What causes all this pain and distress?
Wouldn’t we like to know what “causes” our thoughts, feelings, and psychological experiences? What “causes” our behaviors, opinions, and personality? What “causes” our current state of mind and our view of the world? What “causes” us to be sad or happy, anxious or calm, pessimistic or optimistic? Wouldn’t that be useful information, both for ourselves and for anyone trying to help us? Could anything be more useful to know . . . and, unfortunately, less possible to know? Isn’t it likely that we may gain a better understanding of the nature of the universe than the causes of one human thought or feeling? We would love to know what causes all things human—but can we ever know?
First of all, what do we mean by “cause and effect”? Cause and effect are far from simple concepts. What’s the difference between a cause, a factor, an influence, and so on? When is a single cause necessary and sufficient to create a certain effect? In classical philosophy the subject is usually taught by beginning with Descartes’ example of one billiard ball striking a second billiard ball. The first billiard ball “causes” the second billiard ball to move. This might be thought of as the strict or simple sense of “cause and effect.” In this example one thing is clearly linked to another thing in a logical, proximate, and seemingly singular and sufficient way.
However this sort of explanation never tells the whole story, since it is always possible to raise the question, “But isn’t whatever caused the first ball to move the real reason that the second ball moved?” Indeed, you could wend your way back to the big bang and beyond in what is called infinite regression. Second, is this cause really sufficient for this effect to happen? What if the second ball were glued to the table? The first ball caused the second ball to move only because the second ball was free to move. Still, despite these many technical difficulties, this is what we most often mean by cause and effect: that one thing logically, proximately, singularly, and sufficiently caused another thing to happen.
A reasonable example of “strict causation” might be little Bobby falling out of a tree and breaking his arm. The fall caused the break. This appears straightforward enough. But the simplicity of this picture vanishes the instant we decide to focus our attention one place or another. We can identify multiple causes of anything just by virtue of the direction of our gaze, the nature of our questions, and the categories that we decide to create and include, and this is abundantly true with little Bobby and his fall.
If I ask you, “What caused Bobby’s broken arm?” you might reply in any of the following ways, all of which imply one or another spin on cause and effect: “He’s a reckless rascal,” “Being a boy,” “Fury at our divorce,” “The ground,” “Bad luck,” or “Gravity.” In addition, if you are playing the current illegitimate mental disorder naming game that I’ve described previously, you might also include “attention deficit hyperactivity disorder” or “childhood depression.” Each of these is a different explanation as to what really caused Bobby’s broken arm.
How you choose to look at the matter may have great consequences for little Bobby. If you go with “bad luck,” Bobby may have full permission to keep climbing trees. If, however, you go with “reckless rascal,” you might punish Bobby and curb his tree-climbing exploits. If you go with one of the mental disorder labels, you might agree to have Bobby put on one or more powerful chemicals. These differences matter to Bobby. In the first case we have a Bobby who is free to keep climbing trees, in the second case we have a restricted Bobby who may pine for climbing and grow distressed at his lack of freedom, and in the third case we’ve created little patient Bobby with a mental disorder label and a regimen of powerful chemicals with powerful side effects.
Then there’s the important matter of what effect you choose to look at. You might treat the fall as the effect of interest—the broken arm might grab your attention. But you might instead find it more telling to examine what happened after the fall. If you do that then the fall becomes a cause, not an effect, and it is what happens next that is the attention grabber. Why was Bobby afraid to tell his parents about his broken arm? Why did no one take Bobby to the doctor until the next day? Why is Bobby blaming himself for what was probably an accident? By asking questions of this sort you announce where your interests lie. The broken arm you chalk up to gravity; it is what happens next that interests you.
