Powers, Ron. No One Cares About Crazy People: The Chaos and Heartbreak of Mental Health in America. New York: Hachette, 2017.

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This is an extraordinary and courageous book that took Ron Powers a decade to work up the courage to write. His son Kevin, the younger of his two children, hanged himself in 2005, just before turning 21. Kevin’s brother Dean, two years and eight months older, experienced a psychotic break on Christmas Day 2012; the following summer, he tried to drown himself. Schizophrenia drove both boys to the brink. For years, Powers was determined to not write this book. Thankfully for us, he reconsidered: “I realized that my ten years of silence on the subject, silence that I had justified as insulation against an exercise in self-indulgence, was itself an exercise in self-indulgence” (p. xviii). Powers comes to this passionate and personal project in search of answers. “Something terrible happened to my sons,” he writes, “And I want to know what and why” (p. 126).

This text is part memoir, part social history. The history of mental illness, no one will be surprised to learn, is doleful. Powers provides deep dive accounts of how the mentally ill have been treated over centuries including chapters dedicated to Bedlam, the rise (and fall) of moral treatment, eugenics, the relationship between creativity and madness, the creation of the first psychotropic drugs, deinstitutionalization, the antipsychiatry movement, and the horrors modern warfare takes on the psyche. He interweaves his family’s steadily-worsening crisis with schizophrenia with a broader historical inquiry into how societies have dealt with the mentally ill (not well), and specifically how American society deals with the epidemic today (still not well). The result is a collection of histories tethered together with achingly tender accounts of his beloved boys as they experience carefree and rambunctious childhoods and the beginning of seemingly ordinary teenage years all the while lurking under the surface of all the family happiness is what Powers calls the “scourge” of schizophrenia (p. xv). Below are some of the areas Powers touches on.

What is Schizophrenia?

“This illness,” Powers writes, “shares with cancer, its partner in catastrophic affliction, an almost otherworldly imperviousness to definitive understanding and cure” (p. 2). Even today, it remains the most devastating and feared of all mental disorders. Schizophrenia is best understood not as a single disease, but as a chronic and incurable group of related psychiatric disorders that are thought to be the result of a combination of genetic mutation and “psychosocial” or environmental factors. The illness produces three sets of symptoms: positive, negative, and cognitive. Positive symptoms are often the most dramatic and include auditory and visual hallucinations and delusions. In extreme cases, patients will act on their delusions, sometimes with violent and (self)destructive results. The negative symptoms can be characterized as a range of emotional responses characterized by withdrawal or a lack of something. These take the form of decreased motivation, inability to experience pleasure, cauterized emotions, self-isolating behavior. These negative symptoms are similar, but distinct from clinical depression. Cognitive symptoms can include a loss of memory or diminished ability to process information. A particularly unfortunate feature of this illness, one that often proves to be the greatest barrier to receiving timely (if any) treatment is called anosognosia, or “the false conviction within a person that nothing is wrong with his mind” (p. 27). In psychiatric parlance, this is referred to as a lack of insight.  What this means is that despite their irrational and out-of-control behavior, the patient remains convinced that nothing is wrong with their mind. Anosognosia is a by-product of psychosis and occurs in approximately half of all cases of schizophrenia. Schizophrenia afflicts slightly more than one in one hundred people.

Schizophrenia’s prognosis today is essentially the same as it was during the time of Emil Kraepelin, the early twentieth century German psychiatrist who first used empirical brain science in his quest to understand psychological maladies. Kraepelin is credited with much of the medical community’s initial understanding of schizophrenia. “Dementia praecox,” as Kraepelin knew it was a progressive and neurodegenerative disease that he observed in a significant number of patients in their teens and early twenties. Kraepelin was the first to observe a distinction between manic depression (also known as bipolar disorder), a condition that can also include psychotic symptoms, and what is today called schizophrenia. Swiss psychiatrist Eugen Bleuler was responsible for coining the actual term schizophrenia (or “the schizophrenias”) to replace dementia praecox. In Greek, the word literally means “a splitting of the mind.” Bleuler also introduced the medical community to the “spectrum” concept when he argued that schizophrenia was actually one disorder along a spectrum. Schizoaffective disorder, which includes a mood disorder alongside the basic symptoms of schizophrenia, is listed “Schizophrenia Spectrum and Other Psychotic Disorders” in the the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Though it is closely related to schizophrenia, it is considered to be a different disorder.

Bedlam and Moral Treatment

Powers begins his historical accounting of mental illness with Bedlam and the rise (and fall) of moral treatment. The most influential environmental factor affecting schizophrenia is stress. Because of an Industrial Age intensity toward urban living, “early London was a petri dish for human stress. And madness” (p. 59). The sentiment at the time, one not much different from today, was that the mentally ill contributed nothing to society, held no political sway, and therefore we not fully people: “The mad don’t vote; the mad don’t do anything to generate wealth. Many don’t even know who they are. Why toss good money at them, beyond the costs of keeping them alive?” (p. 63).

As a result, the sane sought accommodations for this growing population at the lowest economic price possible. Their solution was Bedlam, “the vernacular name assigned to the first and most famous madhouse of them all” (p. 59). That infamous institution was London’s Bethlem Royal Hospital and by the mid-eighteenth century, it’s horrifying approach to “caring” for the mentally ill was on full display. This period of time can be marked, according to Powers, as “the true dawn of the epoch in which no one cared about crazy people.” It wouldn’t be the last. In Bedlam, “patients” were routinely shackled, starved, taunted, beaten, experimented upon, hygienically neglected, and forced to live in the most decrepit of conditions. Powers notes how:

patients were “treated,” occasionally and haphazardly—and always, of course, by physicians with no grasp of how the brain worked. More often they were punished…doused with icy water or strapped inside chairs that spun rapidly, or both. These procedures were popular partly because they delivered a double benefit: they also answered as therapy. Some inmates (to use a more accurate term than “patients”) were chained to walls—sometimes for months, occasionally for years, their ankles and wrists festering with gangrene (p. 62).

In response to Bedlam and asylums alike, the first widespread reform movement came about in the late eighteenth century, principled on what came to be known as “moral treatment.” Asylum pioneers such as Philippe Pinel, William Tuke III, and Benjamin Rush advocated a more humane and empathetic approach to dealing with society’s insane. They came to see madness as an affliction that could be cured through respectful relationships and a healthy environment. While reform did occur, it was ultimately short lived. As the general population increased so did the number of insane people needing accommodations and soon new asylums in Western Europe and America were overwhelmed: “There were simply too many more patients, too many more criminals, and too many other kinds of hard cases among patients” (p. 73). Eventually, overcrowding eroded the moral treatment agenda and society once again maintained unkept institutions and asylums notorious in their neglect for patients. It was during this time that Dorothea Dix rose up as an advocate for the mentally ill. Tirelessly, she:

embarked upon an eighteenth-month itinerary that took her to jails and asylums throughout Massachusetts, barging past guards to interview patient-inmates and their keepers. At the end of her journey, she was convinced that the moral treatment asylums were in fact benefiting patients, but that their jailing of excess “mad” people was rampant and their plight a front to humanity (p. 71).

