Great Articles, Part 3

In no particular order, these are some of the best articles on mental illness I have read recently.

Sick Woman Theory by Johanna Hedva (Mask Magazine)

This is a powerful piece of writing about Johanna Hedva’s experience living with chronic pain, endometriosis, and mental illness. It is about her desire to be revolutionary and politically engaged and disabled. Thus, her central question in this piece is: “How do you throw a brick through the window of a bank if you can’t get out of bed?”

“Sick Woman Theory is the insistence that most modes of political protest are internalized, lived, embodied, suffering, and no doubt invisible.” However, it is more than that. It is also a theory for anyone who is wrestling to find their relevance in a society that aggrandizes wellness and shuns disability. Hedva defines sickness as “a capitalist construct, as its perceived binary opposite, “wellness.” The “well” person is the person well enough to go to work. The “sick” person is the one who can’t. What is so destructive about conceiving of wellness as the default, as the standard mode of existence, is that it invents illness as temporary.” For me, this is absolutely spot on. I cannot tell you how often people say things to me like, ”I thought you had that under control” or “I thought you had the medication sorted out” when in fact all relief is temporary, all control is temporary, and mental illness is a constant ghost haunting my days and nights and reminding me how temporary my abilities to work and function are. Therefore, there is a huge danger in our conception of wellness as default. “When being sick is an abhorrence to the norm, it allows us to conceive of care and support in the same way.” When sickness is seen as temporary, “care is not normal.” Anyone who falls on the wrong tracks of this binary is branded unproductive and is usually excluded from the collective discourse. Therefore Sick Woman Theory is also a theory for anyone outside of the privileged mythical class.

The Sick Woman is an identity and body that can belong to anyone denied the privileged existence—or the cruelly optimistic promise of such an existence—of the white, straight, healthy, neurotypical, upper and middle-class, cis- and able-bodied man who makes his home in a wealthy country, has never not had health insurance, and whose importance to society is everywhere recognized and made explicit by that society; whose importance and care dominates that society, at the expense of everyone else.

Hedva references Ann Cvetkovich’s Depression: A Public Feeling to imagine an alternative way conceptualizing sickness. Cvetkovich theorizes depression as political, seeing it as mode of disillusionment that is both constitutes and is constituted by our contemporary neoliberal capitalist society. She writes: “Most medical literature tends to presume a white and middle-class subject for whom feeling bad is frequently a mystery because it doesn’t fit a life in which privilege and comfort make things seem fine on the surface.” Much like Hedva, she sees wellness, as it is imagined in American culture, as “white and wealthy idea.”

In order to stay alive, capitalism cannot be responsible for our care—its very logic of exploitation requires that some of us die. The crux of the essay is that constraints imposed by the market valuation of human work and human time keep us from caring for people who need care—including ourselves—and that we must somehow learn how to care for both ourselves and for others against the demand that we use most of our time satisfying the market instead. Especially because most of the market’s demands are in a broader sense a total waste of time and life and effort compared to the acts associated with caring. Therefore the ultimate anti-capitalist resistance is care—toward oneself and others. “To take on the historically feminized and therefore invisible practice of nursing, nurturing, caring. To take seriously each other’s vulnerability and fragility and precarity, and to support it, honor it, empower it. To protect each other, to enact and practice community. A radical kinship, an interdependent sociality, a politics of care.”

I am sometimes put off by arguments that seem to neglect that illness is a biological reality and not simply a metaphor. But I also appreciate that Hedva is writing this essay as a sweeping, expansive manifesto and that her writing is meant to disturb and provoke more than to achieve technical accuracy. You’re supposed to read this and feel “me too.”


