Book Review-Your Consent Is Not Required: The Rise of Psychiatric Detentions, Forced Treatment, and Abusive Guardianships

It’s just hard to read.  It’s hard to read that people’s liberties are being stolen.  That professional organizations are complicit in the continued harm.  Your Consent Is Not Required: The Rise of Psychiatric Detentions, Forced Treatment, and Abusive Guardianship is a sad story of how it’s too easy for someone to become a prisoner of the mental health system.

What Doesn’t Work

No one should believe that solitary confinement for extended periods of time is therapeutic.  In Chasing the Scream, Johann Hari explains the real reasons that rats preferred morphine laced water over regular water: they were being held in solitary confinement.  Bruce Alexander, in The Globalization of Addiction, explains the experiments that his team did in more detail, including the fact that the water included both morphine and sugar – not just morphine.  When the rats were given socialization and toys to play with, they didn’t seek the morphine-laced water in the same way.  They were adapting to their imprisonment – their solitary confinement – by taking drugs to numb the social pain.

Ubuntu derives from a Zulu saying that literally means, “A person is a person because of other people.”  Social workers think about this as person-in-environment.

Where the Supreme Court Sits

There are a set of cases that are important to how psychiatric care is viewed by the courts in the US.  The point at issue is the Fourteenth Amendment to the Constitution, which guarantees due process under the law.  Much of what happens with psychiatric detention skirts dangerously close to these protections.

In Addington v. Texas (1979), the bar for the standard of evidence for psychiatric detention was lowered.  There are three levels of evidentiary requirements for burden of proof, from the least difficult “preponderance of the evidence” through “clear and convincing evidence” to “beyond a reasonable doubt.”  In this decision, the requirement was moved from “beyond a reasonable doubt” to “clear and convincing evidence,” because the court was concerned that the “beyond a reasonable doubt” standard couldn’t be met given the problems with psychiatric diagnosis.  The opinion states, “The reasonable doubt standard is inappropriate in civil commitment proceedings because, given the uncertainties of psychiatric diagnosis, it may impose a burden the state cannot meet, and thereby erect an unreasonable barrier to needed medical treatment.”

Since then, there have been cases that have raised the bar for expert testimony.  The current standard was set in the Daubert (1993), Joiner (1997), and Kumho (1999) cases.  One of the problems is the inconsistency with which these standards are still applied.  For instance, the Rorschach ink blot test fails to meet these standards according to “Failure of Rorschach-Comprehensive-System-Based Testimony to Be Admissible Under the Daubert–Joiner–Kumho Standard” (2002), but it’s still routinely used by “experts”.  (See also Science and Pseudoscience in Clinical Psychology and The Cult of Personality Testing.)  While courts are supposed to use these standards of evidence, they will often side with a psychiatrist because of their technical credentials even if their work is built on a house of cards.  (See House of Cards: Psychology and Psychotherapy Built on Myth.)

Despite the court’s failure to maintain evidentiary standards, they have repeatedly reaffirmed the need for due process.  In Vitek v. Jones, they required that a prisoner’s transfer to a mental health institution must “be accompanied by adequate notice, an adversary hearing before an independent decisionmaker, a written statement by the factfinder of the evidence relied on and the reasons for the decision, and the availability of appointed counsel for indigent prisoners.”

Too few public defenders have the time or inclination to push back on the civil commitment or guardianship hearings – if there is any defense given at all.  Wipond reports, “Many attorneys asserted to me that only about 5 percent of their civilly committed clients truly meet the standards for ‘dangerousness’ established by the US Supreme Court, and Simonson and I agreed that only a tiny percentage of the cases that we saw revolved around behaviors that either of us considered truly dangerous.”  While this fails the rigor of a study, even if it’s off by an order of magnitude, that still means that half the people who are being held don’t meet the requirements for “dangerousness.”

To understand why dangerousness is essential, we need to go back to O’Connor v. Donaldson (1975) and the finding that held, “A State cannot constitutionally confine, without more, a nondangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends, and since the jury found, upon ample evidence, that petitioner did so confine respondent, it properly concluded that petitioner had violated respondent’s right to liberty.”  Conversely, in Foucha v. Louisiana (1992), the court decided that dangerousness isn’t sufficient – they must also have a serious mental illness.

The lingering problem with dangerousness is that the US Supreme Court has largely left the definition of “dangerous” to the states – who each have different standards.  In some states, like Indiana, they also include the concept of “gravely disabled.”  That is, they’re unable to take care of themselves.

