Theory of Mind, part 1

Writing my story is kicking my ass. It’s bringing up very painful things, both memories and insights, which, some say, may be an important part of healing from traumas. It’s bringing some validation and support from those reading, and yet is hitting me hard in light of my present day realities. So I aim to continue, but need a reprieve from the storytelling. So today, going to try to write about a theory I’ve worked on for about a decade and a half, sharing largely with therapists and professors, that is essentially an alternative paradigm to the mainstream “medical model” of mental health/illness. Knowing me, hopefully the post will be sprawling, filled with asides and tangents, and maybe even some political ranting. Though that said, and though I’m keeping with intention to write stream of consciousness with no editing (yet), I hope I can convey the core idea of the treemap model and how this model informs conditions like post-traumatic stress, depression, mania, and anxiety disorders.

But there is no try, so here goes.

[Rare editor’s note: this post seriously wants some editing. I will do this soonish, read at your own peril.]

What is the medical model of mental illness? Loosely speaking, this is the idea that mental illness is caused by chemical imbalances, which giant pharmaceutical companies have discovered and marketed, so ask your doctor if ____ is right for you. Implicit in this model, often, is the presumption that the chemicals are being improperly balanced or produced due to flawed genetics, meaning that some people are essentially hardwired to be mentally ill, inherited from their parents’ DNA, nothing to be done but take the latest pills. There are ancillary beliefs around all this too — that psychiatry is constantly improving and any year now we will achieve better living through chemistry.

There are far too many problems with this paradigm to dissect all of them. Unfortunately the mass public is so inclined to defer to the authority and presumed hard science of psychiatrists (and increasingly GPs who prescribe psych meds) and the health industry is so inclined to over-simplify and canonize dubious science, and monetary and lobbying pressures exert so much influence…

Okay starting simply, the core problem with this model is the false notion that chemical imbalances are a root cause. A more subtle but equally wrong problem is the idea that if a chemical is imbalanced, it reflects some fault in that person’s basic biological wiring. One can attack the problem using deductive logic — why would genes that seriously impact someone’s ability to function in the world be so prevalent in the population as to be epidemic? Or one can attack the problem with statistics — why if the problem is a chemical imbalance should the rate of just about every category of mental illness be steadily rising in the same population that is also taking more and more psychiatric medications? If the solution is not reducing the problem en masse, perhaps the paradigm is wrong.

Within this wrong paradigm of the medical model, which oversells or fabricates the supporting evidence and fails to take into account even the most basic assessment of individuals’ prospects for meeting core needs, is the also problematic belief that mental illness is like medical illnesses, which are, paradigmatically, caused by pathogens or damage to internal systems that derail normal functioning. That is, the idea that mental illness is “disease”. Such a belief has far flung impacts on stigmatizing and obscuring what it really means to be mentally ill. The very term “mental illness” connotes defectiveness, crazyness, abnormal functioning of the mind.

Given the incredibly high incidence of such illness in the population, a better paradigm might look at what completely normal functioning of a human being can get stuck in pathological states given specific circumstances. Indeed, without such a paradigm, the mainstream models have no way to explain why depression, anxiety, psychosis, mania all occur at significantly higher rates among impoverished populations, displaced populations, and traumatized populations. The result is to stigmatize those populations or sweep the observation under the rug. Since averse life experiences cannot possibly be determining one’s genetic makeup… it must mean that people end up in poverty because of their genes! This is a good example of how harmful an invalid paradigm can be. And self-serving as the health care industry is primarily focused on people with expensive health insurance.

Another problem with existing paradigms is the co-morbidity question. The American Diagnostic and Statistical Manual (DSM), often called the psychiatric bible, arose with the intent of cataloguing all the mental health problems spotted in the wild, ostensibly to allow practitioners to identify common maladies and apply known treatments to known conditions. Sounds great. However problems have arisen from the fundamental facts that all these conditions ONLY existed as the theoretical models that therapists derived, were always governed by the random biases of practitioners and the paradigms of the day (older DSMs had homosexuality as a disorder; the latest has garnered flak for removing autistic spectrum diagnoses; the very fact that the set of things considered a disorder is revised by committee every several years is illustration of the fluidity of these “disorders”).

