For decades, therapy has been pushed to the sidelines of mental health treatment. We’ve been relegated to the bench next to the Gatorade, untying and tying our shoes. We watch as Big Pharma dominates the action on the playing field of mental health.
But it wasn’t always this way. In 1986, people being treated for depression were twice as likely to be in therapy as to be taking pills. Back then, we were the first choice for intervention. Now, for every person in therapy, there are four times as many taking pills for depression. We went from two to one, to one in four. That’s an eightfold loss for therapy. How did we go from being the dominant treatment modality in the mental health field to being a far more marginal player?
The reason is clear. When Prozac was first introduced in 1986—and other SSRIs and SNRIs flooded the market soon after—billions of dollars were spent to push the story that these pills were necessary because people with depression had a “chemical imbalance” that only drugs could cure. This idea gained tremendous traction in our culture, with some surveys from that time showing 94 percent of the population had heard it, and more than half of them had accepted it as true. The drug companies put so much effort into this story because theories of causality are extremely powerful: once you determine the cause of a problem, then the treatment approach follows naturally.
For example, George Washington’s doctors believed in the humoral model of disease: that sickness was caused by an imbalance of humors, or fluids, in the body (bile, phlegm, blood, etc.). So when the first president of the United States had a throat infection, the doctors followed this theory and thought the solution was removing excess fluid by bloodletting. They drained 40 percent of his blood in 12 hours, thereby killing him. This was not the outcome they were hoping for. But his death shows that despite good intentions and hard work, the wrong understanding of what causes illness leads to disaster.
The “chemical imbalance” concept was financed so heavily because it gave people not only a cause, but a solution: swallow a pill and fix the supposed imbalance. The implication for therapy was that people started believing that talking to someone wouldn’t change the brain; only swallowing a pill would make any difference.
But just because a theory is popular doesn’t mean it’s right. When researchers try to measure levels of serotonin in the brains of depressed people (through blood-plasma levels, autopsies, etc.), they find no evidence of a chemical imbalance. None. Depressed people in these studies don’t have lower levels of serotonin than nondepressed people do. This conclusion can be hard to acknowledge, since the belief in a chemical imbalance is so widespread in our culture and propagated by major media outlets all the time. But as researchers Jeffrey Lacasse and Johnathan Leo concluded in PLoS Med in 2005, “There is not a single peer-reviewed article that can be accurately cited to directly support claims of serotonin deficiency in any mental disorder, while there are many articles that present counterevidence.”
When that’s pointed out, the argument people usually make next is that the pills do relieve depression in some people. This is true: they do help some people. But placebos help people as well. In fact, Irving Kirsch at Harvard University concluded that the difference between active pill and placebo is 1.8 points on a 53-point scale, a difference so small it’s considered clinically insignificant.
The next line of defense is to say that psychoactive pills do affect serotonin in the brain, and since some people are helped by them, depression must be caused by a chemical imbalance. But exercise helps people with depression too: it’s just as effective as pills, or significantly more so. So you can make a stronger argument that depression is due to an exercise imbalance than a chemical imbalance. Nonetheless, overthrowing the current cultural narrative means offering a more powerful and convincing framework for understanding the cause of mental health issues, thereby the most effective solution.
Origins of a Different Understanding
Right around the time Prozac made its debut on the market, like a glitzy, diamond-studded celebrity touching down on the field in a helicopter, something quiet but equally profound was happening. It started when a frustrated physician in San Diego, California, asked a patient an unusual question. It was 1985, and Vincent Felitti was running an obesity clinic. Although most of his patients did lose weight, some dropping 100 pounds or more, he found that half of them would abruptly drop out of the program. Puzzled, he wondered why people would simply vanish when they were doing so well with weight loss. The answer came when he was interviewing a woman to understand her history. He asked how much she’d weighed at birth, in first grade, at graduation. But when he asked her, “How much did you weigh when you first became sexually active?” she blurted out, “Forty pounds.”
Confused, he repeated the question, and she burst into tears. “Forty pounds. I was four years old when my father raped me,” she said.
This stunned him. Like so many of us, he’d been taught that incest was extremely rare. In 23 years of practice, he believed he’d seen only one other case. Still, he and his colleagues started interviewing other people in the clinic who were 300 and 400 pounds, and they found that the majority of them had been sexually abused. At the time, this was a shocking finding.