The next complication is that an effect is also a cause and a cause is also an effect. Say that you hate your job, and that produces distress. That distress is an effect. But that distress, existing as pestering thoughts, ambient anxiety, hormonal activity, and so on, affects your system and causes everything from insomnia to stomachaches. The distress is an effect of your job situation and also a cause of your insomnia. Of course, “ultimately” what is causing both the distress and the insomnia is the fact that you hate your job: but still in this chain of cause and effect, and in every causal chain, effects are causes and causes are effects. If we try to separate out “things that are causes” and “things that are effects” we will have oversimplified the matter and hurt our chances of understanding the complicated nature of causal chains in human affairs.
Who knows what the “real” or “ultimate” cause is of anything human? For example, the “real” cause of your fear of dogs may trace all the way back to an actual incident with a dog in childhood, a fear reinforced by all manner of “causes and effects” since then. Now each encounter with a dog “causes” you to panic. However, it is not so much the current dog barking at you that is the “real” cause of your terror but your experience with that “first” dog. But is that even right? Why did that first dog frighten you? Was there already something in your original personality primed to react negatively to a barking dog? Maybe the “real” cause is completely odd and oblique; maybe your fear has something to do with bared teeth, drool, or who-knows-what and not dogs at all. Who could ever say for sure?
I hope you can feel the tangle here and experience the first tendrils of overwhelm. You can see why, if I am tasked with helping you, I might be inclined to quickly offer you chemicals. You can see why I might invent some “most important thing to look at”—say, your dreams—so as to not have to look at all the rest. You can see why I might be inclined to repeat the incantation, “And how did that make you feel?” in lieu of knowing what else to say. You can see why I might accept your version of the story—say, that the pestering of your elderly mother is causing your current sadness—even though I suspect that your formed personality, which prevents you from entering into relationships or venturing out of the house, is the more real cause. All of these are infinitely easier ways to proceed than trying to discern what is “really” causing your distress.
In a medical or biological model, we have some reasonable ways of talking about cause and effect. A virus or a bacterium causes certain effects like fever and nausea. We then treat the cause, the virus or the bacterium, with one sort of medication. We may also treat the effects—the fever and the nausea—with other medications. In this model it is easy to talk about cause and effect, easy to understand how “symptoms of the illness” can be rightly considered effects that can be separately treated, easy to understand how the cause itself might be prevented and no longer troublesome to the species by virtue of, say, vaccines or water purification. While this is an oversimplification of how medicine actually works, it is not such a terrible distortion of the process.
Nothing like this can go on with mental health. We can dream of it going on—we can dream of finding the equivalent of infections that produce sadness and the equivalent of vaccines that will inoculate us against sadness—but that is a pipe dream. We can dream of finding the equivalent of bacteria that cause us to experience life as a cheat and the equivalent of medications that cure us of experiencing life as a cheat—but that is a pipe dream. You can see clearly why mental health professionals—unlike medical doctors who really must deal with the complications of cause and effect if they want to make accurate diagnoses—would want to wash their hands of cause and effect. Who wouldn’t want to avoid this particular morass?
Let’s put some additional difficulties on the table before we try to answer the question, “How should we proceed?” All of the following challenges confront us when we investigate how “cause and effect” operate in human affairs.
The challenge of discerning differences in effects
Is one sadness the same as another sadness? Are there differences among sorrow, grief, mourning, and despair? Can we discern differences in effects such as these that lead us to identify different causes? In medicine we regularly can. A certain sort of arm fracture suggests child abuse, and a different sort of arm fracture is congruent with falling out of a tree. Someone trained and experienced in these matters knows to look for these differences and can discern these differences. But in our sphere, and whatever her training, intuition, and wisdom, how good a job can a human experience specialist be expected to do in discerning some difference between, say, one expression of sadness and another? Given that there are no x-rays to take, no tests to run, and only questionable self-reports to go on, how refined a job can she be expected to do?