Declining Treatment

A problem is that declining treatment – including unnecessary medication – can be seen as meeting the definition of gravely disabled.  Gravely disabled rests on the premise that a person is unable to take care of themselves, including basic hygiene and caring for their medical needs.  I think that few people would argue against someone who is unable to manage diabetes needing additional support.  However, in the case of diabetes, outpatient options are very viable in most cases.

When it comes to psychiatric care, the degree to which a medication is necessary comes into question.  Does the diagnosis apply?  Does the medication prescribed have clinical research that supports that it’s highly effective compared to placebo?  As we’ll see, there’s little consistency in diagnoses, and the medications used to treat these serious mental illnesses show only weak effect.

Under gravely disabled laws, courts often find that a person must take their psychiatric medication, and refusal to do so is used as evidence that they’re unable to care for themselves. In essence, the statement that you don’t have the mental illness claimed or refuse to take your medications is taken as tacit evidence that you’re gravely disabled.  It’s sort of like the tautological argument that you must be crazy to want to die by suicide.  (See American Suicide and The Varieties of Suicidal Experience.)

The medical term for an inability to see one’s own disease is anosognosia.  It’s often used as the excuse for dismissing a patient’s claims that they don’t have a disease.  The NAMI book, You Are Not Alone, speaks of it as a failure of the person rather than a situation of conflicting perspectives that should be resolved by seeking additional input.  Rather than recommending a third party evaluation, the presumption is that the patient is incapacitated – by their mental illness – and therefore can’t recognize they have it.  Few recommend another evaluation and diagnosis, because it’s quite unlikely that an additional evaluation will result in the same conclusion.

Civil Rights

Wipond shares that, since 1972, the US Supreme Court has regarded psychiatric detention as “a massive curtailment of liberty” (Humphrey v. Cady).  Why this is important is because in the US, law enforcement personnel have qualified immunity while performing their duties.  However, the immunity is nullified if it is shown that the officer acted maliciously or recklessly disregarded a person’s civil rights.  (See Undoing Suicidism for a more detailed discussion.)  The immediate detention by a law enforcement officer moves to the psychiatric professional who has no immunity and is ultimately responsible for the psychiatric detention the court acknowledged was a curtailment of liberty.

Brain Chemical Imbalance

In a 2022 Harvard Medical School article, the phrase “brain chemical imbalance” is a “figure of speech.”  However, this dismisses the decades of work that sincerely believed that there was a physical cause for mental illness – including work done by the American Psychiatric Association.  A statement made in 2013 by the chair of the DSM-5 Task Force begins with, “The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant.”  There’s been no progress that I could find since then that connects biological causes to mental illnesses.

Expansion of Mental Illness

The Diagnostic and Statistical Manual (DSM) has, according to Wipond, “barely a whiff of medical science.”  Allen Frances, the task force chair for DSM-4, in a Huffington Post article expressed concern at the broadening of mental illnesses in DSM-5.  The American Counseling Association criticized the expansion, but the most damning quote comes from Til Wykes from Kings College London: “The proposals in DSM-5 are likely to shrink the pool of normality to a puddle with more and more people being given a diagnosis of mental illness.”

Often, people share that a large proportion of those who die by suicide have a mental illness.  The number is cited at 90% or higher depending on the person.  However, as is addressed on SuicideMyths.Org, the answer is substantially smaller than that.  The primary problem is with the definition of mental illness which has clearly been expanding.  Estimates of those who have a mental illness in the US exceed 20% – before accounting for disordered substance use, which, depending on the population being studied, causes the number to rise above 50%.  Based on a 2005 study, lifetime prevalence rates of DSM-IV disorders stand at over 50%.

Maintaining the Status Quo

Frances, quoted above, also stated, “I don’t want people who need help to get disillusioned and stop taking their medicine.  The full truth is usually best, but sometimes we may need a noble lie.”  There are two problems with this statement.  First, the reason that Frances doesn’t want people to stop taking their medications isn’t clear – and second is the inherent paternalism that sits that the core of the problem.

Sudden discontinuation of many of the psychoactive medications has potential lethal consequences.  Certainly, that should cause pause and support caution in the way that we describe the value of these medications.  However, we aren’t communicating that, according to Wipond, “After five years on antipsychotics, 30 percent of patients have already developed tardive dyskinesia—permanent neurological damage that causes motor dysfunctions such as drooling, tongue-wagging, tremors, and shaking.”  I’m not saying that there aren’t some people who absolutely require their medications to be able to function – I’m just saying that if we want to expose the risks, we should do them evenly.