Co-morbidity is when one person has more than one disorder. The problem is that co-morbidity among DSM conditions is so high that for the majority of people, they will have multiple diagnosable disorders. In practice (based on personal observation) this often means that people come to believe they are struggling with a slew of mental problems, each with their own presumed etiology, each carrying the stigma of presumed genetic defects or other innate biological flaws. Most people do not realize that this high co-morbidity is the norm. Theories have been put forth that families of genes may be responsible for conditions like major depression and schizophrenia. This again flies in the face of very basic premises in Darwinian natural selection, and is based on a lot of crap science. (Readers have every right to question my authority on such things, but I’m not meaning to drill into the past century of evolving science surrounding psychology, but rather to discuss at a high level the problems of these paradigms). In a nutshell, high co-morbidity would be better explained with a paradigm that says that, under strain, humans will exhibit failings of mental functioning, which span a spectrum of possible impacts, and that *all people* can succumb to *all types* of mental dysfunction, with each individual’s circumstances and biology leaning towards higher risk of some types of dysfunction.

To pick one last problem with the medical model of mental illness, consider the problem of subjective bias. By subjective I mean that everyone has only their own reality with which to view someone else’s *external* signs, behaviors, communication and self-expression and from this make an educated guess as to what is happening internally. Bias comes into play with power dynamics between the all-knowing doctors and the dysfunctional patients, or the ego-defended normal, not mentally ill family members versus “crazy” black sheep. Such biases inform why someone’s ideations may in one context be considered delusional, hallucinatory, psychotic, but in another context are considered perfectly sane religious beliefs. Or perhaps one person’s righteous anger at being systematically oppressed could be diagnosed as a personality disorder like Oppositional Defiance Disorder.

For more on how individual pathologizing is a reflection of systemic oppression within society, read Foucault or Freud’s Civilization and its Discontents. I don’t want to write a political treatise.

In defense of the mainstream model, I will acknowledge that there are some apparent states which it seems everyone can agree are pathological and sufficiently abnormal as to be qualitatively distinct mental conditions. If you’ve ever dealt with someone who is floridly psychotic, speaking in word salad about how President Truman poisoned the egg salad and so blame the Jews!!, you may well think, okay, *that* person is definitely mentally ill. In some categorically different way than you or I or other mentally normal people. However having experienced altered states including psychosis myself, I posit that such states are outlying in the severity of stressors on a brain’s normal functioning, and not in something as innate as genetics. We impose false assumptions by putting people in such conditions into separate categories. We assume for instance that our own mental functioning is always rational, always sensible to others, always organized. All false assumptions. If your own life circumstances ever overwhelmed your capacity to process things rationally and emotionally to the point that your brain became confused about whether it was awake or dreaming, you too would exhibit bizarre behavior. Count yourself lucky not that you have superior genes or wiring but that your circumstances have allowed you to reliably meet core needs and develop relative security in the world — your perceived ability to meet your needs into the foreseeable future. That circumstance is why you are not breaking down to the point of psychosis.

So I am going to describe a very different paradigm of mental functioning — both in health and in illness. I inevitably am making all sorts of claims sans any reference studies or research citations, and that is because this theory has developed out of 30+ years of studying psychology, while also suffering various clinical symptoms (I’ve joked that I have had almost every diagnosis in the DSM, which is not completely off base), meeting many others in support groups and mental hospitals and peer support workers and therapists and psychiatrists. I’m informed some by having studied biology and neurology and related fields, as well as having done meta-study research on psychiatric medications, outcomes in different countries. I am not implying that my conclusions or ideas are impeccable and that you should take my word for it. I’m saying rather that I’ve integrated a lot from studying different domains and am only trying to convey the overarching ideas. The longer dissertation version is very long and may never see the light of day.

Consider what it means to be mentally healthy. Does it mean “acting normal”? What is normal? Is it healthy to be sad? Angry? Is it healthy to be happy and laughing? More than happy? as George Carlin riffed. Is it healthy to be happy and laughing at the plight of others? Is it healthy to be sad and depleted after the death of a loved one?