As the number of public and private asylums swelled, the agenda for moral treatment became less and less of a priority until it went away entirely. And while conditions never returned entirely to that seen in Bedlam, “the horrid systematic cruelty” towards the mentally ill can still be seen today—“a fact documented by almost weekly news accounts from the human disposal systems that our large urban prisons and hospitals have become” (p. 75).

Eugenics and “the Mentally Unfit”

“It is nearly impossible to make sense of the furious arguments that to this day energize and often impede the interests of the mentally ill without understanding eugenics” (p. 82).

Eugenics, or the practice of manipulating biological systems to refine reproduction, was a movement based on the drastic misunderstanding and misapplied teachings of Charles Darwin’s theory of evolution. Darwin’s theory would become the basis for techniques used by the Nazis to control population through the elimination of the unwanted. However, the eugenics movement was not isolated to Europe and Nazis. The Nazis also borrowed from the U.S. eugenics sterilization program:

In America, sterilization and more invasive measures flourished before and after the war. Indiana enacted the country’s first compulsory sterilization law for the mentally ill in 1909, Washington and California quickly followed…The Golden State became the national leader in the practice, neutering twenty thousand mental patients between the onset and 1979. It was not until September 2014 that the practice was prohibited by a bill signed by Gov. Jerry Brown, following revelations that the state cleaned the ovaries of 148 women between 2006 and 2010 (pp. 98-99).

In 1927, the U.S. Supreme Court decided, by a vote of 8 to 1, to uphold a state’s right to forcibly sterilize a person considered unfit to procreate. The case, known as Buck v. Bell, centered on a young woman named Carrie Buck, whom the state of Virginia had deemed to be “feebleminded.” The law authorized the forced sterilization of anyone deemed to be “unfit.” Buck v. Bell remains law today “and the science of eugenics remains in the annals” (p. 102).

Creativity and Madness

“Do neural links exist between creativity and mental illness? Or, to put it in a couple of other ways: Did Kevin’s and Dean’s artistic gifts put them on a path to schizophrenia? Or, perhaps, vice versa?” (pp. 117-118).

It’s not surprising that Powers dedicates a chapter to the debate over whether artistic talent and mental illness are causally linked. Both of his sons were gifted musicians and writers. He uses this chapter as an opportunity to cite research by psychiatrist Nancy Andreasen, who for more than a decade interviewed and tracked 30 faculty members from the renowned writing workshop at the University of Iowa. She also interviewed and tracked 30 control subjects of similar age and IQ who worked as administrators, lawyers, social workers, and so on. She questioned and diagnosed subjects using a methodology she devised. Instead of identifying a passel of schizophrenic novelists, Andreasen stumbled on extremely high rates of mood disorders like depression and mania among the writers. The gap between the writers and the control subjects was huge with 80 percent of writers reporting some mental illness compared with 30 percent of nonwriters. Andreasen’s findings jive with research done by Kay Redfield Jamison, who in her book, Touched With Fire: Manic-Depressive Illness and the Artistic Temperament, examined 47 prominent poets, playwrights, novelists, biographers, and artists and found that a significant portion of them had mood disorders. Though research has shown that there is a link, it still remains an unqualified and inconclusive one. Powers notes that one major problem for this has to do with coming up with an agreed upon conceptualization of creativity. What exactly is it?

Antipsychiatry

Powers devotes a chapter of his book to “one man tsunami” (p. 156) Thomas Szasz. Szasz was a psychiatrist best known 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 who have had considerable influence. Szasz compared psychiatrists to slave owners and Nazis. During the 1950s and 1960s, Szasz’s ideas gave rise to the antipsychiatry movement, “a loose but enduring affiliation of citizen groups in every state dedicated to the abolition of involuntary mental health care” (p. 160). While this group was small in size, it was disproportionately influential in when it came to legislature and lobbying politicians, medical providers, and the public to partake in their movement.

Modern Warfare and Mental Illness

“The indifference to the suffering of mentally ill servicepeople and service veterans remains a national disgrace” (p. 322).

The demise of eugenics did not result in a moratorium on suffering in the name of “perverted science” (p. 273). Postwar America produced an “unprecedented numbers of disabled servicepeople and veterans—both men and women” and neuropathologist (note: not neurosurgeon) Walter Freeman saw an opportunity to push forth a radical pseudoscientific new cure: the lobotomy. The modern lobotomy, which Powers describes as “the back-alley abortion of brain surgery” was conceived of as an antidote to schizophrenia in 1935. Freeman crudely “simplified” the procedure by using an ice pick to enter the brain under a patient’s eye socket. It was estimated that one-third of his patients’ outcomes were considered “failures” (p. 275). A few medical professionals criticized Freeman and attempted to stop him but because no laws existed to prohibit the procedure, nothing could be done. Freeman was in demand and his impunity derived from a need facilitated by the second world war. Eventually, Freeman was banned from the medical community after losing his operating privileges, but the lobotomy did not die with him. It was still used, albeit rarely once the antipsychotic revolution began.

The war and postwar effects on the mental health of combatants and civilians are incalculable, but due to a “military code of manly silence,” many individuals suffer in silence. Drawing on his own experience of combat, Harry Truman is credited as the first U.S. president willing to recognize the intensity and chaos of war and its effect on the psyche. He was revolutionary in pushing for guaranteed financially protected treatment for not only “warfare’s psychic casualties,” but the rest of the nation’s mental health. In 1946, Truman signed the National Mental Health Act which provided federal money for the first time ever for research into the human mind. Unfortunately, many administrations have cut back or eliminated this funding.

Drugs, Deinstutitonalization, and Disaster

The very notion—Sanity in a bottle! Peace of mind in a popped pill!—so perfectly fit postwar American marketing-conditioned faith in E-Z solutions via consumer products that the wonder-drug blitzkerg was complete as soon as it started (p. 221).

In 1954, a new antipsychotic called Thorazine came on the market.  Among many things, it was touted as a cure for schizophrenia. It wasn’t. At best, it suppressed symptoms. With these drugs and the “atypical” or “second generation” antipsychotics that were pushed to the market in the 1970s came a range of unpleasant and serious side effects including weight gain, heightened anxiety, increased blood pressure, and a condition known as tardive dyskinesia, which resulted in uncontrollable facial tics and tongue-thrusting. It is because of these side effects that a large number of people with schizophrenia stop taking their medication against medical advice.

