Great Articles, Part 2

My Voice for Their Drugs by Sarah Fawn Montgomery (The Rumpus)

Sarah Fawn Montgomery describes her efforts to articulate what it feels like to live with severe social anxiety disorder. In the process, she finds the more descriptively rich and personalized language she uses, the less others understand and believe her. “I try to justify myself, the things I feel and fear. I want to describe them, to name them in a way that others can understand and thereby accept. If they cannot comprehend my pain they will never believe it.” When she tries to describe her pain to others using her unique voice and lexicon, they often dismiss her description as “dramatic and overblown.” In order for her pain to be validated, she finds she must adopt the language of her physician.

This article reminds me of a line so deftly expressed by poet Adrienne Rich: This is the oppressor’s language, yet I need to talk to you. It is through the dominant, standardized vernacular that ill individuals must convey their experience if they expect to communicate most comprehensively and without risk of being misunderstood or subjugated. Yet patients are ultimately silenced when their narratives are rewritten in medically sanctioned language. This is not an act of translation and healing, it is one of erasure.

Montgomery references bioethicist Kristen Steslow who suggests that psychiatrists have a lot of work to do when it comes to correcting their tendency to judge their own descriptions of patients’ experiences as more accurate than their patients’. Patients’ account of their illness are not taken seriously by the medical establishment. Instead the unique voices and articulations of the oppressed patient are silenced. Patients lose their agency. Montgomery cites psychologist, writer, and depressive, Lauren Slater who described being relegated to the minority status of patient. In her memoir, Prozac Diary, Slater asks, “Why is my voice—all my voices—so lost?” The dominant discourse of psychiatry drowns out the sufferer’s voice. I feel compelled to cite bell hooks here since she provides an exquisite description of how oppressive language functions:

[S]peech about the ‘Other’ annihilates, erases: ‘No need to hear your voice when I can talk about you better than you can speak about yourself. No need to hear your voice. Only tell me about your pain. I want to know your story. And then I will tell it back to you in a new way. Tell is back to you in such a way that it has become mine, my own. Re-writing you, I write myself anew. I am still author, authority. I am still the colonizer, the speaking subject, and you are now the center of my talk’[ref]hooks, bell. Yearnings: Race, Gender and Cultural Politics. Boston, MA: South End Press, 1990: 208.[/ref]

Ultimately, the adoption of medically sanctioned language has a steep cost, “for to invalidate a patient’s language, their way of knowing and being in the world, is to remove one of the core features of being human—the power of communication, the agency of narrative.” The consequences are “deeply political, for if a sufferer cannot express herself, she cannot interact with the world. To have language is to have power, voice a way of knowing and being, a form of agency and control. To be unable to explain your pain is to lose everything.” I believe that first-person narratives are crucial to fully understanding psychiatric disorders because the people who suffer from these conditions are the ones who know what the experience feels like. They are also most affected by dominant medical discourse that silence them.

Should a Mental Illness Mean You Lose Your Kid? by Seth Freed Wessler (Pro Publica)

Should a diagnosis of mental illness by itself disqualify a person from being a parent? This article examines the question. Featured is a woman named Mindi who had her daughter removed from her care after she experienced an episode of postpartum psychosis. Despite taking successfully to treatment and being deemed fully capable of raising her daughter by psychiatrists, psychologists, and a panel of judges, her custody was never restored. The court justified its decision using a concept known as “predictive neglect,” which allows the State to step in and terminate a parent’s custody of a child if they conclude that either parent “has a mental illness that renders them incapable of safely raising the child.” In over thirty states, authorities can forcibly remove children from the homes of parents who are diagnosed with mental illness, even when they have not done anything to harm their child. In some cases, parents lose custody and all rights, even after they have consented to treatment.

The concept of “predictive neglect” is vague and troubling and eerily similar to science fiction author Philip K. Dick’s term,“pre-crime” where the State targets interventions towards non-imminent crimes, even when the crime has not occurred and its occurrence is not a foregone conclusion. We know that in reality, people are not routinely arrested for crimes they have not committed. So why is it justified that the courts should be taking actions based on “predictions” of how those with a mental illness may behave?

