thing—what we might call the mind/brain. One can change the processes of one’s mind just through talking, just as one can through pills, or through exercise and teatime. And they all work at about the same rate of empirical success. We’re all trying to treat the mind/brain: Tracy at the Good Life Center, and the smug, well-exercised meditators, and me, and everybody else on earth.
Life is a sweaty and glittery mess. I’m trying to accept that no one has the answers—or that, more accurately, all of us have some of the answers. Psychiatry is not a clear good or evil; neither is the wellness industry. Many of my peers have taken the initiative to criticize various institutions for the way they tell us to live. I am only asking that psychiatry is not spared that fate of college discourse.
Endnotes:
If you’re interested in learning more, I made a critical syllabus to introduce you to some resources, art, and theory about psychiatry. Check it out here: Hero’s Psychiatry-Critical Syllabus
Sources:
Clare Wilson, “Nobody can agree about antidepressants. Here’s what you need to know,” New Scientist, October 2, 2018.
Aaron Carroll, “Do Antidepressants Work,” The New York Times, March 12, 2018.
Daniel Carlat, Unhinged: The Trouble with Psychiatry— A Doctor’s Revelations about a Profession in Crisis (New York: Simon & Schuster, 2010).
Susan Sontag, Illness as Metaphor (New York: Farrar, Straus and Giroux, 2010).
Devin O’Banion, “This is not happiness!,” Yale Daily News, October 13, 2019.
“Learn About Mental Health,” Centers for Disease Control and Prevention, January 26, 2018. Laurie Santos, “The Happiness Lab,” 2019 Pushkin Industries. https://www.happinesslab.fm/