So he teamed up with Robert Anda at the Centers for Disease Control and Prevention, and designed a survey given to more than 17,000 members of a Kaiser Permanente HMO asking about 10 types of childhood trauma, including different types of abuse and neglect, as well as five types of parental dysfunction. Initially, the doctors didn’t expect much from the survey. After all, three-fourths of the people they questioned had been to college and were holding down good jobs, accessing good healthcare, and living in one of the most affluent cities in the United States. When the results came back, however, Anda was so shocked that he wept. The group was harboring much more pain than he’d imagined. Two-thirds had experienced some form of abuse or parental dysfunction, and most of them had survived multiple traumas. Many with alcoholic fathers had not only experienced emotional abuse, but witnessed their fathers physically abusing their mothers.
With a 15-year follow-up, the research team gathered so much data they published more than 60 papers in prominent medical journals. One paper was on the link between childhood trauma and depression in adulthood. Someone fortunate enough to have grown up in an emotionally healthy home had an 18 percent chance of developing depression by middle age. But having just one adverse childhood experience (ACE) boosted the risk by 50 percent. Two ACEs boosted the risk by 84 percent. And people who had five or more ACEs had a 340 percent greater risk of developing depression than someone who’d grown up in an emotionally healthy environment.
Suicide attempts follow closely behind cases of severe depression. People who’d experienced no childhood traumas had a one percent chance of attempting suicide as adults, but for every childhood trauma experienced, that percentage increased. People who had seven or more traumas were 36 times likelier to attempt suicide than those who had none. Ultimately, the data showed that two-thirds of all suicide attempts were linked to trauma in childhood.
Of course, the hallmark of science is being able to replicate the results independently. In 2014, Canadian researchers accessed an even larger sample of people and asked about three types of traumas: physical abuse, sexual abuse, and domestic violence. They found that people who’d grown up with all three were 26 times likelier to attempt suicide as those who’d suffered none. That’s almost a photocopy of the results from Felitti and Anda. But the Canadian study went even further and assessed, both through self-reports and structured interviews, nearly all major mental disorders. Summing across the disorders, the risk of developing one was two and a half times greater for people who’d experienced one type of trauma, four times greater if they’d had two types, and eight times greater if they’d had all three.
This pattern holds true for bipolar disorder, a condition widely considered to be caused by a chemical imbalance, thereby necessitating treatment in the forms of lithium or other pills. These pills can certainly be helpful in controlling symptoms. But research shows that rather than being fundamentally caused by a chemical imbalance, bipolar disorder is significant emotional dysregulation resulting from childhood trauma. Same thing with schizophrenia. In fact, a massive meta-analysis published in Schizophrenia Bulletin by Filippo Varese and others found that people with childhood trauma were three times likelier to develop schizophrenia than those who had none. Major studies in the U.S. and Britain found that having five traumas increased the risk of having symptoms of schizophrenia between 53 and 160 times.
These numbers are so staggering that it’s worth stepping back to recognize what they mean. They show that schizophrenia is not fundamentally a brain disease, nor is it a chemical imbalance. Rather, what we call schizophrenia in most cases is actually people with multiple traumas who have significant difficulty regulating emotions, organizing thoughts, and connecting with reality.
Some clinicians will vigorously protest at this point. They’ll point out that people who report hearing voices have problems in brain structure and functioning. They’ll mention the damage to the hippocampus in the brain, cerebral atrophy, and other structural problems. They’ll say that the HPA axis is overactive in the brain, and that there are abnormalities in certain systems of neurotransmitters. All this is true. However, as John Read at the University of East London has pointed out, those are the same changes that occur in the brains of children who’ve been traumatized.
The conclusion is clear: psychological injuries are the biggest cause of most mental health problems. True, some people grow up in healthy homes and still develop bipolar disorder or schizophrenia, meaning that genetic and biological factors can come into play. Hormonal changes can trigger postpartum depression, and nutrition can play a role. But the largest factor as to why people hear voices, have difficulty organizing their thoughts, or have wild swings in mood and other problems is that they had multiple emotional wounds in the past.