As William Glasser explains in Warning: Psychiatry Can Be Hazardous to Your Mental Health, the evidence for SSRIs is very weak, only beating placebo controls narrowly when the constrains are set strategically.  The truth is that a placebo – or the hope of recovery – is so powerful that it dwarfs the impact of the medication itself.  (See also The Psychology of Hope for how to encourage hope.)

The second concern is that there’s a substantial degree of paternalism in the statement.  It’s not wrong to encourage good behaviors, but disguising the evidence crosses that line.  (See my reviews of Nudge, Happier?, and Undoing Suicidism for more about paternalism.)  It seems to me that paternalism, as it relates to smoking or alcohol use, stands on firm ground.  Paternalism around continuing to take medications that have serious, long-term consequences and questionable efficacy is very shaky ground.

Psychiatric Diagnosis Fiction

The editor of the DSM-5, Columbia University psychiatrist Michael First, acknowledged that labeling people as having particular mental disorders has “no firm basis in reality.”  What would cause someone to reach that conclusion?  A large part of it is the reliability problem with DSM-5.  Reliability refers to the ability for two independent people to produce the same assessment.  On this basis, the DSM-5 doesn’t do well.  Even the title, “DSM-5: How Reliable is Reliable Enough?,” betrays the problem that the same presenting patient will be given different diagnoses by independent evaluators.

Checkboxes

Unlike the immensely valuable checklists championed by Atul Gawande in The Checklist Manifesto, checkbox behaviors cause people to be harmed.  Rather than ensuring that every step is completed faithfully, checkbox behaviors look for the shortest path to diagnosis.  Once someone scores enough “points” to be considered for a diagnosis, the evaluator stops, adds the label, and moves on.

Their behaviors are encouraged by psychiatric assessments that identify people at a substantially higher rate than even the designers of the tools believe are true.  However, two of the three frequently used tools, the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) survey, were underwritten by the drug company Pfizer.  Higher false-positive rates are good for business.  (See Rethinking Suicide for more about false positives.)

Prediction

What the public wants is for highly accurate prediction of the risk to which someone is to themselves and to others.  However, both are problematic.  On the suicide front, the ability for trained clinicians to predict short-term suicide risk is only slightly better than chance – and few clinicians have this level of training.  (See Rethinking Suicide.)

On the danger to others, the same predictive problem exists.  The US Supreme Court in California v. Ramos (1983) decided that predicting dangerous was difficult, but not impossible – and, strangely, a job for the jury. “The possible commutation of a life sentence does not impermissibly inject an element too speculative for the jury’s consideration. By bringing to the jury’s attention the possibility that the defendant may be returned to society, the Briggs Instruction invites the jury to assess whether the defendant is someone whose probable future behavior makes it undesirable that he be permitted to return to society, thus focusing the jury on the defendant’s probable future dangerousness.”

Another curious decision by the court in Barefoot v. Estelle (1983) states, “Moreover, under the generally applicable rules of evidence covering the admission and weight of unprivileged evidence, psychiatric testimony predicting dangerousness may be countered not only as erroneous in a particular case but also as generally so unreliable that it should be ignored. Nor, despite the view of the American Psychiatric Association supporting petitioner’s view, is there any convincing evidence that such testimony is almost entirely unreliable, and that the factfinder and the adversary system will not be competent to uncover, recognize, and take due account of its shortcomings.”  What makes this so curious is that the court completely discounts the American Psychiatric Association – who one would reasonably presume are the experts in psychiatric matters – only to insist that experts should be able to predict dangerousness in a way the association insists isn’t possible.

These cases, of course, predate the more recent standards of evidence.  However, their existence is a roadside attraction left to be reclaimed by the elements sending a clear message of the journey we’ve been on to uncoil the snake of psychiatrists who choked the life out of so many innocent people.

Housing Fourth

One policy approach is to work towards getting people stable housing first.  While the definition of stable housing can vary, conceptually, it’s having at least basic assurance that there will be a warm bed for the person.  Detractors of this approach cite the character of the people and their behaviors that have led them to their current situation.  The detractors see these problems as personal failings rather than systemic issues that lead some people into a downward spiral.

The alternative is what is called “housing fourth.”  It insists that people resolve their issues first and only then will they receive guaranteed housing.  I mentioned above that much of what we think about substance use disorder is wrong – and based on a fundamental misunderstanding of the “Rat Park” experiment.  There’s plenty of evidence that increasing shame and guilt creates an even greater need for and dependence on substances to make the world more tolerable.

Anne Case and Angus Deaton in Deaths of Despair work through, in greater detail, how the systems of capitalism create challenges for those near the bottom of the socioeconomic stack.  However, they don’t cover Wipond’s point that sometimes people exist outside the system.  Underage runaways aren’t able to get housing or a job.  That forces them into places where they have to find ways to survive outside the system.  These runaways may be escaping their parents or the foster care system – so there’s no way to get their approval for housing or jobs.

We shouldn’t continue to tolerate destructive behavior – but we can’t expect it to change unless we’re willing to change the conditions and pressures on people.

Funnels Leading to Detention

If people are detained against their will, how do we end up there in the first place?  There must be a mechanism whereby people are led to the place where someone decides to hold them.  It turns out one of those funnels is wellness checks.  You can, as a concerned citizen, ask for the police to check on the welfare of another person.  These checks often result in some kind of action.  It can be that they result in a hospital stay – and perhaps a psychiatric hospital stay.

However, wellness checks aren’t the only funnels towards involuntarily detention.  Sometimes it’s a call the person places themselves to 988 – or, formerly, to the National Suicide Prevention Line (NSPL).  Wipond shares that about 2% of these calls result in some sort of police response.  That’s particularly frightening when you consider that the average call length is 10 minutes.  We’re back to the prediction problem.  Certainly, the response rate shouldn’t be zero.  Some people will call and then welcome an in-person response.  The issue is the fact that people believe these lines are anonymous, and many come to find out that they’re not.  They find that information the police would have been required to get a warrant for is readily available to 911 operators – and the relationship between 988 and 911 operators isn’t clearly articulated.

One of the final pathways to detention are the programs that encourage laypeople to drive others toward getting help.  Like most things, it’s not bad to encourage people to get help.  It’s bad when the people that you’re referring them to have a profit motive.  For instance, Mental Health First Aid is run in the US by the National Council on Mental Wellbeing.  It’s a lobbying group for 3,500 treatment providers.  There may be a reason to consider their motives in what is being taught.

Moral Calculus

Albert Bandura’s tome Moral Disengagement explains what you do if you want people to behave in ways that are against their morals.  (See also The Righteous Mind for the foundations of morality.)  One of the ways that people can live with themselves is to believe that “we help more people than we hurt.”  They cannot ignore the fact that people are harmed by involuntary commitment – so they must use different moral calculus.  (See How We Know What Isn’t So for more on being forced to accept the truth.)

There are two problems with the statement.  First, the magnitudes of help and harm aren’t known.  Second, the frequency of both help and harm aren’t known.  So, we cannot know whether the net impact of these coercive processes are helpful or harmful.  Too many of us are looking at the research and conclude that we need to find a different balance.

Don’t Just Say No

In my formative years, Nancy Ragan surrounded herself by youth who would shout, “Just say no.”  This anti-drug campaign had a lot going for it.  The problem is that it didn’t appear to have any impact.  It fundamentally ignored the complexity and social pressures involved in the moment.  Conceptually, the decision is simple, but anyone who has been a teenager knows that the decisions aren’t that simple when peer groups are involved.

Scared Straight and Drug Abuse Resistance Education (DARE) were similarly ineffective – or, rather, slightly harmful.  They used fear and shame as the levers to change behaviors – but those are precisely the wrong levers to use when we’re talking about people’s mental health.

Going Back to the Trauma Roots

There seems to be at least some degree of consensus that there’s a causal relationship between trauma and mental illness.  Certainly not everyone who encounters trauma will develop and retain a mental illness – but trauma seems to lead to mental illness.  The greatest tragedy of confinement is that, rather than helping the person deal with their prior trauma, we heap on more.

Forced Treatment Doesn’t Work

In the end, the real problem is that, by-and-large, forced treatment doesn’t work.  It’s not that it’s never helpful.  It’s that it’s rarely helpful.  Given the chance of inflicting harm, we should be thinking more carefully and putting more protection in place.  Perhaps the starting point would be to address when Your Consent is Not Required.

Book Review-Affective Neuroscience: The Foundations of Human and Animal Emotions

This book earns the title for the longest time between starting to read it and finishing it.  Affective Neuroscience: The Foundations of Human and Animal Emotions is packed with information on a hugely important topic.  Generally, since Rene Descartes, we’ve focused on the impact of reason, but evidence points to the idea that it isn’t reason that’s king – it’s emotions.  (See Descartes’ Error and The Righteous Mind.)  The critical and underappreciated importance of emotions meant better understanding them was essential, and the material was deep enough that I had to be in special places and times to give it the attention it deserved.