Perhaps most concerning is the actual process of taking a child away from a mentally ill parent. The decision to remove a child from their home is based on the recommendations of evaluators who often rely entirely on case reports and psychological tests administered to the parent. They do not spend time interacting with the parent or observing them in the act of parenting. Many have argued that this procedure is not ideal but is a result of limited resources such as time and money. Unfortunately, as long as the system remains completely underfunded and understaffed, terrible injustices will continue to happen and the results will be abysmal. The law itself is outdated and needs to be reformed. It is a stark reminder that mental illness is still a deeply stigmatizing disease that can strip a person of their human rights. Mindi had a single psychotic incident that will now forever be used against her. The State should never have unfettered ability to literally steal a child from a parent under such dubious conditions. And I do not believe it is a coincidence that systematic oppression by the State—both covert and overt—is an underlying factor in perpetuating mental illness.

20% of Anorexics are Men by Nathaniel Penn (GQ)

Men have eating disorders too—and often can’t talk about them.

While anorexia is continually portrayed as an illness that only affects females, large population studies suggest that up to 30% of those suffering are male, with many more cases undoubtedly going unreported. Yet the widespread perception that only women suffer from anorexia has devastating consequences for men because they often suffer in silence. The exceedingly brave few who do speak up and ask for help face severe limits when it comes to their treatment options:

Many residential centers don’t admit men, out of a belief that treatment should be sex-specific. There is no data to support this belief, though clinicians think that certain gender-specific issues are best addressed in therapy or in single-sex groups within a larger coed facility. Some centers prefer not to treat men, because they may inadvertently remind female clients of the trauma they have endured at the hands of abusive fathers, husbands, or lovers. Of the fifty-eight residential treatment centers listed in the Alliance for Eating Disorder Awareness’s 2011-2012 guide, only twenty-five admit men.

Finding appropriate treatment is absolutely essential for anyone with this disease. Anorexia has the highest mortality rate of any mental illness—approximately 10%. The exact cause behind the high rate of fatality is slightly more complicated, but approximately half die from starvation and metabolic collapse and the other half from suicide. Anorexia lasts an average of eight years in men which is a third longer than in females. For those who do recover, 20% will die before reaching their life expectancy. “Like a layer of soil that reveals a long-ago period of drought, the organs of an anorexic’s body seem to retain the scars of being starved.”

Will Brooksbank is one of the four young men profiled in this article. When Penn interviewed Will, he was a patient in an acute eating disorders treatment center and weighed only 55lbs. During the interview, Will tearfully recalled the start of his obsessive interest in food restriction which began when he was 11. Soon, a preoccupation with food and body image took over every aspect of Will’s life and prevented him from getting healthy. He describes how nearly all of his attempts at recovery were impeded in some way by his gender:

Getting help at that young of an age and being a male was like shooting in the dark and expecting to get a bull’s-eye. When I did find places, I was the only male, and a lot of the material that they were doing in the groups was all about females. On some issues, like the body-image stuff, their concern was completely different than mine. A lot of the females are dealing with abuse, so they’re not going to trust men. And I would take that personally at time, because I do just love people and want to help. Then it’s awkward because they don’t want to say certain things because I’m there, and I see that in them, and then you just don’t feel like you can open up to really anybody.

Less than a year after this article was published, Will died at age 22. Penn points out, “He had spent exactly half his life battling his anorexia.”

Book of Lamentations by Sam Kriss (The New Inquiry)

A few weeks ago, I came across a thread on Twitter inviting people to recommend must-read books in preparation for the Trumpocalypse. I tweeted my only suggestion at the time. I was mostly kidding.

Still I am thankful to have unearthed Sam Kriss’ witty and imaginative critique of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders—the DSM-5. This essay is basically a book review of psychiatry’s “bible” as if it were a sci-fi dystopian novel. Tongue in cheek, yes. But in some ways, Kriss isn’t wrong.

The DSM-5 has a bad reputation for medicalizing ordinary and normal human experience and this is what Kriss is digging at in this essay. The manual essentially distills mental illnesses down to their constellation of outward presenting symptoms and ignores the root of the mental disorder (when there is one). The DSM-5 almost forbids the admission of the patient’s subjective and possibly rational reasons for their thinking and behavior. Instead, doctors are left treating symptoms. Anxious? Have some Xanax; Manic? Have some lithium; Sad? Have some antidepressants. Great for symptom management of those with more neuro-based diseases like bipolar disorder and schizophrenia. Not so great for dealing with the more societal and interpersonal diseases such as the much plagued personality disorders.

The parody seems to stumble a bit with Kriss’ disparate criticisms. Is it merely poor categorization or are we reading about a doomed project? Is mental illness purely a social construction? If our diagnostic categories are going to miss the mark, should we make them broad and risk overpathologizing, or narrow and risk underpathologizing (thereby refusing to treat people who could be helped)? What do we even want from a concept of mental disorder? Should a diagnostic manual consider etiology, or attempt not to make contentious claims about causes when we basically know nothing about most of them? What do we do with culturally-specific expressions of disorder? Tough questions.