The challenge of “idea as cause” and “idea as effect”
For human beings, our thoughts, ideas, and opinions amount to powerful and singular causes and effects in our causal chains of distress. The idea of “cause and effect” in the physical world has about it the sense that one real thing is acting upon another real thing, like one billiard ball striking another billiard ball. But in human affairs, we have thinking to factor in. Consider all of the following. “I am having these troubles because of my bad deeds in another life.” “The witch cursed me, and now I have these pains.” “God is punishing me for my sins.” Billions of people explain “cause and effect” in these ways. The “solutions” that naturally flow from these occult explanations of distress are charms, potions, prayers, incantations, offerings, and so on, solutions that are completely reasonable given the explanations at play. How do we deal with the fact that human causal chains include ideas?
The challenge of describing an effect without inadvertently labeling the person
Let’s say that you see some red dots on a person’s arm. To instantly call those red dots “a rash” is already to characterize it and to hint at what you believe are its causes. But what if the dots are a tattoo? What if the dots have been painted on? What if he is a housepainter? In these three cases, calling those red dots “a rash” would amount to a fundamental mistake. You would be obliged to begin looking at “what causes a rash” or “how rashes are treated” when no rash is present. Likewise, if you shop a lot and I label you with a shopping addiction, I have set us up for “addiction work” just because of the language I’ve chosen to use. Can helpers train themselves to refrain from labeling and hone that surprisingly rare skill of observing without labeling? Can they witness sadness, mournfulness, gloominess, or despair and somehow prevent themselves from thinking “depression”? At the very least, can they grow better aware of the nature of this “inadvertent labeling” problem?
The challenge of distinguishing a “cause” from a “factor,” an “influence,” and so on
In a strict sense, you can’t cause me to strike you unless you wire me up to some apparatus that makes me involuntarily strike you. You can provoke me, influence me, affect me—but not cause me. Very often when we use the word “cause” in human affairs, we actually mean influence, affect, contribute, and so on. The one billiard ball causes the other billiard ball to move. What in life is like that? If I don’t posit you with some free will not to strike me when I provoke you, if I conceptualize you as merely reflexive, determined, and robotic, haven’t I done you some injustice? Likewise, if I imagine that some complex behavior on your part, something like marrying or divorcing, has been caused by some one thing, as opposed to arising from many influences and factors, aren’t I terribly oversimplifying the matter? Do we ever actually mean “cause” in human affairs—or are we always talking about multiple factors, multiple influences, and so on?
The challenge of factoring in the possibility of biological malfunction as a cause or the cause
As a human experience specialist, I would know that nothing of a biological nature has been proven to “cause” “effects” like “depression” or “schizophrenia.” There are hypotheses galore regarding the biological “causes” of such “mental disorders”—but no proof and no compelling evidence. So would I want to send you for a workup when I already know that no tests exist to pinpoint any biological causes of “mental disorders”? On the other hand, if you have a thyroid problem that is causing your fatigue or a brain tumor that is causing your headaches, that is clearly another matter.
Given this complicated reality, that “mental disorders” are made-up labels but that there might still be something organic “causing” one or another of your “symptoms” or “effects,” what is my best or most reasonable course of action? Might I create a handout that explains my views on biological cause and effect and that presents that a medical workup is imperative and yet may find nothing and may prove nothing? Would I offer up this conclusion not only to protect myself from litigation but also because this is what I believe, that in life some unwanted effects are of the biological malfunction sort while the vast majority are not?
The challenge of the patent invisibility of most causes in human affairs
If you lash out at people because you feel cheated by life, how can I possibly comprehend that causal chain if, for example, you will not admit that you feel cheated by life and if you deflect all of my efforts at understanding your motives and your reality? What if a “root cause” of your anger is that you never got over the fact that you were adopted or that you were the product of rape and that information never gets on the table? Won’t I be obliged to deal with the “effects,” your anger and your lashing out, without having any access to the causal chain in play? You do not see cause and effect written in the look of graphite. You do not see the world of sub-atomic particles, the strong force holding nuclei together, or anything else about its history. If you did not know chemistry and physics you would know just about nothing about how cause and effect has operated to create the graphite in your pencil. Since we have nothing like chemistry or physics available to help us understand you, where does that leave us?