Health shares etymology with “whole” and “heal”. To be healthy is to be complete, robust, thriving. By this definition, to be ill means not being complete, not robust, not thriving. Therefore mental illness means to not be thriving within the realm of the mental — cognition and emotions. Most people could agree that while it is not pathological to be sad (given some identifiable reason), it is pathological to be sad always. Here is an example where its not the state that makes something healthy or unhealthy, but being stuck in a state beyond some localized context. In fact, the DSM (III?) once added a disclaimer around descriptions of major depression that the diagnosis *did not apply* if the person’s symptoms could be explained by grief, loss of a job or housing, or other major life events. This was later removed, possibly because it stood out that the health industry was attempting to define some condition as a disease, abnormal, chemically imbalanced, *unless* of course events in someone’s life caused the identical condition to happen normally.

Is it healthy to be awake or asleep? To be aroused or introspective? Content or passionately fighting the status quo? These are the wrong questions, just as it is wrong to perceive any mental state as healthy or unhealthy devoid of the context of that person’s life and circumstances.

From a different angle: you just witnessed a murder, 10 feet away from you, gruesome death of an innocent bystander. Is it healthy to suppress memory and awareness of the event? Well, the way humans process trauma (often defined as one’s own life or someone else’s life being threatened but without capacity to do anything about the threat at the time) is pretty standard across humans. The event is cordoned off in short-term memory so as to avoid the massive task of processing it into long-term memory, which itself would be very destabilizing. This suppression serves the immediate-term goal of allowing the person to function as usual, go to work, pick up the dry cleaning, feed the kids, without having to examine the full sociopolitical context of sudden dramatic violence. Without having to integrate the extreme arousal state of fight-or-flight. In fact, for humans it is normal to suppress such events potentially indefinitely, causing permanent effects as the event is effectively imprinted on the biology. The same mechanism used to promote “healthy” functioning in the short-term becomes a source of dysfunction in the long-term, as the energy required to suppress processing the event steals internal resources, generates chronic hypertensive effects and occasional extreme mood disturbance when the suppression fails temporarily and one is flooded with the unprocessed emotional signals as if the event were recurring now, years later. In fact, the most common progression of post-traumatic effects is that over time the energy needed to suppress the trauma is overwhelmed as people age, often resulting in debilitating PTSD symptoms later in life, and, ironically, often without awareness of the person suffering or those around them of any ties to some old buried trauma, since by nature, the natural, healthy response was to prevent the event from being processed and integrated.

This example is meant to illustrate the blurry distinction between a healthy and non-healthy response. Ideally, in the case of trauma, one would be able to wait until other demands on their system are relatively low, and supports are high, so as to find time and energy to actually process the event. To integrate the excited emotions, the impact of the event on one’s world-view, the lessons taken to avoid similar trauma in the future. When people are able to do this, they become stronger, wiser, and the energy of suppressing a major life event is lifted. It does not need to be suppressed. Because it is no longer in “short-term storage” it can no longer be triggered into flashbacks or emotional flooding by random stimuli. However, in cases where one never manages to be in such a supported, low demand circumstance, they may instead suppress the memories forever, and suffer the symptoms of PTSD forever.

Post-traumatic stress is therefore both healthy and unhealthy. It helps one deal with the here and now, but at the expense of a more overloaded body and mind. It raises the probability of going into fight-or-flight mode when triggered, and more generally lowers the threshold for becoming activated — anxious, aroused, insomniac, angry. The suppressed traumatic memories are like constant low-level agitators to the nervous system. And it’s distinctly unhealthy in that the reasons for such agitation are buried and completely unconscious, unexamined. The lessons that could be learned have literally never been learned (since that requires processing the events).

[core idea not well articulated: Mental phenomena or states that are adaptive and serve health-promoting purposes can become pathological when not resolved in time.]

This example of post-traumatic stress can be applied to many other cases of mental dysfunction. It’s healthy to be sad when something life-dampening or life-ending happens; it is unhealthy to be permanently sad and therefore unable to experience joy or adventure. It is healthy to be anxious before a public speaking event or big job interview; it is unhealthy to be chronically anxious to the point of being unable to concentrate or experience relaxation and openness to experience. It is healthy to be energized and consuming long hours and lots of calories building a new business or settling into a marriage and building a home; it is unhealthy to become overwhelmed with signals of limitless resources and the excitement of opportunities that the brain overwhelms its own capacity for judgment and inhibition of bad ideas and causes someone to burn bridges in relationships or rack up credit card debt betting on the stock market. It is healthy to step outside the box and challenge dominant paradigms and ideologies to see things in new ways, to be creative and innovative, a thought leader; it is unhealthy to become untethered to consensual views of reality to the point of “psychosis” — once defined explicitly as someone who is out of touch with reality.

None of these states in themselves are healthy or unhealthy, and none need be thought of as abnormal states corresponding only to those individuals who have abnormal brains. What is missing in such analysis is the context of circumstances. And the most invisible circumstance is the existing shape of one’s brain, of one’s mind. By shape I mean here the unique mind/brain that has evolved over this lifetime, developed from infancy to present day maturity, been informed by countless experiences, values, lessons, traumas, and external realities.

An analogy to help explain the primary significance of the existing mind as part of one’s circumstances. (Bad sentence!):

A classic trope in psychology ideas is that two people can be put in identical circumstances — say separated twins adopted into similarly middle-classed blah blah families — and yet react in radically different ways. This type of experimental setup has often been used to justify the belief that minor innate differences can have huge impacts on outcomes, so for instance a handful of genes might determine how one behaves across their lifespan. It always bothered me how much this analysis ignores chaos theory and the butterfly effect. That is, two superficially similar circumstances might be radically different circumstances based on the different developmental trajectories of the individuals. One stepped on a butterfly when he was 5 and the other did not; as a result by age 20 one had developed a very different world view than the other.

But okay the better analogy:

Imagine you took two people and dropped them into the middle of 1943 Poland, and gave them each the same task: you have to escape the country, using no maps or navigational equipment. In the experiment, one person moves fairly swiftly to major routes and on to cross the border, while the other wanders aimlessly in backyards and woods and never gets close to the border. A simple explanation might be that one of the participants has some far superior, perhaps more “normal” ability to navigate geospatially, they are just better with directions. The other person is suffering Escape-Route Determining Deficiency. Since they are in identical circumstances, the difference must come down to innate differences of the individuals.  However a more nuanced and better explanation might be that only one of the study participants learned to speak Polish when they were younger.

This not greatly described analogy is meant to illustrate that *what we have learned* in our past experiences is enormously influential on our present circumstances. That is, your circumstances cannot reliably be determined from simple external observation. And so studies claiming to exhibit distinctions between people in the same circumstances are flawed, insofar as they chalk up behavioral differences to innate differences in functioning.

Ok getting too wordy and low on insights maybe.

But to recap: we want a paradigm that is superior to the medical model in describing mental health and functioning. Superior in its ability to explain and therefore predict outcomes in a variety of conditions, in its ability to match observable data like extremely high co-morbidity of mental illnesses and diagnoses, and superior as a guide in helping people recover (or obtain) high health, meaning robust ability to thrive, meet needs, and experience desirable subjective states like joy, happiness, relaxation, contentment. And finally, superior in its ability to integrate an individual’s past experience with real or imagined biological differences they are born with.

And that brings me to

The Treemap model

Consider the purpose of the brain. The ancient Greeks thought it primarily served as the body’s cooling system. While they weren’t wrong that it serves that purpose, they missed the mark on its primary purpose. One might offer the more modern idea that the brain is for thinking, or for recognizing patterns, or for governing actions and behavior. Sure, but to what end? What is good thinking and good action vs bad? And what does the brain add that DNA cannot encode? Many animals and plants have many behaviors that are more or less contained within the genes and shaped by the predictable physical environment.

The purpose of the brain is to be a map of the universe. Specifically, mapping internal needs to external reality. The reason for the brain is contained within this purpose. Biological needs may largely be driven by simple chemical processes that have stayed stable for tens of millions of years, whereas the shape of the external universe is constantly changing, not just between generations, but day by day, year by year within individual lifetimes. For a map to successfully traverse that constantly changing universe, the map itself must constantly be changing.

In order to best understand and illustrate how this view of the brain — and subsequently mental robustness vs pathology — I present the Treemap model. This model is not simply conceptual but corresponds to the actual structure of the brain (along with the nervous system, endocrine system, microbiome, immune system, etc.) As I’ll explain, the model is also helpful in understanding the various ways the brain shifts into altered states as part of the natural process of evolving and adapting to life’s circumstances, and why some circumstances can cause those altered states to become stuck in maladaptive places: pathological states.