The development of pharmaceuticals to treat schizophrenia became the impetus for a well-intentioned social program that had disastrously unintended consequences for the mentally ill. On the eve of Thorazine came the Community Mental Health Act (CMHA), signed by President Kennedy in 1963. The CMHA was “designed to solve, once and for all, the malingering scourge of decrepit mental asylums and barbarous care” by allocating promising $150 million in funds over four and a half years to be spent on grants to states for establishing community health centers for the mentally ill. It sounds good, but it quickly “became one of the century’s most enduringly disastrous policy experiments for the mentally ill” (p. 187). Powers writes:

This historic blunder has a name that grotesquely fits the elegance of its design and effects. The name is deinstitutionalization. Deinstitutionalization uprooted what meager stability insane people clung to—the dismal care of state mental asylums—and drove tens of thousands into the streets where they pioneered an entirely new urban subpopulation, the accursed demographic of the mad that we call the homeless (p. 3)

The mentally ill homeless soon shuffled between the streets, hospital ERs, and jails and prisons. The worst of that unmerciful world, unsurprisingly, is the world of US jails and prisons – a world that comes into the ambit of the book because of the legal problems his son Dean encounters. “The American prison system is an archipelago of barbarity,” he writes with damning directness“ (p. 146). According to a Department of Justice study, more than half of the country’s roughly two million prisoners suffer from some kind of mental health problem. Particularly unforgivable and gruesome are the liberal uses of solitary confinement which is known to trigger schizophrenic-like symptoms such as hallucinations and delusions in people who are mentally fit. For people who are already ill, “it is a quick route to deep and lasting psychosis” (p. 148). Powers describes solitary as “a petri dish for the suicidal impulse” (p. 148). Powers’s spends a good amount of pages detailing the fact that jails and prisons have become the de facto mental institutions. The criminalization of mental illness fuels some of the book’s most scathing prose.

Involuntary Commitment

Good intentions and unintended consequences borne by the mentally ill are a theme in this book and in legal history of mental health issues. A desire to preserve autonomy and civil liberties of individuals with mental illnesses has resulted in legislature that presupposes that a person who displays a mental disorder is fully capable of choosing her own treatment, including medications, and therefore may not be forced into doing so. The Lanterman-Petris-Short (LPS) Act, passed by then California governor Ronald Reagan, set the precedent for involuntary commitment procedures today.

According to Powers, these laws fail people with schizophrenia and their families, functioning:

to barricade state hospital doors against the admittance of stubbornly resisting patients—at least until a hearing was held. Not a medical hearing, with psychiatrists, but a judicial hearing, with a judge and lawyers. Because stubbornly resisting patients almost always were patients in psychotic states who almost always were in the collateral grip of anosognosia, the legislation meant that the most desperately vulnerable of all sufferers were the ones least likely to get help (p. 195).

Anosognosia is another theme that runs the course of Powers’s book. While it foremost describes the companion affliction of schizophrenia and schizoaffective disorder that blocks a person’s self-awareness and insight into their disease, it also serves a symbol of society’s collective denial and obliviousness towards the needs and humanity of the mentally ill.

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Ultimately, Powers intends for this book to comfort families dealing with severe mental illness, to shock general readers with examples of atrocities befalling the mentally ill, to show that “crazy people” are rarely dangerous to anybody but themselves, and to push for significant reform. “I hope you do not ‘enjoy’ this book,” he writes in the Preface. “I hope you are wounded by it; wounded as I have been writing it. Wounded to act, to intervene” (p. xiii). Readers will certainly feel that wound, and they will finish the book more convinced than ever of Powers’s central anthem: “Too many of the mentally ill in our country live under conditions of atrocity” (p. xix).  If any book can begin to change those conditions, this is the one.

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.”

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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.

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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.”

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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)[ref] Kirk, Stuart A., and Herb Kutchins. The Selling of the DSM: The Rhetoric of Science in Psychiatry. New York: Aldine De Gruyter, 1992.[/ref] 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.”

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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.

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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.

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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.”

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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.

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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.

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.

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.

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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.

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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.

Behind the Yellow Door; A Man’s Mental Illness Worsens by Stephanie McCrummen (Washington Post)

The man behind the yellow door hadn’t come out of his house more than a few minutes in two years. A former Capitol Hill staffer gripped by schizoaffective disorder, he didn’t think of himself as sick, but rather that God was speaking to him through his two young sons. In the past, his frightened family would have been able to have him committed to a psychiatric hospital, but with the passing of laws expanding the rights of those who are mentally ill, their only choice is to wait for him to become a danger to himself or others before he can be forced into treatment. “With no other treatable illness do we wait for someone to hit bottom before providing treatment even though acute signs and symptoms are apparent. Why do we, the families of people living with serious mental illnesses, have to continue waiting and weeping?”

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The Rise of the Neuronovel by Marco Roth (n+1)

“The last dozen years or so have seen the emergence of a new strain within the Anglo-American novel. What has been variously referred to as the novel of consciousness or the psychological or confessional novel—the novel, at any rate, about the workings of the mind—has transformed itself into a neurological novel, wherein the mind becomes the brain.” Roth argues that the recent interest in contemporary novels in the disordered wetware of their characters represents a defeat for fiction. “…the new genre of the neuronovel, which looks on the face of it to expand the writ of literature, appears as another sign of the novel’s diminishing purview.” This is a nicely written and thought provoking essay, but ultimately I disagree with Roth. Novels are not about the same things as they were during Dickens’ time. Get off my lawn.

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When My Crazy Father Actually Lost His Mind by Jeneen Interlandi (New York Times Magazine)

Interlandi follows a sobering episode in the debilitating bipolar history of her father, revealing flaws in the nation’s mental health and criminal justice system, specifically with laws requiring that the acutely psychotic meet the imminent danger standard—that they pose an immediate threat to themselves or someone else—in order to be involuntarily committed to a psychiatric facility. Interlandi describes her family’s experience of being trapped in a broken system: “During the three months in which my father cycled through the system, he racked up five emergency room visits, four arrests, four court appearances…and too many police confrontations to remember. He spent 25 (nonconsecutive) days in a psychiatric hospital and 40 in a county jail.” I like this piece because it effectively uses the deeply personal to illustrate a national crisis, and because it doesn’t flinch in the face of uncomfortable truths.

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God Only Knows Where I Am by Rachel Aviv (New Yorker)

Aviv’s article is a poetic ode to a struggling woman. Like so many with delusional disorders, Linda Bishop does not believe she has a psychiatric illness. Because of her deteriorating mental condition, Linda is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial and then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up care, or notification of family. After her release, she takes shelter in a little-used New Hampshire home, surviving on only apples and rainwater until she succumbs to starvation. This article raises the important question of what should happen when patients reject their diagnosis.