Simple Inquiry
Let’s say that despite all of these challenges, a human experience specialist still wants to take a stab at understanding what is causing the distress a person is reporting. The way to proceed is actually simple and straightforward: ask. Yes, all that she would get is a self-report. But that self-report might be revealing. That human beings are regularly defensive and tricky doesn’t mean that they aren’t also sometimes truthful and insightful. Shouldn’t we give them that opportunity? Shouldn’t we give them the chance to help us—and help themselves?
What might this inquiry into cause and effect look like with someone who is willing to cooperate? It might amount to nothing fancier than filling out a questionnaire. The questionnaire, however, would have to allow breathing room for this complicated human being to have a chance to really think about the matter. Checking off boxes would not do. There would need to be space for long answers—which means that the information would then have to be read by another human being, not a machine. Clearly our human experience specialist would be making work for herself by virtue of her commitment to trying to understand.
What might such a questionnaire look like? Let’s create a medium-sized one for the “presenting issue” of “despair.” Let’s hold it to thirty questions—it could easily be double that in length—and let’s skip the details and explanations that would need to be included (for instance, we would need to define terms like “original personality” and “formed personality”). The following is the skeleton of what a full-fledged questionnaire might include:
1. What is causing your despair?
2. Have you despaired a lot in your life? If so, can you say why?
3. Have you recently despaired more? If so, can you say why?
4. What triggers your despair? Do you know?
5. Has a particular incident triggered your despair? If so, do you know why that was triggering?
6. Do you suspect some biological basis for your despair? What are your thoughts on that possibility?
7. Do you suspect some psychological basis for your despair? What are your thoughts on that possibility? (Since this may prove the crux of the matter and since this may also prove too large and unwieldy a question to answer, try your hand at a bulleted list of ‘psychological reasons for my despair.’ Creating this bulleted list may help you identify many possible psychological sources or causes of your despair.)
8. Are there historical reasons for your despair, events that have happened in your personal history?
9. Are there dynamics or events from childhood that may have caused your despair?
10. Are there family dynamics that may have caused your despair?
11. What in your current circumstances might be contributing to or even causing your despair?
12. Looking at your work life specifically, is there anything about your work life that might be contributing to your despair?
13. Looking at your relationships specifically, is there anything about your relationships that might be contributing to your despair?
14. Do you have a strong sense of life purpose? If not, might that lack of life purpose be contributing to your despair?
15. Do you experience life as meaningful (or meaningful enough)? If not, might that lack be contributing to your despair?
16. Are you living your life aligned with your values? If not, might that be contributing to your despair?
17. Is there some important goal or dream that has eluded you and that continues to elude you? If so, might that be contributing to your despair?
18. Does your way of life suit you? If not, might that be contributing to your despair?
19. Are you happy with yourself? If not, might that be contributing to your despair?
20. Do you regularly make yourself proud by your efforts? If not, might that be contributing to your despair?
21. Is some strong emotion like rage simmering under the surface? If so, might that be contributing to your despair?
22. Do you have the sense that some features of your original personality are contributing to your despair?
23. Do you have the sense that some features of your formed personality—your worldview, your self-talk, your habits, the very “way that you are”—are contributing to your despair?
24. Is something about the culture in which you live contributing to your despair?
25. Is your physical health (or lack of physical health) contributing to your despair?
26. Are you currently under any special pressure? If so, do you suspect that is contributing to your despair?
27. Are you currently “out of control” in any way (for example, with your drinking, your eating, your sexual activity, etc.)? If so, is that lack of control contributing to your despair?
28. Has any recent random or stray thought triggered this despair?
29. Has any recent random or stray feeling triggered this despair?
30. What else might be contributing to your despair?
Would a filled-out questionnaire of this sort get a human experience specialist a full, true, or complete picture of cause and effect in this person’s life? Probably it wouldn’t. But would it provide interesting and useful information? I don’t see how it could not. Even if the responses were scanty, defensive, evasive, rote, or anything else under the sun, even such responses would help her understand. As complicated as the concept of cause and effect is and as mysterious as the operations of cause and effect are in human affairs, this route of simple inquiry is bound to produce some useful dividends.
