I started writing a long comment in response to this article (more to respond to the original catchy headline this topic first went live with "Mental Illness Is Not in Your Head").

I decided I'd turn it into a blog post and have posted it for discussion here: https://news.ycombinator.com/item?id=33201781

Here's it is as a comment:

This is a response to an article currently being discussed on Hacker News [Two recent books by historians explore the crisis in biological psychiatry, originally titled Mental Illness Is Not in Your Head]. I believe that the, now replaced, catchy headline of the article is not correct. I believe mental health is in your head, but this does not mean that mental health is controllable through altering neurotransmitters (or in fact altering any specific biological process).

~All mental health issues use the same biological structures[1]. A structure which interprets the emotional dynamic of the situation you are currently in. Another structure which reactivates the emotional memory you have associated with that dynamic.

Most likely the same mechanism is used for both happy and unhappy paths:

# Happy paths:

If you grew up with a loving (but not overwhelmingly loving) and calm family, your unconscious association between the emotional dynamic of a situation you are in, and the emotional memory associated with it are positive. These could range from: "Everyone is having fun right now, I can relax and have fun too!", to "That person did something that made me uncomfortable, I know it's safe to express my needs and feelings, so I can communicate calmly to the person who upset me how I their behaviour made me feel".

# Unhappy paths:

If you grew up with caregivers who were stressed by certain situations, your unconscious association between the emotional dynamic of a situation you are in, and the emotional memory/requirements associated with it will contain protective responses. These could range from: "Everyone seems to having fun right now... but everyone got so stressed out when I was anything other than calm and happy when I was young, I better keep all my stressed feelings hidden inside, and be act like I'm happy and having fun too - even if something is going on for me which means deep down I'm not feeling good", to "That person did something that made me uncomfortable. Everyone go angry so quickly when I was little, that I’m sure this person will get really angry too if I say anything to them. I will just pretend that I’m ok with what they did.” This list goes on and on, and will depend on the subtle dynamics of the relationships you were raised in.

You will notice that in the happy paths there is not a separation between your external world and your internal worlds, whereas in the unhappy paths there is this split. This split is uncomfortable and it is lonely. It requires a tense form of control that the person on the happy path doesn’t need to apply to themselves.

# Things get worse […before they get better?]

I’m sure a bit of you related to the unhappy paths that I described. That is because we all have them. One of the biological survival mechanisms we have as highly dependent infants is to bend our emotional responses into ones which mean we get what we need from our caregivers.

This is such a common requirement for making it through infancy that the human is built to shed these leant emotional shackles. I am in a controversial minority within psychotherapy that believes that the precise diagnosis of these emotional shackles is the function of dreaming (https://psyarxiv.com/k6trz).

Getting rid of an emotional shackle is not complicated when it is clearly visible. It is not particularly pleasant, but you simply have to unlearn the fear by facing up to it. If you notice you keep your stressed feelings inside, you’ll need to find the courage to start opening up. If you are not setting boundaries when you feel yours are getting trodden on, you need to find the courage to start having those (initially) awkward conversations. The same is true for whatever unuseful emotional conditioning you are trying to get free from.

The mechanism behind this approach is very simple. We are extremely scared of facing these learnt fears (the type and level of fear we typically[2] only know in infancy). When we repeatedly face these fears and survive they are very quickly unlearned from the brain. It is highly inefficient for the brain to keep a fear in place that we now know (at an experiential, not only cognitive, level) to be superfluous, and the brain does not seem to want to do this.

But what happens if no one is there to help you work our your emotional shackles and you are left to suffer their isolating consequences on your own? Again, I am in a bit of a controversial minority of the mental health community, but I believe it is the useful response that mental health symptoms should worsen.

If things worsen both you and others begin to notice that something is wrong. If they notice something is wrong, there is an increased likelihood that you will get the emotional care that might lead you to successfully removing your emotional shackles; reducing your stress and isolation. Many people start treating their mental health because things have gotten bad, but the treatment (the process of discovering and facing up to unconscious fears) doesn’t need to stop when you return to your base level.

In summary, I think there is a strong component of mental illness that is very much within our own heads. Because the happy and unhappy paths of mental illness use the same structural processes we cannot force a change at the biological level. Instead we have to explore, challenge and ultimately change the underlying emotional memories that are elicited in the structural processes. From my personal experience, this causes the greatest improvement to our mental health/reduces our “mental illness”.

[1] I'm aware that I am talking with one of two layers of abstraction. I'm not talking about the specific parts of the brain, but these processes are consistent in all of us.

[2] Stressful situations we experience as adults that cause PTSD are ones where our emotional processing of the situation we are going through mimics our childlike experience. The experience is overwhelming.