The Causal Arrow

Before we can explore emotion and how it functions in the brain, it’s important to address the common misbelief that reason is in charge.  Jonathan Haidt’s Elephant-Rider-Path model, as discussed in his The Happiness Hypothesis and by Dan and Chip Heath in Switch, makes it clear that our reason, the rational rider, is only in charge when the elephant, our emotions, aren’t engaged.  In The Righteous Mind, Haidt goes on to explain that what we call “reason” really acts like a press secretary justifying the decisions that have already been made.

Daniel Kahneman reaches a similar conclusion from a different direction.  In Thinking, Fast and Slow, he explains his model of two systems.  System 1 is the automatic pattern matching that we use to navigate our days, and the more glucose-expensive System 2 makes our rational decisions.  System 1 is the same system from which we get our emotions, and Kahneman explains that it can “lie” to System 2 – or not engage it when it’s appropriate to.  In short, System 2 is subject to the rules of System 1.  Reframed in Haidt’s language, the rider only goes where the elephant wants to go.

For some, accepting that our reason and rational consciousness doesn’t have the control we believed it had our whole lives can be difficult.  It can be hard to accept that what we think of as “self” is just the tip of the cognitive iceberg.  However, work from many different directions seems to agree that this is the case.  Even Charles Duhigg explains that the reason comes after the action in The Power of Habit.

Genetics and Epigenetics

The science of genetics is well established.  We know that certain traits are inborn.  Our eye color is determined by the genes of our parents and random probabilities.  Other traits are impacted not just by our genetics but also by the environment that people live in.  It’s become more accepted that we can have genes in our biology that are activated or deactivated by our experiences.

From a genetic point of view, lab-raised rats who had never met a cat showed remarkable differences in their play after being introduced to cat fur.  Cats are, of course, a natural predator of rats – but not the rats who were born in the lab.  Somehow, the exposure to cat fur was recognized by even those with no experience with cats.  This and other experiments show that we have certain genetically transmitted fears.

Toxoplasma gondii is a microbe that has an interesting neurological trick it plays for replication.  It suppresses the fear of cats in rodents that have it.  This causes the rodents to be eaten by the cats.  The Toxoplasma then infects the cat as well as other mice that come in contact with the cat’s stool.  (See The Neuroscience of Suicidal Behavior for more on Toxoplasma gondii.)  Thus, it’s possible to change items even if they’ve been laid down by genetics.

Robert Sapolsky in Why Zebras Don’t Get Ulcers shares the famous adverse childhood experiences (ACEs) study and the impact that childhood traumas have on the long-term health of humans.  This was a landmark study in increasing understanding about the impact of epigenetics, which means “above” or “over” genetics.  This and other studies began to shed light on the ability for genes to be expressed differently based on current and historical environments.

Sapolsky also notes the work of David Barker, who discovered what is now called fetal origins of adult disease (FOAD).  This work demonstrated that even stress to the mother during pregnancy can have long-term consequences for the baby’s health.

Judith Rich Harris in No Two Alike and The Nurture Assumption explains how neither genetics nor good parenting can guarantee that a child will end up a certain way.  There are too many uncontrolled variables that are enabling and disabling genes.  There are too many conversations that you can’t be in the room for.  There are just too many things to expect that you can control the development.  Instead, we’re encouraged to do the best we can and recognize that even our best efforts may not generate the results we want.

They Made Me Feel

One of the common – but incorrect – statements that people make when they’re in an argument is, “You made me feel…”  It’s usually a person who has been hurt trying to connect their feelings to the actions (words or deeds) of another person.  In some cases, we can draw the connection between the actions and the resulting feeling.  In other cases, it’s harder.  Even in those times when the resulting feeling makes sense given the actions, that doesn’t mean that one person can cause another person to feel a certain way.  If it were possible, it would be a dangerous power for others to have.

Our feelings are, necessarily, a cognitive process that relies upon our experiences and our biology.  They are subject to our desires and our whims.  While one person’s actions can influence our feelings, they cannot directly cause us to feel a certain way or another – ultimately, we own our emotions.

I can hear it now.  “But you don’t know what they did.”  That’s true – but it really doesn’t matter.  We’ve met those people who have come out of a divorce happier than when they were married.  Infidelity and irresponsibility aside, they are happy that they can start on the next chapter of their life.  If people can choose their attitudes they find themselves divorced by a betrayal by the other person, can’t we choose our attitude when someone slights us?

One of the most common feelings that we ascribe to others is anger.  “You made me angry.”  They could have done something (or not done something) that we are angry about – but that doesn’t mean they made us angry.  There’s an intervening internal process.  Our process includes the judgement that we make about others’ behavior and how they might have violated it.  (See Emotion and Adaptation.)  This judgement is ours – and the disappointment it triggers is the precursor to anger.  Anger is just one example where our processing of the information creates the feeling – not the actions (or inactions) themselves.