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Intake: Locked on the Psych Ward by Rosalind Adams (Buzzfeed)

This Pulitzer worthy year-long investigation raises several concerns about how America’s biggest psychiatric chain—Universal Health Providers (UHS)—made its earnings, suggesting that UHS “turns patients into profits.” The report, for which 175 current and former UHS staff were interviewed, raises serious concerns about the extent to which the company’s large profits were achieved at the expense of patients, some of whom shouldn’t have been hospitalized at all.

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What Michael Did by Amy Dempsey (Toronto Star)

A powerful feature story about a schizophrenic man named Michael Stewart who killed his mother during a psychotic episode. Michael was found not criminally responsible and now lives in a forensic health institute in Canada. The article documents how Michael and his family have tried to piece their lives back together after such a horrific event and, in the process, develop both forgiveness and understanding for one another. This is an exceptional piece that humanizes Michael and his illness in a way that I rarely see. He is not a criminal. He is someone who is trying to climb out of a dark pit and fix himself.

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Madness by Eyal Press (New Yorker)

A shocking exposé that documents how prison guards at the Dade Correctional Institution in Florida have subjected mentally ill prisoners to vicious beatings, scalding showers, and severe food deprivation. Many prisoners have been driven to suicide. These guards have acted with near impunity since prison staff, including mental health workers, often fear reprisals for speaking out. Through on the record interviews of former employees, Press paints a portrait of a deeply dysfunctional institution where violence, retaliation, and retribution against prisoners by prison staff is commonplace.

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Trouble in Mind by Brandi Grissom (Texas Monthly)

This is part five of a six-part series that explores the intersections of the mental health and criminal justice systems in Texas through the case of Andre Thomas, a death row inmate who began exhibiting signs of mental illness as a boy and committed a brutal triple murder in 2004. While incarcerated, he clawed out both of his eyes and ate one of them. Yet the state of Texas remains unconvinced that he is too mentally ill to be executed.

The toughest questions that Andres’ case presents, however, are not political in nature but moral. As a society, we want justice for the victims of his horrific crime. But what if Andre is not capable of understanding right from wrong or of comprehending why he is facing execution? Conversely, if the death penalty is not intended for someone who cuts out the hearts of two children, then for whom is it meant? At the center of this dilemma is Andre himself, who, now almost thirty, is presently too mentally ill to be housed on death row. For the past four years, he has been confined to a special psychiatric prison facility, where he remains indefinitely. All of which raises perhaps the most difficult question of all: What should be done with Andre Thomas?

His case offers a lens through which to examine the effects of a long underfunded mental health system and raises important questions about how Texas punishes the mentally ill. In my opinion, if Andre Thomas is not insane then the insanity defense law certainly is.

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The Death Treatment by Rachel Aviv (New Yorker)

This poignant and troubling essay is about assisted suicide for people with non-terminal illnesses. Aviv writes about Godelieva De Troyer, a Belgium woman with a severe psychiatric disorder who was euthanized by Wim Distelmans, an oncologist and professor of palliative medicine at the Free University of Brussels. He was one of the leading proponents of a 2002 law in Belgium that permits euthanasia for patients who have an incurable illness that causes them unbearable physical or mental suffering, including psychiatric disorders. In seeking to understand his mother’s death, her son exposes a darker side of this law which includes minimal and poorly funded outpatient care. He also finds out that prior to being approved for euthanasia, Godelieva was not required to undergo more invasive procedures such as electroconvulsive therapy even though it is effective in about half of patients with depression. I used to unequivocally support the right to euthanasia, but as I learn more about how it works in Belgium and the Netherlands and as I learn more about the nature of psychiatric disease, I realize what a complex issue this is with no simple black and white answers.

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Patient Observation by Skip Hollandsworth (Texas Monthly)

I am happy to read anything that Skip Hollandsworth writes. In this article, he recalls his early fascination with North Texas State Hospital, an in-patient psychiatric facility located in Wichita Falls. He describes riding past the state hospital in his adolescence in the back of a pickup truck with his friends, looking for madmen. “For us, the state hospital, which nearly everyone referred to as LSU, or Lakeside University, because it was located across from Lake Wichita, was our real-life haunted house. The fact that two thousand adults were being treated for “insanity” out in those buildings, just past the city limits sign, simply tortured our imaginations.” Later he found himself returning to the hospital, volunteering in different departments and even playing his cello for patients. He writes that he was drawn “for reasons I couldn’t then explain” to what he described as this “community of odd souls who had never been able to make it on the outside.” His fascination with the state hospital is what ultimately led him to a career in journalism.

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The Prozac, Paxil, Zoloft, Wellbutrin, Celexa, Effexor, Valium, Klonopin, Ativan, Restoril, Xanax, Adderall, Ritalin, Haldol, Risperdal, Seroquel, Ambien, Lunesta, Elavil, Trazodone War by Jennifer Senior (New York Magazine)

The contours of former Army medic and surgeon’s assistant David Booth’s life have been drastically redrawn. After suffering and eventually recovering from a severe injury (which included breaking his neck) during a combat mission, he was left with severe chronic pain, sleeplessness, and PTSD for which he now takes a glut of powerful psychiatric medications to quell. And he is not a unique case. It is reported that of 20,000 soldiers, up to a quarter have received some kind of mental health treatment in the last year.

Defense Department spending on Ambien, a popular sleep aid, and Seroquel, an antipsychotic, has doubled since 2007, according to the Army Times, while spending on Topamax, an anti-convulsant medication often used for migraines, quadrupled; amphetamine prescriptions have doubled, too, according to the Army’s own data. Meanwhile, a study by the Rand Corporation has found that 20 percent of the soldiers who’ve deployed in this war report symptoms of post-traumatic stress and major depression. The number climbs to almost 30 percent if the soldiers have been deployed more than twice.

While substance abuse and criminal activity are increasing among active-duty service members, even more ominously, the suicide rate for military members has surpassed that of the civilian population’s. And there is a direct correlation between military suicides and psychiatric drugs. Many soldiers are taking more than one kind of medication and are mixing several pills into daily cocktails.

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Schizophrenia in America by Jonathan Cohn (Huffington Post)

Cohn’s deep dive into our lacking treatment of schizophrenia is worth your time. The article begins in 1974 with Glenn, a smart high school student with a knack for building robots, who began experiencing episodes of psychosis. He was diagnosed with schizophrenia and given the standard grim prognosis, being basically told by everyone that his life was over. Yet four decades later, there is a breakthrough treatment approach being used in places like Australia with the hopes that people with schizophrenia can actually lead normal lives.