Injured Psyche, Injured Body
Psychological injuries have a surprising impact on physical health as well. Just consider what it’s like growing up with a parent who might lash out at you at any time. Children in this situation are frequently in fight-flight-or-freeze mode. Cortisol and adrenaline are pumping into their little blood vessels multiple times a week, sometimes for hours at a time. Given how often their amygdala is activated, they get easily launched into an alarm state, and take much longer to calm down. The sympathetic nervous system is firing over and over and over. Fear, anger, shame, guilt, and sadness flood through their body repeatedly. As a result, the areas of the brain responsible for planning and emotional control don’t develop fully. The insulation on brain cells, the myelin, doesn’t form correctly. Even the DNA is altered: the more frequent and intense the trauma that people experience, the more methyl groups are attached to their DNA, which can turn off certain genes. Repeated trauma shapes the person’s biology at a deep level.
Teenagers with nervous systems frequently in alarm states often turn to substances to soothe the pain and fear they feel. In fact, when people have four or more childhood traumas, they’re more than two times likelier to smoke, five times likelier to use illegal drugs, almost seven and a half times likelier to abuse alcohol, and 10 times likelier to inject drugs as someone who has no traumas. They’re also 30 percent likelier to be sedentary, and 60 percent likelier to be severely obese. These are huge numbers.
Of course, using cigarettes, drugs, alcohol, and food to cope with negative emotions has a brutal impact on people’s health over the years. These addictions result in heart disease, cancer, chronic lower respiratory diseases, stroke, diabetes, kidney disease, and suicide. If this sounds scary, it is. These are seven of the 10 leading causes of death in the United States. And each one of them is far likelier to happen to people with higher numbers of childhood traumas.
In one study that looked at the impact of childhood trauma on heart disease, researchers controlled for all the physical variables, such as smoking, being overweight and sedentary, and having diabetes and high blood pressure. After they accounted for these factors, as well as demographic variables, they found that people with multiple childhood traumas have more than triple the risk of heart disease compared to people raised in emotionally healthy homes. The story is similar for cardio-obstructive pulmonary disease, the third biggest cause of death in the United States. People with four or more traumas were 350 percent likelier to have COPD than those with no childhood trauma. They were 570 percent likelier to have a stroke, and three times likelier to develop diabetes.
True, some people grow up in healthy homes and still develop heart disease, COPD, and more. There are genetic factors, but they’re less important than the role of psychological injuries. A recent Harvard Heart Letter described a risk score for heart disease using 57 genetic variants. The people at the top level of genetic risk had a 60 percent higher risk of coronary artery disease. But remember, people with multiple traumas had three times higher risk of heart disease, even after controlling for nine different risk factors. Same story for cancer. The National Cancer Institute informs us that inherited genetic mutations play a major role in about five to 10 percent of all cancers. However, having multiple traumas increases the risk of smoking by 220 percent and the risk of cancer itself by 238 percent. Genes are dwarfed by the role of psychological injuries and unhealthy patterns of coping with them.
Achieving Our Resurrection
So after laying out all this scientific data, where do we go from here? What do we do with the knowledge that psychological injuries have such an impact on both mental and physical health problems? Are we simply doomed to suffer the consequences, since you can’t swallow a pill and heal psychological injuries? Of course not—and here’s where psychotherapy can gain the renewed primacy in mental health care that it deserves.
What distinguishes therapy is that it’s the best way to heal psychological injuries. It’s unique in its ability to unearth and neutralize the shame that someone carries after being sexually abused as a child, or create a healthy self-concept in someone who was emotionally abused by a spouse. Sure, the pills may be helpful in certain instances, but the psychological injury model of understanding mental health issues—as opposed to the “chemical imbalance” narrative—means the pills are no longer primary. Instead, they’re an adjunct, a part-time servant to the more important work of healing the psychological injuries that caused the depression or anxiety in the first place.
And the healing from therapy goes deeper and lasts longer than we previously thought. When Julia Morath and other German psychologists studied refugees with PTSD, the number of breaks in the refugees’ DNA was equivalent to that of people who’d been exposed to an atomic bomb blast. That’s how badly trauma affects every cell in the body. But after therapy, not only were their PTSD symptoms gone, but their DNA was as healthy as people who’d never been traumatized. The healing was complete. However, that effect only held for those who received psychotherapy. Even though more than half the people in the wait-list control group were taking psychotropic pills, the pills had no impact either on PTSD or on healing DNA breaks.