It’s important, in a book titled Affective Neuroscience, to understand that it’s the way we process the world that creates our emotions and the meaning we take from it.

Emotions and Reason

Fundamental to cognitive behavioral therapy (CBT) is the awareness that our thoughts, emotions, and moods are intertwined.  When we think about something, we change our emotions, and our emotions change our ability to think.  (See Drive.)  If we were to think about the neurons that make up our brains as a very large and three dimensional spiderweb, when we tread on one of the strands, the other strands move, adjust, and vibrate in ways that cannot be isolated.

No doubt this is why Jaak Panksepp proposes that both behavior and reason are both linked to emotional arousal.  He suggests that there is probably no emotional state that is free of cognitive ramifications.  He goes on to say, “There is no emotion without a thought, and many thoughts can evoke emotion.”

Spontaneous Facial Expression of Emotion

Panksepp says, “The fact that the face spontaneously expresses emotionality is not controversial.”  At the time of publication, that was true.  In 1998, when Affective Neuroscience was first published, it was an established fact.  Lisa Feldman Barrett in How Emotions Are Made does, in fact, challenge this premise.  More broadly, she directly challenges the work of Paul Ekman.  (See Nonverbal Messages, What the Face Reveals, Telling Lies, and Emotional Awareness for his work.)  I agree with Panksepp’s perspective and don’t believe Barrett’s concerns about this are particularly warranted.

The spontaneous facial expression is important to the discussion of rationality and neuroscience, because the amount of time rational processing takes exceeds the time that these facial expressions are shown.  In other words, there must be multiple pathways from emotions – and not all of them are typically under conscious control.  When the spider web of our neurons makes sense of something that has an affective component, we may show it on our faces before we’ve been able to process it.

Overwhelmed

Panksepp says, “To be overwhelmed by an emotional experience means the intensity is such that other brain mechanisms, such as higher rational processes, are disrupted because of the spontaneous behavioral and affective dictates of the more primitive brain control systems.”  In part, this statement is an echo of Kahneman’s statement in Thinking, Fast and Slow that System 1 can lie to System 2.  However, there’s more to the statement in terms of the impact of being overwhelmed.

He doesn’t talk about the psychological defenses that we automatically deploy when we’re overwhelmed.  We can temporarily use compartmentalization to say that we’re not able to process all the emotion at the moment.  Nor does he discuss dissociation – the “not me” defense that can leave us feeling as if we’re watching the scene from outside our body.  (See Traumatic Stress and Trauma Therapy and Clinical Practice for more on compartmentalization and dissociation.)

With or without defenses, Panksepp is speaking about trauma.  Trauma, as he describes, opens the door for long-term serious mental illness.  (See The Myth of Normal for more about the relationship between trauma and mental illness.)

Four of Seven

Panksepp proposes that there are seven major emotional-behavioral-motivational systems in humans.  Four of them are:

• Seeking – This system drives the desire to explore, investigate, and find rewards, essentially the motivation to actively pursue something
• Panic – Associated with feelings of separation anxiety, loneliness, and distress when feeling disconnected from a caregiver or social group.
• Rage – Represents anger, aggression, and the urge to fight back when threatened or frustrated.
• Fear – The basic emotion of anxiety triggered by perceived danger, leading to “fight or flight” responses.

The remaining three are lust, care, and play.  Panksepp believes that it’s these systems that are the major systems that direct behavior in animals (including humans).

Reiss wrote about 16 motivators in Who Am I? and The Normal Personality.  These motivators don’t track to Panksepp’s systems directly, but they don’t contradict them either.  One of the challenges with trying to isolate the major motivators is that the frame that you look at the problem defines the problem.  Approaching from the neurobiological point of view often leads to different answers than when viewed from the behavioral perspective.

Distributed Parallel Processing

At the dawn of the computer revolution, most computers were made up of a central processor with a wide array of supporting electronics to take input, buffer data, and perform other operations while the central processor was too busy.  Mainframe computers boasted great overall processing capacity with limited amounts being able to be used.  The rise of the personal computer focused on one central processor with fewer supporting processors – but still many.  Eventually, personal computers gained multiple processors of equal performance.  The move to multiple processing went even further as video cards began supporting graphics processing units (GPUs) that could do hundreds of computations simultaneously.  (GPUs should really be called math processing units.)

While we can trace the changes in computer technology and identify which periods focused on a single central processor and which leveraged more distributed processing, we cannot make such a delineation for brains.  Every brain, from the lowest level to the highest order of thinking, fundamentally processes signals in a parallel and networked kind of way.

“A single neuron typically receives input from thousands of synapses.”  In other words, there’s no one signal that creates one output.  Instead, there’s a collection of inputs and conditions that drive an output of a neuron.  It’s one of the reasons why our simplistic, causal reasoning doesn’t hold up.  Neuroanatomically, there is no one cause to create a single neuron firing and therefore a single thought and a resulting single behavior.  It’s an illusion that serves us.  It helps us take in an overwhelming world of information and cope with it based on our limited capacity.  (See Thinking, Fast and Slow.)

Specialized Skin Tissue

What people rarely consider when thinking about our brains is that they are formed by a specialization of the embryonic ectoderm – the outermost layer of the embryo.  It specializes into many different organs, most notably the brain.  This understanding is important, as we often downplay the role our skin plays in our cognition.  Our brains are made of the same stuff as our skin, and we retain a deep connection to the signals that our skin provides to the brain.

Kindling

One of the challenges in studying the brain is the lack of indication of the underlying function.  A structural review of the brain often doesn’t reveal clear indications for why someone does – or does not – behave in a particular way.  Instead, there seems to be a yet unseen organization of information that doesn’t surface in a structural view.

Consider a process called kindling, where a targeted electrical stimulation is applied to the brain.  Once the electrical stimulation has occurred (a few times or even once), the brain will be particularly sensitive in that area – either by further direct electrical stimulation or natural activation of that area of the brain.

What makes this sensitivity interesting is that it doesn’t appear to be caused structurally.  There are no specific structural changes that can be identified – and thus the brain is both changed and unchanged at the same time.

Chemical Manufacturing

In some ways, our bodies – and our brains – are quirky chemical factories.  They crank out long chains of amino acids that are sliced up by enzymes into shorter chains of useful amino acids.  The whole process is a dance between the creation of the large and the targeted reduction into useful tools.  The complexity of this process means that if any part of the process gets out of balance, it can shift the availability of the neuropeptides – which has incalculable shifts in emotional processing.

Complicating this process is that the amino acids created by our bodies can have components that are consumed by different areas of our body.  Without a map, we can only guess the impact of a surplus or deficiency of these chemical messengers.

Blood-Brain Barriers

Our brains don’t have blood circulating through them.  Blood is kept out of the brain while vital amino acids and nutrients are allowed through.  Drug manufacturers are constantly trying to find ways to penetrate the blood-brain barrier to deliver pharmaceuticals to the neural tissue.  Obviously, many substances have psychoactive results.  However, in general, the blood-brain barrier – made of cells similar to our skin – is designed to enable only the “approved list” of things through.

The blood-barrier is a necessary protection and creates a challenge for the power hungry brain.  There’s a maximum rate of transfer – including for the transfer of glucose – and this can sometimes starve the brain when there has been sustained high consumption.  (See The Rise of Superman.)

Stimulating Governing

Imagine your doctor telling you to get your six-year-old child to like coffee.  You’d arrived with the problem of your child’s hyperactivity, and by now you’re scratching you head and wondering if your doctor had heard you right or if they have something seriously wrong with them.  This paradoxical recommendation for caffeine or other stimulants to address hyperactivity can be explained when we realize that there is a part of the child which is insufficiently activated.

It’s believed that children with hyperactivity may have insufficient cortical arousal and thus have less impulse control.  The psychostimulant (in this case, caffeine) increases cortical arousal and creates the capacity for decreased activity – because of a stimulant.

Defining Stress

Robert Sapolsky took a whole book to explain stress from an animal and human behavior perspective.  In Why Zebras Don’t Get Ulcers, he focuses on the biological impact of stress.  Panksepp offers a reason why approaching stress from a biological perspective is easier: “Psychologists have traditionally had a difficult time generating a satisfactory definition of ‘stress.’ In psychobiology, it is much easier: Stress is anything that activates the pituitary-adrenal system (the ACTH-cortisol axis).”  However, what this perspective doesn’t explain is why some people are stressed and others are not in the same circumstances.  It also doesn’t explain why some stress is good – and even necessary – while other stress can be harmful.

Mihaly Csikszentmihalyi’s work on flow may answer the first question.  Csikszentmihalyi discovered a psychological state that is highly productive, which he called flow.  (See Flow, Finding Flow, and The Rise of Superman.)  His critical observation is that flow exists in a narrow band where challenge and skill are balanced.  If the challenge far exceeded the skill, anxiety (and stress) would result.  If the challenge were insufficient, people would be bored.  Thus, the answer to why some people are stressed in a situation while others are not may hinge on their skill.