That said, I still enjoyed this immensely. I’m about as pro-psychiatry as it gets and the idea of taking the DSM-5 as a Borgesian literary stunt is just too awesome for me to get too upset over. The whole essay is pretty brilliant. Here is one of my favorite bits:

If there is a normality here, it’s a state of near-catatonia. DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquillized and bovine-eyed, mutely accepting everything in a sometimes painful world without ever feeling much in the way of anything about it.

Which Way Madness Lies by Rachel Aviv (Harper’s Magazine)

What is it like to be aware of your own sanity slipping away from you? How might you distinguish delusions from reality? Or as Rachel Aviv puts it, “When does a strong idea take on a pathological flavor? How does a metaphysical crisis morph into a medical one.”

Aviv has written several excellent articles about mental illness—this one is fantastic too. I love how she always seems to bring a non-judgmental gentleness and generosity to people she writes about, people who are clearly experiencing the fragility of their own grasp of reality.

In this essay, she explores the early warning signs that someone might be sliding into a psychotic break, or “conversion” as it is termed in psychiatry. Aviv focuses on the prodrome of psychosis. The prodrome is:

the aura that precedes a psychotic break by up to two or three years. During this phrase, people often have mild hallucinations—they might spot a nonexistent cat out of the corner of their eye or hear their name in the sound of the wind—yet they doubt that these sensations are real. They still have “insight”—a pivotal word in psychiatric literature, indicating that a patient can recognize an altered worldview as a sign of illness, not a revelation.

In addition to conducting interviews with several young adults who had been identified as “prodromal” for schizophrenia and detailing their struggles to maintain insight in their everyday lives, she also covers the controversy surround the attempt to formalize a diagnosis in the DSM-5 of “prodrome” as well as the ethical problems that might result from identifying individuals who show a risk of madness (Attenuated Psychosis Syndrome was added to the DSM-5 in 2013).

Unlike many articles on psychosis, Aviv pays attention to the nature of the delusions themselves. The standard practice among clinicians has been to encourage the patient to discredit the content of delusions, dismissing them as errant chemicals or glitches in brain function. But these delusions matter because many patients search in them for signs of truth or unreality. Anthropologists have found that delusions show cross-cultural variability. While delusions are by definition divorced from reality, they also appear to elaborate upon a society’s own contemporary anxieties. Examining their nature may offer insight into how these delusions affect the way others respond to prodromal individuals.

Breakdown: Mental Health in Colorado by Jennifer Brown (Denver Post)

This is a powerful, powerful piece on a mental health system in crisis. Millions of people with serious mental illnesses go without treatment in the United States and few places feel the problem more acutely than Colorado where the fallout from a scarcity of resources for mental health is severe: suicides, mass shootings, a population of prisoners, and an influx of homeless on the street. The Denver Post investigates the mental health crisis in Colorado with a heart-wrenching four-part series written by Jennifer Brown and including photography by Craig F. Walker and video by Mahala Gaylord. “More than 50 years after states began shuttering mental institutions, the system hasn’t recovered—leaving emergency rooms, jails and shelters as last-ditch stops to handle the most severe cases,” Brown writes. “Each year in Colorado, about 260,000 adults and children need treatment for the most severe mental illnesses—schizophrenia, bipolar disorder, major depression and serious emotional disturbances. Yet tens of thousands go without care; nationally, only about a third of people who need treatment get it.”

The first part of this series features an overview of the mental health crisis in Colorado. It begins with a vignette of Dee Fleming and her son who was diagnosed with schizoaffective disorder. One day after finding her son nearly catatonic, Dee took him to the emergency room where she told the doctors that he was suicidal. They sent him home. Two days later, her son overdosed on a variety of medications and cleaning supplies and set himself on fire in the front yard. He was burned so severely that he spent 10 months in a hospital burn unit. Once his burns were adequately treated, he was released from the hospital. Doctors stated that he did not require in-patient treatment for his mental disorder. When Dee and her family threatened to sue, the hospital managed to find him a bed at a psychiatric center, but the center was not equipped to treat her son’s extensive burns and so he was sent to another hospital where he was kept for only four days. Again, the hospital stated that he did not require in-patient psychiatric treatment and he was released to a temporary, assisted-shelter for people with mental illness. The Fleming family looked into private options, but without the treatment being ordered by a physician and without insurance authorization, a private psychiatric treatment center would easily cost them $20,000 a month.