In America, not much has changed from the way Glenn was treated in the mid-1970s to today. In the US, those who have schizophrenia are usually diagnosed only after they have reached an advanced state of the disease. The treatment du jour includes massive dosages of psychotropic medications combined with therapy. Not much else is done. This lack of progress in schizophrenia research is troubling considering the pressing impact it has on our society.

Not many people would include schizophrenia on a list of major diseases that burden American society, but that is what it is. Schizophrenia affects about 1 percent of the population, roughly three times the number of Americans who suffer from Parkinson’s. Because the disease typically appears in adolescence or early adulthood, it claims many more years of healthy life than conditions like leukemia and HIV. Its suffers also die earlier, about 12 years before the typical American. Economists say that schizophrenia costs the U.S. at least $60 billion a year, and probably a good deal more.

In contrast, Australian researchers have begun to focus on treating patients when they first develop symptoms and what they discovered was that there were less pronounced changes in prefrontal cortex and gray matter and greater sensitivity to medication which allowed for lower doses and less debilitating side effects. Researchers carefully developed detailed questionnaires and other intervention methods in order to target the early stages of the disease in patients. We may not be able to cure schizophrenia, but we can make life so much better for those who have it. So why don’t we?

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Brain Attack by Erin Digitale (Stanford Magazine)

When he was only 7 years old, Paul Michael Nelson suddenly flew into a violent psychotic rage. His terrified parents rushed him to their local emergency room where the medical staff seemed incredulous and even suggested to the parents that Paul Michael must have had a bad temper tantrum. He was released, but the rages got worse. Over many months, Paul Michael cycled through psychiatric hospitals as his doctors struggled to find what was wrong with him. One team of physicians eventually came to a surprising conclusion: Paul Michael was suffering from an autoimmune disease that was making him crazy. “When the immune system gets derailed from its usual infection-fighting role and attacks the brain, it can trigger obsessive-compulsive actions, anorexia-like refusal to eat, severe anxiety, violent outbursts and other symptoms of mental illness, as well as a host of neurological problems.” Paul Michael was the first of more than 70 children who have been evaluated at a new clinic at Lucile Packard Children’s Hospital at Stanford for pediatric acute-onset neuropsychiatric syndrome (PANS), a disease that doctors are still working to define.

 

 

 

Potter, Nancy Nyquist. Mapping the Edges and the In-Between: A Critical Analysis of Borderline Personality Disorder. New York: Oxford University Press, 2009.

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Nancy Nyquist Potter’s critical analysis of borderline personality disorder (BPD) is empathetic, thoughtful, and thorough. Her central task in this book “is to press questions of to what extent the symptoms of the classificatory disorder BPD represent pathology, or instead, cultural disapproval or social disvalue” (p. 4). She argues that in order to better understand and treat BPD, we need to address a number of symptoms that warrant closer analysis.

Potter challenges the reader to think beyond the standard diagnostic manual, the DSM-5, and to view the behavior of BPD in the context in which it originally developed. She points out that much of the criteria in the DSM-5 for BPD are feeling-based and therefore do not lend themselves to description and measurement. She is under no illusion that many of the diagnostic criteria for BPD such as anger, self-harm, unstable relationships are socially constructed and they are philosophically messy and complex. She sees BPD as socially situated. The majority of those diagnosed are women (about 75%) and this is neither coincidental nor peripheral to treatment.

People diagnosed with BPD have a reputation of being extremely difficult, impulsive, explosive, and angry people. In the first part of the book, Potter discusses several criterion of BPD on their own: identity disturbance, anger, interpersonal relationships, impulsivity, self-harm, and manipulative behavior. At every point, Potter questions the tendency to pathologize or medicalize these behaviors and argues that doing so often interferes with real understanding and connection with a BPD patient. She introduces a detailed philosophical explanation for each of these “problems” and then delves into the social and cultural contexts including a careful exploration of gender.

In her discussion of identity disturbance, Potter locates the individual within the dialectic of the self and other. She argues that the Western notion of identity creates sharp boundaries between self and other that contribute to feelings of isolation and alienation. This construction of identity is culturally distinct—different cultures have different ways of drawing boundaries between self and external world. Therefore the Western concept of identity as unified and stable is a product of dominant ideology. In addition, gender roles and stereotypes contribute to accentuating the view of the male as “subject” and the female as “other” and when females attempt to assert autonomy, they may be viewed as acting outside behavioral norms. Potter writes:

As a class, girl children and women of all ethnic groups experience subordination, disrespect, invisibility, and other forms of oppression—even in societies that have increasingly offered females more opportunities for development and free choices. It is not surprising that the mixed messages and the thwarted attempts to actualize their goals may create, in some women, feeling of emptiness and contradictory sense of self (p. 28).

Potter also tackles the diagnostic criterion of “inappropriate anger” associated with BPD patients. She argues that we need to explore the concept of anger and determine the difference between pathological and reasonable anger as well as the norms that govern the distinction. Our tendency to frame appropriate anger in terms of reasonableness is problematic because that norm is based on a theory of rationality that is biased and gendered. Contrary to men, women’s anger gets pathologized, mocked, and ignored. Understanding emotions and behaviors requires that we attend to cultural milieu in which it is located. Psychiatry decontextualizes the individual, viewing them as a separate entity without considering the larger sociohistorical causes of personal distress. The judgement of an “excess” such as the criterion of inappropriate anger is located in terms of the appropriate response relative to the context. One reason why it is so unclear on what counts as excess anger in BPD patients is because the DSM-5 treats these criteria as simple facts detached from context when they actually require evaluative judgements.

Potter develops an insightful and novel analysis of self-injurious behavior in BPD patients and what marks off socially acceptable and unacceptable body modification. She asks us to consider the body as a text and self-injury as an act of communication. The only way we are likely to learn the meaning of the act of self-injuring is to “give uptake” to the patient’s experience. The concept of uptake comes from philosopher John Austin who argued that when we use words we are performing actions. To give uptake is to recognize the patient’s meaning-making. It requires that a listener hears the speaker. “We have few if any language conventions,” Potter writes, “that lead us through the discourse about self-injury in a way that preserves the integrity of the communicator” (p. 142). Since clinicians are often at a loss to understand the actions of individuals who self-injure, it is so important that we “try to understand what the world looks like from the communicator’s position” (p. 141). Potter’s emphasis on uptake is about a different kind of listening that asks the listener to suspend his or her usual interpretative framework to some degree. Giving uptake can be understood as a methodology. A proper response by the listener is one that conveys an empathetic attitude toward the communicator and an earnest attempt to understand things from the communicator’s point of view.

