Kramer, Peter. Listening to Prozac: The Landmark Book About Antidepressants and the Remaking of the Self. New York: Penguin Books, 1997.

When it was published in 1993, Listening to Prozac by psychiatrist Peter Kramer became an instant bestseller. Kramer captured a revolutionary moment in psychiatry with the advent of a new class of antidepressants (SSRIs) that included the drug, Prozac. Prozac was released by Eli Lilly in 1987. Kramer’s book caused a sensation because it painted a very optimistic and hopeful picture of Prozac’s nearly miraculous ability to transform people’s lives in positive ways. Prozac was demonstrated to help patients with many types of mental disorders: depression, obsessive-compulsive disorder, eating disorders, substance abuse, and attention-deficit disorder. And it did all of this with very few side effects.

But the book also raised many important questions. Among them is whether or not it is ethical to prescribe a drug that increases a person’s self-confidence, resilience, and energy level even when there is no underlying medical condition. It also forces us to consider whether it is possible for a medication to rob us of the characteristics that make us uniquely human, characteristics that include anxiety, guilt, shame, grief, and self-consciousness. Isn’t a certain amount of depression and anxiety part of the “norman” human condition? Kramer wrote: “In the work of existential philosophers like Kierkegaard and Heidegger, the individual’s struggle with anxiety is the preferred route to self-discovery” (p. ix). Are we not losing sight of something important about ourselves and our conception of self when we view guilt, shame, and grief as things to be treated rather than as seeing them as part of the human condition? Prozac may eliminate illness, but in doing so it may also be eliminating what are perfectly sensible reactions to life’s circumstances. Is the overuse of Prozac an indication that our culture is seeking to anesthetize itself from the inherent pain of human existence?

Kramer’s thoughts on Prozac arise from his interactions with his mildly depressed patients who underwent remarkable positive transformations in personality while on the drug. He makes it clear from the beginning that he is only going to focus on case examples where patients responded to Prozac by becoming “better than well” (p. x). As such, he makes no mention of the non-responders, mild-responders, side effects, or withdrawal syndromes. Kramer is concerned with the ethical issues related to prescribing Prozac, which he considers a wonder drug. In between filling out prescriptions, he grapples with whether we should prescribe drugs to improve on normality rather than to treat pathology. He coins the term “cosmetic psychopharmacology” to describe the former. The transformative power of Prozac on the lives of ordinary individuals leads him to question whether the medicated or unmedicated version is the person’s “real” self. Do the transformations Prozac induces reflect an unnatural idealized social norm or are they unveiling a healthy individual trapped in an unnatural state? Kramer speculates that the true self in his patients is masked by years of depressive illness. Many of them upon stopping the drug would remark, “I am not myself again” (p. 10). For these individuals suffering from mild depression, compulsions, or anxiety, the medicated self ironically becomes the true self despite being in an altered biological state. Kramer believes that Prozac has a positive role to play in the ultimate struggle to understand the self. He believes antidepressant have the power to liberate individuals:

In my experience, many patients, including some who may never have had a diagnosable mental illness, are better able to explore their past and their current circumstances while they are taking Prozac. For these people, to whom medication constitutes help in recovery from childhood trauma or protection from a threat of terrible decompensation, the drug seems to aid rather than inhibit the struggle to locate the self (p. 278).

Key to this text is the concept of “cosmic psychopharmacology.” Kramer wants to know if Prozac should be used to treat those who are not suffering from a mental illness, but still want to enhance themselves. He asks us to consider: “What if we knew that for certain people had a nonaddicting, relatively safe drug that increases alertness, quickness of thought, and verbal and mechanical fluency? Should each person be permitted to weigh the risks and benefits and choose to take the drug, even in the absence of illness?” (p. 245). Prozac is a drug that seems particularly helpful for people who do not have severe mental illnesses, yet whose careers, relationships, and happiness are seriously compromised by problems such as anxiety, social isolation, compulsive behaviors, and low self-esteem. The medication seems to alter parts of the individual’s personality. It is this remarkable ability of a drug to create personality changes that Kramer finds exciting and a little disconcerting (I say a little because he continues to prescribe the drug to the mildly depressed and even some who don’t appear to be mentally ill at all). He also raises the question about how much of our personality is biologically determined.