An early study by Steven Evans and Mark Hollon looked at people treated with either therapy or pills for depression, and followed up with them two years after all treatment had been stopped. Of those who’d received therapy, 30 percent had relapsed back into depression; however, of those treated with pills, 80 percent had done so. This study was not a fluke: a meta-analysis looked at people who get either therapy or pills for depression. After all treatment is stopped, people who receive therapy are 260 percent likelier to be well at follow-up, compared with those who took pills. Similar results have been found in treatment of panic disorder and insomnia. Across multiple presenting problems, people who receive therapy experience healing that lasts much longer than those who do not.
When we weave these threads together, a new picture emerges. We’ve seen how psychological injuries are the single biggest cause of both mental and physical health problems. We understand that therapy is the approach that’s best suited for healing emotional wounds—and that the healing can go right down to the DNA level and bring benefit that lasts far longer than pills do. Does this not suggest that psychotherapists are the most important healers in our industrialized world? Who else can truly address the emotional pain that shows up as substance abuse, or suicidal thoughts, or the many other patterns that push people into an early grave?
This may come as a shock to some, given that we’re so often poorly paid for our services and receive so little status relative to other healthcare providers. But until now, our field has never been able to go up against the narrative promoted by the drug companies. Their voice has dominated the playing field of mental health for decades. They have billions of dollars in advertising and more lobbyists than there are members of Congress. They own skyscrapers and private jets and supercomputers.
But we have something different. The numbers and science are on our side, and there are more than 850,000 therapists practicing in the United States. What if each of us gave a talk at our local school or community center or library? What if we taught the public about the research they’ve never heard of, the science that explains why they feel so sad at times or abuse substances and damage their bodies? What if we showed them how therapy is best positioned to bring healing to them? What if each of us posted about it twice a week on social media?
We can also educate other professionals in the community about the enormous role of psychological injuries in both mental and physical health problems. The first time I shared these data with a physician, he stared at me in astonishment. “You mean there’s no such thing as a chemical imbalance?” he exclaimed. When I said no, he grabbed me by the elbow and dragged me down the hall to the lunchroom where four other doctors were eating. He threw the door open and announced, “You have to listen to what this guy has to say.”
The public is just as eager to hear the truth. The first time I presented the material in this article at my community library, I received 15,000 clicks on my website, three newspaper articles about what I had to say, TV coverage on the biggest news program in the province, and coverage in a book. In fact, the room where I presented was so full that we had to turn dozens of people away, even after jamming in as many chairs as we could. There were plenty of questions, with people asking, “Why haven’t we heard this before?” and “When will you teach us more?” and “Do the doctors know this yet?” They’d never heard the full story linking psychological injuries to nearly every mental health problem. And because they wanted deep healing, not just to numb the pain for a while, they called the office to schedule appointments for therapy.
If you’re in an agency, you can use the science to advocate for greater funding for your organization, making a compelling case that therapy should be front and center in healthcare and would lead to an enormous savings downstream in intensive treatment for both mental or physical health problems. And because the healing lasts, people would be a lot less likely to be readmitted to expensive residential treatment.
Support for doing this kind of work depends on being part of a group. One person speaking up is easy to dismiss. Two people are a little louder. And when an entire field speaks up, change is likely to occur.
Instead of fussing over professional differences, we need to speak up as a larger therapeutic community. We need to step onto the playing field of healthcare, push aside the chemical imbalance myth that’s been propagated by the drug companies for their own profit, and prove that we’re the healers who can most improve people’s health, making body and mind whole as emotional wounds are treated. Only then will we be able to stage a comeback, not for our benefit, but to enhance the level of health and well-being in our entire society.
For all references, please see www.Primacyoftherapy.com/References.
Want to earn CE hours for reading this? Take the Networker CE Quiz.
LLUSTRATION © ILLUSTRATIONSOURCE.COM/TONY VITA
Eric Kuelker, PhD, R.Psych, is a practicing clinical psychologist. He’s the only psychologist in Canada to publish aggregate data on how much his clients progress in therapy. His work has been featured in TEDx talks, TV programs, books, and newspapers.