To provide a framework for ethical responses to and interactions with patients who self-injure, Potter also draws on the theory of signification. With signification, signs are composed of a signifier (marks on a page or sounds) and a signified (what those marks on a page or sounds mean). The signified is the meaning that is inscribed in a term or utterance. The task of the listener is to determine whether or not something is being communicated and, if so, to interpret it. However, it should not be automatically assumed that the patient who self-injures is trying to say something. Not all self-injury necessarily has to have meaning. It is also true that the sign may not be just one thing—it may contain contradictory meanings. She argues that when we interpret signs written on the body, “we must be skeptics with respect to cultural and linguistic norms” (p. 89). This means remaining open to what an individual may—and may not—be saying when a BPD patient burns or cuts herself. In order to understand what is being said, we need to consider not only the cultural norms that shape meaning and interpretation but also the individual speaker. For example, in the context of an economy and culture where body commodification and objectification proliferates, women become increasingly alienated from their bodies. Hence the need to self-injure may be seen as a need for women to experience their body as real.

Potter closes out the first part of her book with a discussion of manipulative behavior. While manipulativity is not listed as a diagnostic criterion for BPD, it is ubiquitous in the literature when discussing and describing patients. It is often the clinician who equates BPD patients with manipulativity and forewarns others about them. Potter argues that due to the pejorative nature of the term and because it refers to behavior that is thought to require management, the use of the term manipulativity needs to be more precise. The usage and meaning of manipulative in society and in clinical contexts is messy. Clinicians tend to use the term as a catch-all category under which morally wrong ways of interacting are included. However, lumping all of these behaviors together is not therapeutically helpful because it does not allow for differentiation between kinds of behavior that vary among BPD patients. Potter draws on Erving Goffman in suggesting that most people on occasion deceive, are indirect about what they want, disguise their true feelings, and intimidate others yet BPD patients are always characterized as manipulative. She asks:

Why are patients viewed through this lens rather than seen as participants in an acceptable social-role interaction in the context, or engaged in a type of persuasion, or as making a move in a negotiation? How can we distinguish normal manipulative behavior from pathological, especially with the apparent variations between behavior and usage? (p. 106).

She argues that the characterization of BPD patients as manipulative may not necessarily be something objectively real in these individuals but due to stereotypes that circulate about these patients. More context is required.

In her analysis of some of the symptoms that characterize BPD, it is worth noting that Potter does not argue against the existence of pathological behavior altogether. She believes there is such a thing. She continually reiterates the seriousness of maladaptive behaviors in BPD patients and the real harm they can cause. Her concern is the sneaky intersection of the medical and cultural when people behave in ways that go against society norms or disrupt standing power dynamics.

In the second part of the book, Potter proposes a series of ethical responses to BPD that she considers to be crucial virtues. Without these virtues, she argues, clinicians are unlikely to be able to form effective and healthy therapeutic relationships with BPD patients. The first of these virtues is trustworthiness. This “virtue of character” is critical to develop when working with individuals who may have experiences of having their trust shattered. Potter states that a “clinician can show her trustworthiness by engaging in critical self-reflection about the rejecting attitudes, assumptions, norms, and expectations that she may be bringing to the therapeutic encounter, as well as institutional (psychiatric) biases” (p. 130).

The second virtue is giving uptake which Potter describes as the “attempt to genuinely understand the communicant’s point of view” (p. 41). She states that “part of knowing how best to treat a particular BPD patient is coming to an understanding of what their behaviors mean to them, and to do that requires an ethics of communication, a central feature of which is the virtue of giving uptake” (p. 146). If we are to give uptake to BPD patients, we will treat each expression of anger, self-harm, each statement or behavior on its own terms and not assume that it “means” nothing. Giving uptake is a virtue that clinicians need to cultivate if they are to assist BPD patients in flourishing. Giving uptake is a such an important virtue because our participation in dialogue and discursive practices create the conditions for us to be fully flourishing individuals. Alternatively, being barred from participation has the effect of impeding our development. Structural injustices sometimes impede members of minority groups from being recognized. A dominant group may or may not decide to uptake a person’s claims on the basis of their membership to a subordinated group. Such constitutes oppression. Potter doesn’t touch much on power, but I think it is important to consider the power dynamics not only of clinicians and patients, the psychiatric institution and patients, and a male-dominated field and BPD patients (who are mostly women). We can imagine situations where some speech acts might be unspeakable for patients or women in some contexts due to political, cultural, or gendered power(lessness). Although the words can be uttered, the utterances fail to count as the actions they were intended to be because they are not taken up by the dominant power. I love the following quote:

The ability to perform speech acts of certain kinds can be a mark of political power. To put the point crudely: powerful people can generally do more, say more, and have their speech count for more than can the powerless. If you are powerful, there are more things you can do with your words…If you are powerful, you sometimes have the ability to silence the speech of the powerless…But there is another, less dramatic but equally effective, way. Let them speak. Let them say whatever they like to whomever they like, but stop that speech from counting as an action. More precisely, stop it from counting as the action it was intended to be.[ref]Langton, Rae. “Speech Acts and Unspeakable Acts.” Philosophy and Public Affairs 22, no. 4 (1993): 299 .[/ref]

The third and final virtue is empathy. This is a virtue that is often lacking in the treatment of patients with BPD. Potter argues that a central aspect of a clinician’s feelings of anger and entrapment toward BPD patients is the attribution of choice and responsibility for their behavior. In other words, they see patients as blameworthy. However, according to personality disorder theory, patients with BPD do not have full control over their behavior and moral philosophy holds that people ought not to be blamed for things that are beyond their control. Therefore, BPD patients who are genuinely personality disordered and mentally ill deserve empathy. Clinicians need to cultivate empathy in order to emotionally experience others’ worlds, specifically, the world of particular patients.

Potter is a philosopher and her intended aim is to raise questions, not provide answers. While some of the concepts that Potter employs are difficult and complex, her analysis is clear and navigable. She provides an alternative approach for clinicians to relate to BPD patients which reduces the chance of misdiagnosis and helps those suffering from this disorder. She expects a lot out of clinicians who treat patients with BPD and seems to focus less on the responsibility for patients with BPD to take for the therapeutic relationship. However, I do not see this as problematic considering so much literature has focused negatively on patients as being difficult or to blame for this disorder. Potter argues that our understanding of BPD needs to incorporate the careful dissection of taken-for-granted concepts and “epistemic humility” or the willingness to let patients tell their stories.

Aviv, Rachel. “The Death Treatment.” New Yorker. June 22, 2015. http://www.newyorker.com/magazine/2015/06/22/the-death-treatment (accessed September 3, 2016).

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Those unfamiliar with the spate of assisted suicides taking place in the Netherlands and Belgium would do well to read up on the harrowing issue in Rachel Aviv’s “The Death Treatment,” from the June 22, 2015 issue of The New Yorker. In both countries, patients can be euthanized even if they do not suffer from a terminal illness:

In the past five years, the number of euthanasia and assisted-suicide deaths in the Netherlands has doubled, and in Belgium it has increased by more than a hundred and fifty per cent. Although most Belgium patients had cancer, people have also been euthanized because they had autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression.