The second part describes mental illness in the criminal justice context. An innovative Court to Community program designed for mentally ill criminals is introduced. The majority of those who participate in this program are charged with crimes such as shoplifting, trespassing, prostitution, disturbing the peace. This courtroom is sometimes referred to as “therapeutic jurisprudence”—its supposed to feel more like therapy than punishment. Court to Community is meant to be an alternative to incarceration in an attempt to lessen the burden of housing mentally ill individuals in the Department of Corrections. Brown notes that jails and prisons are no longer simply the holding centers for inmates to serve their time, but have become full-fledged treatment centers that employ mental health staff and spend exorbitant amounts of money on antipsychotics and other mental health drugs for inmates. “Colorado prisons treat more than four times as many people with mental illness each day as all of the psychiatric hospitals in the state. The Department of Corrections, by default, is the largest mental health treatment center in Colorado. A third of inmates, 5,760 prisoners, have mental problems.” The huge costs of funding mental health services in prison are a result of a failure to invest in the early treatment of mental health.

Part three focuses on mental illness and homelessness. Two-thirds of the chronically homeless in Denver are mentally ill. “The causes of homelessness—job loss, family breakups, alcohol and drug abuse—often are rooted in mental illness, and treatment of mental health problems becomes even more difficult without a stable home. Brown describes a radical shift in philosophy that sees housing as healthcare. Research shows that severely mentally ill people who obtain housing have a better chance of attaining mental stability. When you are warm, have food, and a safe place to sleep, it is much easier to remember to take your medications. Yet Denver has a shortage of affordable housing, leaving nonprofits and government agencies to offer a patchwork of psychiatric services to the homeless that barely reaches beyond the most severe cases.”

The last part documents the grim realities of mentally ill children. Early treatment is crucial to improving mental illness, “yet kids younger than 6 are the age group least likely to receive mental health care if they need it. About half of adults with mental illness had problems as children, and three-quarters of adults with mental illness had symptoms by age 22.”

It is frustrating that we only talk about mental health care reform in the wake of a tragedy. This well researched series provides more proof that the most effective way to use resources is to invest them into prevention and early treatment at the onset of mental illness, long before catastrophe.

Beyond the Brain by Tanya Marie Luhrmann (Wilson Quarterly)

This is an excellent article about the rebirth of interest in how social experiences affect the development of schizophrenia. Tanya Marie Luhrmann is an anthropologist who looks at how mainstream Western psychiatry’s biomedical model of schizophrenia is finally beginning to recognize the heavy influence of culture on the development of the disease. “Increasingly, treatment for schizophrenia presumes that something social is involved in its cause and ought to be involved in its cure.” Her opening account of one particular patient, Susan, shows how different responses from culture can shape the course of schizophrenia, even within the U.S.:

Susan was a success story. She was a student at the local community college. She had her own apartment, and she kept it in reasonable shape. She did not drink, at least not much, and she did not use drugs, if you did not count marijuana. She was a big, imposing black woman who defended herself aggressively on the street, but she had not been jailed for years. All this was striking because Susan clearly had met the criteria for a diagnosis of schizophrenia, the most severe and debilitating of psychiatric disorders. She thought that people listened to her through the heating pipes in her apartment. She heard them muttering mean remarks. Sometimes she thought she was part of a government experiment that was beaming rays on black people, a kind of technological Tuskegee. She felt those rays pressing down so hard on her head that it hurt. Yet she had not been hospitalized since she got her own apartment, even though she took no medication and saw no psychiatrists. That apartment was the most effective antipsychotic she had ever taken.

Ever since the biomedical model of schizophrenia fell into vogue in the 1980s, psychiatrists have been consistently repeating in psychiatric literature that schizophrenia can be found globally in equal measure around the world despite the fact that this assertion is not true. Manifestations of schizophrenia do vary in different countries and surprisingly, Luhrmann has found that “people with schizophrenia do better in the developing world.” Most interesting is her contention that of the variety of social and demographic factors that affect whether a person develops this disease in the United States, migrants are particularly at risk. And when individuals move into neighborhoods where they are the ethnic minority, their chances of developing schizophrenia increase. Luhrmann puts it this way: “If your skin is dark your risk for schizophrenia rises as your neighborhood whitens.” This new focus on a cross-cultural influence and expression of mental illness is also explored in Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche.