Readings in Humanistic Psychiatry
“The person who tries to live alone will not succeed as a human being. His heart withers if it does not answer another heart. His mind shrinks away if he hears only the echoes of his own thoughts and finds no other inspiration.”
How strange that Ms. Buck’s view of loneliness would turn out to be true on a basic neurological level so many years after she wrote these words. For neurobiologists are now learning that loneliness does, indeed, have profound effects on brain structure and functioning.
Human beings are troop primates by nature. When we are faced with prolonged loneliness it goes against our primal impulses to be a part of a group. The brain reacts to loneliness as an emergency situation. The hormones of our stress response- the glucocorticoids- are kept at an elevated level. On an unconscious level we essentially prepare our bodies to travel in search of other humans.
Those glucocorticoid hormones have widespread effects on our brains and bodies. The stress hormones oppose the actions of insulin. Weight gain, abdominal obesity, and Type II diabetes become more likely. The resultant abdominal fat secretes hormones of its own and those hormones predispose people to anxiety and depression.
Researchers have also discovered that lonely people tend to sleep poorly. Adequate sleep is necessary for the healthy functioning of one of the most important brain areas involved in emotional wellbeing- the hippocampus. This crucial structure manufactures new brain cells every day in response to a protein called Brain-Derived Neurotropic Factor ( BDNF). Our antidepressant treatments work though this pathway.
When people are depressed their hippocampi may shrink by almost 20% and recovery involves building new brain cells here. In the schizophrenic illnesses the hippocampi are often small and misshapen from birth. Patients with Borderline Personality Disorder also commonly have mal-structured hippocampi - often in response to emotional traumas suffered while their brains were developing.
We’ve learned that both poor sleep and prolonged exposure to glucocorticoid hormones reduce BDNF levels. Interestingly, lack of physical exercise and living in unstimulating environments have exactly the same effect. So if we truly want to optimize the mental health of our mentally ill citizens we must find ways to provide them with the things that their brains require on a fundamental level. They need mentally stimulating activities, physical exercise, healthy diets, adequate sleep, and freedom from excessive stress hormones. And, most of all, they need to feel that they are connected with other humans.
Of course, loneliness and social isolation are not confined to people with severe mental illnesses. While technology has provided degrees of communication that would have been unthinkable fifty years ago, at the same time we are becoming more alone. The tightly-knit family groupings that have always typified humans have been replaced by casual electronic relationships with relative strangers. Just because we don’t yet understand the long-term effects of such changes on our brain functioning doesn’t mean that they aren’t important.
Non-psychiatric physicians encounter the effects of loneliness on their patient’s physical health all of the time but these are not always readily apparent. Common manifestations include difficulty stabilizing blood sugars with conventional diabetic regimens and persistent complaints of insomnia. Some clients will abuse alcohol or other drugs in efforts to deal with the pain of social isolation. And depression itself may present in myriad “medical” ways: unexplained bowel problems, weight loss or gain, fatigue, pain, and heightened anxiety are all commonly encountered.
While busy primary care physicians can’t be expected to function as therapists or social workers, when patients don’t respond to conventional treatments in conventional ways it’s always wise to inquire whether there are psychosocial factors- such as profound loneliness- that might stand as impediments to successful treatment. A tight focus on medication treatments alone may result in escalating dosages of diabetic meds, sleeping pills, or analgesics when the company of other humans is actually what is needed.
Even a casual observer of our current mental health system will immediately recognize that we have a problem here. Many of our clients cannot provide these essential social commodities for themselves and we have not, historically, done a good job of helping them in these areas. Far too many of our mentally ill people live extremely isolated lives. They have no sense of belonging to a greater community. And their loneliness cuts them off from one of the single healthiest factors for their brains; Laughter reduces the effects of those toxic stress hormones in ways that none of our medications can replicate.
“What should young people do with their lives today? Many things, obviously. But the most daring thing is to create stable communities in which the terrible disease of loneliness can be cured.”
Like Ms. Buck, Mr. Vonnegut must have had a real intuitive sense for neurobiology. For this is exactly what we must accomplish as a society. There is a widespread tendency to believe that the advances in the treatment of the mentally ill will come in the form of new and improved medications yet the most effective pills for the major mental illnesses have all been around for decades. The real breakthroughs in treatment will come, instead, in the form of specially designed living environments that will provide our clients with the things that their brains so vitally need. And the things that they have such a hard time obtaining for themselves. This is precisely what Touchstone Mental Health is trying to accomplish with the creation of our model community for the mentally ill, the Rising Cedars facility.
Rising Cedars is a new 40 unit assisted-living facility for people with severe mental illnesses. Each client will have an independent apartment that they can call “home’ but congregate dining and activities are offered as well. Lounges and common areas are set up so that people will be able to have privacy when they need it and opportunities for socialization when they want it.
On-site medical and psychiatric care will be combined with a Wellness Center that will provide a variety of complementary therapies, groups, educational activities, and physical exercise. Work, healthy diets, reliable transportation, horticulture, and ties to existing community supports are all essential elements of the program. When people are in need of increased services we plan to bring them right to the client’s residence rather than continually move them back and forth from psychiatric hospitals based on fluctuations in their clinical condition.
This novel program is based upon principles and ideas that were initially elaborated in the “Truly Insane?: How to Fix America’s Broken Mental Health System” section of this website. Among those principles is the common-sense idea that we should directly involve our clients when we are designing housing or supportive programs for them. Over a thousand suggestions for the development of this facility were solicited from clients and staff in Touchstone’s existing programs. Project for Pride in Living, the Urban Works architectural firm and The University of Minnesota College of Architecture all helped to create a physical environment that will be as close to optimal as we could make it. Hopefully this program will serve as a template for a new generation of residential facilities for the mentally ill and will, ultimately, change the way that severe mental illnesses are conceptualized and treated for decades to come.