Aviv’s poignant article begins with one such case of euthanasia. Godelieva De Troyer, a Belgium woman, suffered from severe depression since she was 19. In 2010, her life spiraled out of control following a breakup. Compounded with a fractured relationship with her son and daughter, she decided that she wanted to end her life:

Godelieva felt as if her emotional progress had been an illusion. She had seen the same psychiatrist for more than ten years and had consulted him on every decision, even those involving financial investments and home renovations, but she had now lost faith in his judgment. She complained to friends, “I give him ninety euros, he gives me a prescription, and after ten minutes it’s over.” Her psychiatrist acknowledged that there was no cure for her condition; the best he could do, he said, was listen to her and prescribe antidepressants, as he had been doing for years.

In September 2011, De Troyer saw Dr. Wim Distelmans, sometimes dubbed “Dr. Death,” at his clinic. Distelmans, an oncologist and professor of palliative medicine, has devoted his career to ending people’s suffering through assisted suicide. On April 20, 2012, Tom Mortier, De Troyer’s son, received a short letter from his mother that was written in the past tense. She explained that her euthanasia had been carried out the day before at the Free University of Brussels.

The bulk of the article focuses on Mortier, whose life changed dramatically when he was informed that his mother was dead and that she had chosen her death. Mortier responded by seeking answers from the doctor who euthanized her. He was enraged that he was not informed of his mother’s choice until after she had carried it out. A week after his mother’s death, Mortier emailed a psychiatrist named Lieve Thienpoint, who, with Distelmans, founded Utleam, a clinic for patients who are considering euthanasia. Aviv reports that in the past three years, 900 patients have gone to Ulteam, half of whom complained that they were suffering psychologically, not physically.

She writes:

Since Ulteam opened, in 2011, Thienpoint said it has been “overrun by psychiatric patients”—a phenomenon that she attributes to the poor quality of psychiatric care in the country. In Belgium, it is not uncommon for patients to live in psychiatric institutions for years. Outpatient care is minimal, poorly funded, and fragmented, as it is in most countries.

Let me be clear: I am all for assisted suicide. But I find this article disturbing. Belgium’s policy for euthanasia seems to me to be very mechanistic: send in an application, have it reviewed by three specialists who determine whether your suffering is “unbearable” and your condition “untreatable” and, if they agree, you get your wish. As Aviv writes: “The laws seem to have created a new conception of suicide as a medical treatment, stripped of its tragic dimensions.”

The destigmatization of mental illness has been achieved in part by claiming that mental illness is just as debilitating as physical illness and should be treated accordingly. But if mental illness and physical illness are similarly incapacitating, should we use the same standards in deciding how to best alleviate the overwhelming suffering they cause? Part of the rationale behind allowing euthanasia for the mentally is that if we are willing to help a terminal-cancer patient to die why shouldn’t we do the same for a person suffering from an “incurable” mental illness. The problem seems to lie with the term “incurable,” which is subjective in the case of psychiatric conditions.

One study has shown that many psychiatric patients euthanized in the Netherlands may have in fact suffered from treatable conditions. 66 cases of people who received either euthanasia or assisted suicide between 2011 and 2014 for psychiatric reasons were published online by the Dutch regional euthanasia review committee. Of the patients whose case files were studied, more than half had previously refused at least one form of treatment with many of those patients citing “lack of motivation” as the reason for their refusal. In Aviv’s article, it was reported that De Troyer did not undergo electroshock therapy (ECT) prior to requesting and being approved for euthanasia despite the fact that ECT has been shown to have successful outcomes in treating severe mood disorders. The study also found that one quarter of cases involved differences of opinion between physicians and yet death hastening proceeded anyway.

Euthanasia in Belgium and the Netherlands also raises concerns over informed consent. It is debatable whether the deeply disconsolate can make truly informed decisions. Undoubtedly, some competence is lost with severe depression. Mental illness affects the way one sees reality and it would be wrong to assume that all severely depressed individuals can realistically appraise their likelihood of having a better future. It is known that many suicidally depressed people are prone to impulsivity and therefore are not going to weigh the pros and cons of being dead. They just want to not hurt right now. This raises the question of whether someone who is suffering from a severe mental illness even has the capacity to make a life-and-death decision.

Another factor to consider is the state of a society’s mental health system. Significant gaps exist in mental healthcare including lack of treatment, long waits, and insufficient training for health-care providers. Is it right to give the mentally ill access to euthanasia if we cannot give them full access to treatment and support options? Would resources be better spent investing in quality and affordable mental health services?

As a society, we do not usually encourage suicide, much less assist in it. Public health policy has focused on suicide prevention. When we come across people who are suicidal, we try to help them to live rather than kill themselves. Doctors are supposed to play a key role. If they have reason to believe that a patient is suicidal, do they not have a duty to try and protect that patient from self-harm?

The upsurge in euthanasia and assisted-suicide cases in the Netherlands and Belgium is concerning. In her book, Night Falls Fast: Understanding Suicide, Kay Redfield Jamison touches upon the reality of an effect called “suicide contagion.” Media publicity surrounding a suicide has been repeatedly and definitively linked to a subsequent increase in suicide, especially among young people. Suicide prevention advocates have even gone so far as to develop guidelines for news media coverage of suicide deaths. The idea is to avoid emphasizing or glamorizing suicide, or to make it seem like a simple or inevitable solution for people who are at risk. We should question whether in allowing the option of euthanasia for psychiatric maladies, we are not also running the risk of increasing its likelihood in young and vulnerable individuals.

These are important ethical issues that must be addressed in psychiatry and society when considering how to help patients with the complexity of prolonged suffering that many psychiatric conditions bring. The ultimate goal should be to find the best ways of helping patients with intractable and unbearable psychiatric illnesses in the most effective and ethical way possible. It may not be that prolonging life in severe psychiatric conditions is the best choice. However, it is clear that given the number of unresolved ethical quandaries involved in this issue that a serious discussion is necessary.

Jamison, Kay Redfield. Night Falls Fast: Understanding Suicide. New York: Vintage Books, 2000.

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Suicide is a particularly awful way to die: the mental suffering leading up to it is usually prolonged, intense, and unpalliated. There is no morphine equivalent to ease the acute pain, and death is not uncommonly violent and grisly. The suffering of the suicidal is private and inexpressible, leaving family members, friends, and colleagues to deal with an almost unfathomable kind of loss as well as guilt. Suicide carries in its aftermath a level of confusion and devastation that is, for the most part, beyond description. (p. 24)

In Night Falls Fast, Kay Redfield Jamison delves into a discussion of suicide with precision and aplomb. Her ultimate goal is to shine light into the darkness of suicide in an effort to gain a better understanding of the act. She examines a variety of facets of suicide including its history, its connotations, its biological underpinnings, as well as its psychological implications. This is a book that helps us to understand the suicidal mind and to recognize and come to aid of those at risk. She is a firm believer that suicide is preventable and her arguments are compelling.