Due to the success of Prozac, which works on a person’s biology, he begins to question whether personality and temperament are biological characteristics. He writes: “Spending time with patients who responded to Prozac had transformed my views about what makes people the way they are. I had come to see inborn, biologically determined temperament where before I had seen slowly acquired, history-laden character” (p. xii). Much of Listening to Prozac provides suggestive evidence that mental illness can come from problems with brain wiring and chemistry that are either inborn or develop in response to traumatic events or stressors. Even though psychotherapy might help a patient gain important self-knowledge such as understanding conflict and traumatic events and how they have affected the patient’s behavior and thoughts, the patient cannot fully recover without dealing with the biological manifestation of the problem. Moreover, failing to treat the biological component of minor mental illness can be devastating. Kramer describes many research studies demonstrating that if mild depression is not treated, changes can occur in the anatomy and chemistry of the brain. Mild depression can escalate into becoming severe depression or bipolar depression, both of which are extremely difficult to treat.

Kramer describes his first clinical experience with Prozac with a patient named Tess. She succeeded in life despite not having a stable family to support or guide her while growing up. At an early age, she was tasked with the stressful responsibility of having to care for her siblings. Later in life, she developed an unhealthy relationship with an abusive man. When prescribed Prozac, according to Kramer, she “blossomed all at once,” became more relaxed, and had more energy (p. 8). Only on the drug did she truly feel herself she declares, “as if I had been in a drugged state all those years and now I am clearheaded” (p. 8). Her masochistic relationship towards men disappears and she was transformed from a socially awkward woman into a confident and “social butterfly” (p. 11). She found herself to be more successful at her job. After several months, she went off the medication and immediately proclaimed that she did not feel like herself. Kramer agreed to prescribe the drug again, pondering, “who was I to withhold from her the bounties of science?” (p. 10). “[T]here is no unhappy ending to this story,” Kramer declared about Tess (p. 10). This may be somewhat ominous to someone who does not consider a few years to be an adequate measure of a drug’s effectiveness and safety.

Tess’s remarkable transformation on Prozac was not an isolated case. Kramer next introduces another patient, Julia, who suffers from pronounced perfectionism and a desire that all things in her life be orderly. Although Kramer believes that her marriage issues would best be left to a psychotherapist, he goes ahead and prescribes her Prozac. Once she starts taking the drug, she reports that her marriage has improved. The drug also gets her “out of the house and into the workplace,” where she is independent and competent (p. 40). When her dosage is lowered, she becomes pessimistic, prone to anger, and demanding of her family. Like Tess, she tells Kramer that she doesn’t feel like herself. Kramer argues that Prozac makes us rethink both psychiatry and the self because the drug improves people without pain or insight that are typical of psychotherapy. The medicine makes Julia better to the point where she questions the point of seeing a therapist. Instead, the drug makes Julia happier “without any increased self-knowledge” (p. 32). Kramer prefers biological arguments about the functions of mood and dismisses attributing misery in adulthood to a childhood psychological trauma as is typical of psychoanalysis. He provides many more case studies throughout the book and the general consensus is that Prozac makes them the people they should have always been.

Critics have accused Kramer of advocating medication over psychotherapy when it comes to achieving personality changes not directly related to depression, such as improving one’s social confidence or job performance. He answers those critics in the afterword of this book by expressing his wonder at the resilience of psychotherapy as a technology and his insistence on the need to integrate psychotherapy with the new pharmacology. He believes that “psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety” (p. 292). However, this is not the tone that he takes throughout most of the text.

One of the strengths of Listening to Prozac is the way that Kramer addresses his own and others’ misgivings about using Prozac to transform others. A drug that has such power raises important ethical questions, especially when it appears to have no downside—that is, the risks and negative effects that typically must be weighed against the benefits of the drug. In 1993, Kramer was reasonably certain that Prozac had no significant side effects for most patients. However, this has changed and has been addressed in the afterword to the 1997 edition of the book. Sometimes it is only after a drug is approved and is widely used for several years that side effects and harmful effects come to light. Prozac is now known to frequently cause sexual dysfunction, digestive difficulties, insomnia, sinusitis, and other problems. The drug is linked to birth defects when taken during pregnancy. In rare events, it can cause suicidal thoughts in some users, especially in the first month or two of use. This potential effect is so dangerous that in the United States, Prozac packaging must come with a black-box warning stating that the danger of suicidal thoughts while taking the drug is particularly likely to happen in young people. An FDA black-box warning is the most stringent precaution a drug can carry before it is pulled from the shelves.