Black Girls Don’t Get to Be Depressed by Samantha Irby (Cosmopolitan)

Samantha Irby authors a great (and very funny) essay about mental illness, race, and stigma. Growing up as a Black woman in the suburbs of Chicago with a disabled mother, Irby writes that she struggled with depression and anxiety, but whenever she considered seeking treatment, she faced all sorts of cultural and social pressure not to get help. “No one in my house was talking about depression. That’s something that happened to white people on television, not a thing that could take down a Strong Black Woman.” This resistance to being labeled as mentally ill resulted from stereotypes stemming from her race and gender and a society that interpreted her suffering in a less-than-compassionate way. Eventually the pressure to resist became internalized. She writes:

[I]f you’re African-American and female, not only are you expected to be resilient enough to just take the hits and keep going, but if you can’t, you’re a black bitch with an attitude. *Rolls eyes for sarcastic effect.* You’re not mentally ill, you’re ghetto…because I wasn’t actively trying to kill myself and could keep a job and make friends and pay my rent and not do heroin, I made peace with it.

What makes this short article a compelling read is not only for its much needed focus on how social, cultural, and racial factors impede people from getting help for their mental illness, but the focus on Irby’s metacognition—her continuous commentary in her head about her own thinking. People who suffer from depression or anxiety often have a more tortuous relationship with thinking that the average non-sufferer does not experience. This running conversation can be particularly brutal, circular, and self-flagellating. This is why any writing that can help take a reader inside the head of someone suffering from mental illness is important.


The Myth of Thomas Szasz by Jeffrey Oliver (The New Atlantis)

This is a fascinating article about (crackpot) psychiatrist Thomas Szasz’s legacy and his impact on psychiatry. Szasz was most famous for undermining his own profession, accusing it of being fraudulent, misguided, abusive, and based on a concept that he believed did not exist: mental illness. Szasz’s iconoclastic views, expounded upon in his countless publications, brought him an ardent (if small) devoted following. But they made him a pariah in the academy and among clinical psychiatrists. Oliver writes:

Today, of course, Szasz is mostly remembered, if he is remembered at all, as the great silly, a flat-earth adherent in the time of telescopes and globes. Most medical students graduate without ever hearing his name. Peers who once grappled fiercely with his ideas are now surprised to find out he is still alive. His voluminous writings largely gather dust in libraries and used book stores…One can hardly be surprised if Szasz has assumed the role reserved for all failed revolutionaries—a marker of backwardness against which to measure our enlightenment, his name a synonym for error. The disease model of mental illness is now so central to American medicine and culture that the most common response to Szasz—aside from utter disregard—is typically something like: “Just look around—anguished teenagers, depressed adults, distracted children. Only a fool would believe that mental illness is a myth.” Indeed, to the modern psychiatric mind, rejecting the legitimacy of mental illness is not just an error but an act of inhumanity, leaving the sick without the hope of a cure. The Szaszians of the world are not just fools but monsters.

However, even though most psychiatrists and psychologists agree that Szasz was too extreme (he once compared psychiatrists to slave owners and Nazis), Oliver believes that he is due credit because his work exposed “the potential dangers of an excessively psychiatrized society.” This is increasingly exemplified in modern psychiatry’s tendency to invest so much hope in the biology of mental illness. “We are led to believe that new disciplines like neuroscience are putting old ambiguities to rest. We hear of “explosions in scientific knowledge of the brain” and “remarkable advances in understanding the human mind.” Evidence of the biological basis of mental illness would seem to be so overwhelming that to doubt is akin to doubting evolution. Yet a review of the facts fails to reveal the sort of breathtaking advancement commonly claimed.” Oliver further writes:

[I]f mental illnesses truly begin in the brain, no psychiatrist on earth can conclusively say when, why, or how…Given the complexity of the human psyche, this makes sense: we can hardly expect the many moods and miseries of human life, even the most extreme, to have simple neurological explanations. But given the grand ambitions of modern psychiatry—to explain the human condition, to heal every broken soul—the reliance on behavioral observation has led to the medicalization of an ever-growing range of human behaviors. It treats life’s difficulties and oddities as clinical conditions rather than humanity in its fullness.