Jamison is a prominent professor of psychiatry at Johns Hopkins University and the author of An Unquiet Mind: A Memoir of Moods and Madness and Touched With Fire: Manic-Depressive Illness and the Artistic Temperament. She is a renowned authority on mood disorders and suicide. Jamison begins the book with the painful story of her own suicide attempt. Like many who have bipolar disorder, Jamison knows suicide in an intimate way. When she was twenty-eight, after a damaging mania followed by a prolonged depression, Jamison took a massive overdose of lithium:

It was simply an end of what I could bear, the last afternoon of having to imagine waking up the next morning only to start all over again with a thick mind and black imaginings. It was the final outcome of a bad disease, a disease it seemed to me I would never get the better of. No amount of love from or for other people—and there was a lot—could help. No advantage of a caring family and fabulous job was enough to overcome the pain and hopelessness I felt; no passionate or romantic love, however strong, could make a difference. Nothing alive and warm could make its way in through my carapace. I knew my life to be a shambles, and I believed—incontestably—that my family, friends, and patients would be better off without me. There wasn’t much of me left anymore, anyway, and I thought my death would free up the wasted energies and well-meant efforts that were being wasted on my behalf. (p. 291)

Jamison was lucky: she survived. Following the attempt on her life, she turned her attention and scholarly skills to understanding what had happened to her.

Jamison emphasizes the highly disproportionate suicide rates among those suffering from the major mental and mood disorders of depression, bipolar disorder, and schizophrenia. These psychiatric conditions are by far the most commonly associated with suicide. The co-occurence of alcohol abuse and chemical dependency are frequent concomitants of suicidality as well and increase one’s risk for taking their life. Many neurotransmitters, such as serotonin, and hormones are critical to the regulation of mood and to the activation of the many behaviors such as impulsivity, aggression, and violence that are implicated in suicide and suicide attempts.

Jamison’s vigorous program for suicide prevention centers on prescription drugs that modulate levels of neurotransmitters. She emphasizes the underdiagnosis of depression and underutilization of antidepressants to treat severe depression and suicidal ideation. This is in opposition to reports that antidepressants are being handed out like candy by American physicians. While she does make room for the psychological and social factors that often precipitate the final decision to act on suicidal impulses, she makes it clear that she will not tolerate any dissent that suicidal depression is inherently biological and human behavior in general and mental health in particular are primarily determined by our genetic makeup and the chemicals in our brains:

Philosophical views and assumptions about the causation of suicide, while strongly held and necessarily and importantly debated, are not sufficient to disregard the massive and credible medical, psychological, and scientific research literature about suicide. Ignoring the biological and psychopathological causes and treatments of suicidal behavior is clinically and ethically indefensible. (p. 255)

Jamison is confident that the development of forms of biological analysis and neuroimaging may someday allow scientists to detect neurochemical and anatomical changes in the brain associated with an increased risk of suicide. And while she does not dismiss the value of psychotherapy in treating depression and preventing suicide, but believes that self-reflection is secondary to medical intervention:

The complexity of the suicidal mind and brain demands for its care a complexity of clinical thought and treatment. Psychotherapy alone, if used without addressing or treating the underlying psychopathology or biological vulnerabilities, is generally unlikely to prevent profoundly suicidal individuals from killing themselves. The ability to diagnose psychopathology accurately and to refer patients to colleagues for medication when necessary is a nonnegotiable fundamental of good clinical practice. Not to do this is malpractice. (p. 253)

Jamison’s persuasive use of statistics to demonstrate that suicide is a public health crisis makes it clear to the reader that suicide is a topic, as uncomfortable as it is, that needs our immediate attention. Even though her statistics are dated, the current numbers tell the same horrifying tale. It is a societal illusion that suicide is rare. In the United States, a person commits suicide every thirteen minutes. Suicide is the third leading cause of death among persons aged 10-14 years, the forth among persons aged 35-44 years, and the fifth among persons aged 45-55 years. Among high school students, 17% of students seriously considered attempting suicide in the previous year and 13.6% of students went so far as to make a plan about how they would attempt suicide.[ref]Suicide Facts at a Glance 2015. Centers for Disease Control and Prevention. http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.PDF[/ref]

Part of the strength of this book is the quality of Jamison’s writing. She writes with gravitas and immediacy. She excels at articulating the desperate pain of a person contemplating suicide and their often inability to think themselves out of it. She combines poetry, diaries of suicide, summaries of research studies, and her own experience. Her talent for synthesis and prose cannot be overstated. The result is a very informative book that reads like excellent literature.

While Jamison does a fantastic job in exploring the etiology of suicidal intent, the treatment of a suicidal mind, the prevention of suicide, and the portrayal of suicide in the media, I am disappointed that she did not investigate the ethics of suicide. There is a fascinating and disturbing report of a young Dutch woman who had been sexually abused and suffered from depression and other severe mental illnesses for more than a decade who recently ended her life by assisted suicide after psychiatrists deemed her condition incurable. In recent years, there has been a marked increase in the number of individuals in the Netherlands who have chosen to end their lives due to mental illness. Should people with a non-terminal illness be helped to die? Does a severely mentally ill person who wishes to escape prolonged suffering lack the capacity to make such a life-and-death decision?

Jamison notes the media’s role in potentially increasing suicide attempts. Many stories concerning a young person committing suicide are deemed newsworthy. It is known that news coverage of a suicidal event tends to heighten the public’s preoccupation with suicide. Sensationalizing suicide is also thought to be associated with a contagion effect. One wonders if suicide is indeed contagious as Jamison seems to suggest, is not her book itself a potential source of infection? Is it possible that someone who is thinking about suicide may find this text triggering? Or is the opposite true in that this book may symbolize hope in a person who is severely depressed in providing solace that they are not alone?

Lastly, is there a danger in placing nearly all of one’s faith in biological explanations of human behavior? While I agree that there is an indisputable link between biology and depression, it could be argued that Jamison endows the clinical research into prescription drugs and medical therapies with far too much authority. Convincing evidence exists that suggests the important role that psychotherapy plays in alleviating the symptoms of severe mental illness.

Overall, Jamison has produced an authoritative and passionate look at the importance of bringing suicide to the forefront of discussions about public health. She covers a difficult subject with compassionate insight and credible clinical research. Jamison is one of the bright lights of American psychology.