Imagine a giant tree with billions of branches and trillions of leaves. Its root system has hundreds of millions of roots. The tree is your reality, what you experience. It is your mind. Physically, the roots of the tree connect to internal needs — the biochemical requirements of a collective hive of trillions of cells, from a hundred million species (including human). Needs like water, sugar, amino acids, and shifting levels of elements needed to respond to shifting internal states. Individually these needs are simple feedback loops, adjusting levels of chemical signals based on other chemical levels. Collectively they form the complex feedback loops of homeostasis (regulating a consistent baseline state) and allostasis (maintaining stable states despite constantly evolving baselines).

The roots therefore grow inwards, into our biology. They are largely determined by our genes as they represent systems that have evolved over millennia. The leaves on the tree, conversely, are connected to objects in the external world. They are people, places, and things. These things have common aspects that have evolved over millennia — e.g. places consistently have a topography and people give off chemical pheromones — but in the complex specifics, these things are incredibly mutable. People, places, and things come and go, and have attributes specific to this culture, this identity, this era.

Branches of the tree contain associated collections of leaves. A branch might be your hometown, or workplace, that within it contains leaves for individual friends, places to get a cup of coffee, a preferred parking spot.

If you want to nitpick the graph theory of using a tree in place of the brain, it is worth noting that the latter contains graph structures not seen in actual trees. Loops or cycles, where external “objects” associate back to specific root needs or are branches to other branches. The model should not be taken so literally as to assume the graph structure of neural topology, but is a good approximation when looking at how the tree grows and changes over time. Likewise “people, places, and things” are the clearest examples of objects, but even these are much more accurately branches rather than leaves, as they are extremely complex objects. And some branches/leaves may correspond to *ideas*, which are part of the external universe in the sense that they are not core biology, but are abstracted away from tangible objects. So for instance the branch of the tree that is the Polish language, or the idea of democracy.

Likewise internal needs exist that are abstractions of core needs. Human beings have genetically hardwired needs to feel belonging within community, and security. While these are not as simple as single-chemical feedback loops corresponding to nutrient levels, they are internal needs (and are still governed by chemicals like hormones) as opposed to being objects in the external world. One way to think of such higher level needs is that they correspond to the ability to robustly meet lower level needs. Only with community can an individual reliably meet all their basic needs, and security is the need to perceive that needs will be well met now and in the future.

With this model, one can broadly define mental health as having a strong map that is functioning well in terms of meeting core needs. A strong map means that ones basic needs can reliably be met based on their awareness and understanding of the world around them. An explicit assertion I am making here is that IF someone can reliably meet all of their basic needs, now and into the future, they will tend to be mentally healthy, and IF they cannot meet some or many of their basic needs either now or in their perceived future, this will alter the balance of natural states used to maintain and grow the map. Depending on how much change to the map is required, this can result in pathological or chronically pathological states.

[Ed: the treemap model is NOT the new paradigm, but is a model used to explain the paradigm, which I’ll outline in the next post.]

As a final point about the model, consider that some basic needs not being met will result in illness that is primarily physical and not particularly mental. If you have a specific vitamin deficiency maybe it results in skin rashes and brittle nails, which is a physical illness. But unless such detriment is significantly impacting the higher order needs for which our brains exist, it may never enter into mental life much at all. The point being that the brain and its map is there to adapt to the things that we can consciously (or unconsciously) adapt to, and most pathologies of the mind have to do with higher level needs that we cannot manage to adapt to, despite trying. That said, we can see in this model why mental illness should be so much higher in resource-starved populations. Their map may be accurately reflecting their external realities and yet still insufficient to point to consistent and stable means to meet basic needs like food, water, housing, community, belonging, or purpose.

I’ll continue to explore the model in the next post, getting more into the specifics of pathological states including depression, anxiety, mania, psychosis, personality disorders, post-traumatic stress syndromes, and addiction. Maybe will finally circle back to discuss what useful role, if any, psychiatry and current mainstream health care plays in alleviating mental illness within the idea of the Treemap.

Thanks for reading.