In a nutshell, Oliver makes his overall point:

It is hard to doubt the reality of mental illness, especially when the suffering of affected individuals is so complete and the impairment so extreme, when psyche and identity are crippled almost beyond repair. But it is also remarkable how much of modern psychiatry is still theoretical rather than empirical, and how many of the supposed mental illnesses that appear (and multiply) in the Diagnostic and Statistical Manual of Mental Disorders have no known biological underpinnings or explanations. Although Szasz’s critique often became a caricature, his intuition about the limits and deformations of modern psychiatry cannot be ignored. Many sick people have surely benefited from psychiatric treatment, both “talk therapy” and pharmacotherapy. But psychiatry’s long history of error—from snake pits to ice baths to spinning chairs to electroshock to lobotomy—should give us pause. Skepticism is not backwardness, even if Szasz often took his skepticism to rhetorical extremes.

He argues that our solution rests hopefully with a new generation of psychiatrists and critics who do not reside at the fringes but instead they remain aware of psychiatry’s achievements and potentials but also its limits.

Interesting tidbit: “A piece in the New York Times Magazine titled “Mental Illness Is a Myth” reportedly induced more reader response than any article in the magazine’s history.”


The Dictionary of Disorder by Alix Spiegel (New Yorker)

This is a great exposé on the near total unreliability of biomedical psychiatry conveyed through a biographical portrait of the psychiatrist Robert Spitzer, who was elected by the American Psychiatric Association to head the Task Force responsible for developing the ground-breaking DSM-III of 1980. It was Spitzer who banged the final nail into Freud’s coffin and led psychiatry into the modern biomedical era.

Spitzer was given basically unlimited administrative control in overseeing the creation of the DSM-III. “He established twenty-five committees whose task it would be to come up with detailed descriptions of mental disorders, and selected a group of psychiatrists who saw themselves primarily as scientists to sit on those committees.” However, Spitzer tasked himself with the majority of the work, impressing his peers as he banged out hundreds of diagnostic descriptions and criteria for both old and brand new mental diseases. Many of these entries were included in the DSM-III with minimal revision. In the process, Spitzer “not only revolutionized the practice of psychiatry but also gave people all over the United States a new language with which to interpret their daily experiences and tame the anarchy of their emotional lives.” However, the process was vague, subjective, and seemingly improvisational—everything the new psychiatry purported not to be.

Spitzer surrounded himself with a team of neo-Kraepelinians—a group of biologic psychiatrists who were dissatisfied with the profession’s the lack of clear diagnoses and classification of mental disorders as well as the low reliability among psychiatrists. One of their main goals in writing the DSM-III was to tackle the issue of reliability. They believed there were two reasons for a lack of reliability when it came to making a psychiatric diagnosis. The first was informational variance which resulted because different doctors had different rapport and interview styles with patients. These variations resulted in psychiatrists getting different information from the same patient. The second was interpretative variance, or the idea that each doctor carries in his/her own mind ideas of what a specific disease looks like.

One goal of the DSM-III was to reduce interpretative variance by standardizing definitions. Spitzer’s team reasoned that if a clear set of criteria were provided, diagnostic reliability would inevitably improve. They also argued that the criteria would enable mental-health professionals to communicate, and greatly facilitate psychiatric research. But the real victory was that each mental disorder could not be identified by a foolproof little recipe.

Diagnostic unreliability was seen by Spitzer and his team as a fundamental problem in psychiatry and one that the DSM-III, which its diagnostic criteria and reliance on science, was supposed to solve. Yet studies have shown that the reliability problem is much the same as it was in the 1950s. The most obviously major problem with the manual’s new reliance on science was that there hadn’t been any science done yet. Yet immediately after the DSM-III was published, Spitzer began a PR campaign aimed at the media and anyone who would listen that touted the DSM-III as highly reliable and superior to previous incarnations. It was largely based on these untrue public statements that the DSM-III was taken up by rapidly by psychiatrists and psychologists. Herb Kirk and Stuart A. Kutchins have extensively studied the DSMs and conclude that its status as an authoritative classification system is not based on any legitimate data but on propaganda. They note that the manual’s “revolution in reliability is a revolution in rhetoric, not in reality” (p. 53) 1 Spitzer himself even admitted to Spiegel that the reliability results were less than ideal by remarking, “To say that we solved the reliability problem is just not true. It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem.”


Notes:

  1. Kirk, Stuart A., and Herb Kutchins. The Selling of the DSM: The Rhetoric of Science in Psychiatry. New York: Aldine De Gruyter, 1992.