It’s important to qualify that, for Csikszentmihalyi, experience that was converted into inherent, tacit understanding still counts as skill.  Gary Klein’s internal models of situations and how they work that drive recognition primed decisions are a skill – and one that isn’t easy to teach.  (See Sources of Power and Seeing What Others Don’t.)  As a result, in most cases, the more experience we get with something, the less stress it will induce.  Trauma and the reinforcement that can happen is a notable exception.  (See Traumatic Stress.)

Nassim Taleb explains in Antifragile how we need stress to help us become stronger.  The stress needs to be the right kind, at the right intensity, and at the right time – but it’s essential to our growth.  In How We Learn, it’s called desirable difficulty.  We don’t remember well those things that we don’t try hard to learn.  The more that there is difficulty associated with our learning, the more we learn.

Stress Kills Brain Cells

Panksepp shares, “The neurons that contain the cortisol receptors can tolerate only so much stimulation. If cortisol secretion is sustained at excessive levels, the metabolic resources of hippocampal neurons become depleted and die prematurely. In short, a sustained stress response can kill certain brain cells!”  This is nearly identical to Sapolsky’s language in Why Zebras Don’t Get Ulcers.  Sapolsky goes on to explain how we’ve subsumed a process of stress and fear that was designed for short term use to deliver us to safety instead of the belly of a beast.  Instead of fearing the lion, our unique human gift of seeing into the future allows us to fear losing our job, our house, or relationships, and a variety of other things that threaten our psychological survival if not our physical survival.

The physical and neurological impacts of sustained stress are why we need to learn to manage our stress response.  Matthiew Ricard in Happiness encourages meditation, as does the Dalai Lama.  (See The Book of Joy and The Dalai Lama’s Big Book of Happiness.)

Dreams

Our brains take in overwhelming amounts of information while we’re awake.  We’re bombarded with visual and auditory information while needing to attend to our internal state and our sense of touch, smell, and taste.  Much of what we encounter isn’t processed in the moment.  Instead, during our sleep, we process our days, develop our long-term memories, and perform sense-making to the day.  This is why sleep is critically important for learning and for our health in general.

Dreams are what we experience while post-processing our days in REM sleep.  As Freud recognized, dreams are “windows to the soul.”  Panksepp expresses it this way: “Dreams tell us the way we really think and feel, not the way we pretend we think and feel.”  While we are conscious, we can delude others and ourselves as to what our beliefs are.  (See Immunity to Change for more on our ability to hide what we really believe while awake.)  Our dreams are unfiltered expressions of our true beliefs.

Schizophrenic Break

If you’ve never been around someone who has had a schizophrenic break – a disconnection from reality – I don’t recommend it.  It’s unsettling to see how someone can exist in reality and yet be so disconnected from it.  From a neurological point of view, schizophrenic breaks are interesting because, for the most part, “Schizophrenics do not exhibit any more REM than normal folks, except during the evening before a ‘schizophrenic break,’ when REM is in fact elevated.”  REM refers to the rapid eye movement (REM) phase of sleep.

Sleep helps us process our day and the information we’re taking in – both from our internal states (see How Emotions Are Made) and our external environment.  What the research seems to say is that, prior to the break, we see their minds struggling to find ways to make sense of the information that it’s receiving.

Slow-Wave Sleep

Slow-wave sleep (SWS) is an even deeper form of sleep than REM sleep and performs another important function.  Where REM sleep seems to be primarily integrating a day’s experiences, SWS seems to be designed to allow for bodily repair.  It seems to be when the body is the most relaxed and when the body’s natural repair systems are the most active.

It’s important to recognize that not all sleep is REM sleep.  Sleep is a like a layer cake, stacked from SWS and REM sleep to necessary but less restorative phases of sleep.

Love and Marriage

While it’s common to believe that we are totally monogamous by nature, Panksepp argues against this notion: “Indeed, it seems likely that human bonding is not totally monogamous by nature, but our neurobiology is compatible with long-term serial and parallel relationships.”  This is, of course, consistent with Helen Fisher’s work, Anatomy of Love.

Amygdala

Most people associate the amygdala with emotion.  It’s associated with fight or flight and a host of other basic – limbic – responses.  Panksepp explains, “The main reason the amygdala may appear to be so important in generating affect may arise largely from the fact that most emotional episodes in adult animals are closely linked to learning and cognitive appraisals.  These are the types of emotional stimuli that converge on the amygdala.”  In short, it’s implicated because all “neural roads” lead to it.  However, there’s much more involved in Affective Neuroscience.