As a human experience specialist, you could go the route of formal inquiry with questionnaires and so on. You could also just guess. You might hazard a guess from what you’ve heard from the person sitting across from you and what you’ve observed about him. For example, it is not at all uncommon for a therapist to say something like, “Your father beating you may have made you very angry, and you may have squelched all that anger and become depressed instead of angry.” The therapist is guessing (in the language of psychotherapy, “making an interpretation”) about an unseen chain of causes and effects. This is a cornerstone interaction and technique of therapy.
The therapist is saying, “The anger is not visible to either of us, but my understanding of your story, human nature, and the look of your passivity suggest underlying anger to me.” This “interpretation” may be extremely useful if the therapist has guessed right. But what if the therapist has guessed wrong? Then the relationship may in fact be harmed, as his client or patient (which is what he is calling the person sitting across from him) is now less likely to credit the therapist with insight. So guesses about cause and effect are double-edged swords, especially if they are presented too smugly and with too much conviction and assurance.
A human experience specialist would likewise sometimes guess but would use language to make it apparent. Displaying no conviction or assurance, a specialist might say, “I have absolutely no idea if the following is on point. But sometimes right underneath sadness is anger. Given your history of abuse, I could see that being true for you. Does that ring any bell for you?” There would be no hint of smug certainty, no reliance on the pseudo-science of theory, and no subtle or overt labeling. It’s rather like a friend saying, “Are you maybe angry?” and completely different from a therapist saying (or rather thinking), “With this sort of neurotic passive-aggressive personality there’s always anger just underneath the surface.”
Cause and effect are the “Why?” “Why do you prefer frozen vegetables to fresh ones?” translates as “What is causing you to prefer frozen vegetables to fresh ones?” “Why are you drinking so much?” translates as “What is causing you to drink so much?” “Why do you stay at a job you hate?” translates as “What is causing you to stay at a job you hate?” In general, helpers respond to cause and effect in one of three ways. They inquire: that is the method and rationale of psychotherapy. They ignore: that is the method if not the rationale of psychiatry. Or they proceed directly to help: that is the method and rationale of coaching.
Since it is possible to proceed with the helping without investigating any cause-and-effect matters—AA works this way, for example, folding cause-and-effect questions into ideas like “powerlessness” and “disease” and moving right on to the tasks of sobriety—it is right if we ask, “Do we actually need to know much (or anything) about cause and effect in order to be of help?” Could a human experience specialist, rather like a coach, move right on to the present and the future without inquiring about possible causal chains that landed the person across from her in his current situation? Is that a legitimate option? We’ll return to this question when we look at “what actually helps.”
However, while it may prove possible for an individual sufferer or an individual helper to skip investigating cause and effect and move right on to the help, it is imperative that researchers do not. To the extent that we throw in the towel in the face of too much complexity, a terrible paucity of genuine knowledge, and what looks to be the very real possibility that we can’t answer the questions we pose, to that extent we have allowed psychiatry and the chemical industry to win the battle over what constitutes “treatment” for distress. If research throws in the towel, if our best and our brightest avoid tackling the biggest questions of human nature and instead proceed down the narrow paths dictated by their academic discipline, then the future of mental health will remain firmly in the hands of chemical companies.
You may not need to know what is causing your sadness—it is possible that what you need to know is how to relieve your distress, not what has caused it. As a helper, you may not need to know what is causing the person across from you to be experiencing so much distress—it is possible that all you need to know is how to relieve that distress. But as a society, we need more. As a society, we desperately need a large-scale, focused inquiry into the mechanics of cause and effect in human affairs. As messy, unwieldy, frustrating, and even impossible an inquiry as that may prove to be, a future that includes better mental health depends on it.