Overall, his book is informative, well written and engaging. The text mixes scientific information with engaging personal stories from Kramer’s patients. Kramer is deeply thoughtful, not shying away from tackling the concerns expressed by critics of Prozac and is frank in his admission about the moral questions that Prozac’s effects have raised in his own mind.

This book is not without problems though. First there is the issue of using case studies as scientific evidence. Some may argue that clinical trials are more important to understanding Prozac’s efficacy than the anecdotal first-hand accounts of patient’s lived experience. (Although there are many who may suggest that just the opposite is true.) Then there is the bias that is inherent in all of us. A psychiatrist’s expectations may distort her judgement and there is the chance that she will pay more attention to the positive results than the negative ones. Additionally, the psychiatrist only sees the cases she treats. She is not privy to the lived experience of other patients whom she does not see. There are other valid criticisms with the drug itself. A 2014 study found that Prozac was no more effective than monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants or placebos. There have been studies suggesting that there is no evidence of a chemical imbalance in depression. After reading Kramer’s unequivocal support for Prozac, I am also disappointed about some of the issues he did not raise. Namely, the unhealthy interdependencies of Big Pharma, physicians, and insurance companies as well as flawed drug trials. There are important questions to consider with regards to Prozac and drugs alike. Are we as a modern society overmedicated? Are we too eager for a quick fix, a green-and-off-white capsule to deal with our emotional pain? Are we so fixated on “performance” in our capitalist society that we feel compelled to “keep up” with pharmaceutical brain enhancers? What are the essence of self and personhood and what are the philosophical implications of using drugs to alter personality? This book raises these questions but does not necessarily provide any answers.

Cvetkovich, Ann. Depression: A Public Feeling. Durham, NC: Duke University Press, 2012.

This is Ann Cvetkovich’s queer feminist project of theorizing depression from a cultural and social context that values feelings and emotions and frames depression as political. She sees depression as a mode of disillusionment and discontent that reflects, and is produced by, contemporary society and neoliberal capitalism. Rather than as a disease that plagues the individual, she positions depression as a political or a social feeling. Cvetkovich situates her work in the Public Feelings Project in cultural studies, a central goal of which is to “reintroduce feelings into politics” (p. 104). Her approach reflects Public Feelings’ emphasis on the inseparability of affect from politics:

Rather than seeing negative feelings of failure, mourning, despair, and shame as getting in the way of politics or needing to be converted to something more active in order to become politics, such work attends to felt experience as not only already political but as transforming our understanding of what counts as political (p. 110).

In this text, Cvetkovich is interested in alternatives to the medical model of depression which advertises pharmaceuticals as its treatment and cure. Discussions about the biochemical causes of depression might be plausible,” she writes, “but I find them trivial. I want to know what environmental, social, and familial factors trigger those biological responses—that’s where things get interesting. A drug that masks the symptoms of a response to a fucked-up world or a fucked-up life doesn’t tell me anything. I want to hear about the people like me who’ve decided not to take drugs” (p. 15). For this, Cvetkovich keeps an “archive of depression” where she draws inspiration from other academics, writers, and artists about how they manage to get through life with feelings of despair and alienation from a number of different angles that do not involve pharmaceuticals. Cvetkovich does convincingly argue that we need new forms of memoir writing about depression that counter the mainstream personal narratives of folks like Andrew Solomon, Lauren Slater, and Elizabeth Wurtzel, which all conclude that antidepressants are some sort of savior. Although the author is ambivalent about the self-help genre, she still compares her writing on depression to a self-help book aimed at “an audience of academics and queers, especially those who remain curious about the genre despite their reservations and disidentifications” (p. 209). This book envisions depression as a form of “being stuck” (Cvetkovich seems to prefer this terminology to depression) and envisions new ways of moving forward or new ways of living that go beyond medical intervention. She envisions depression as an instructive feeling, one that is productive of new kinds of knowledge.

One thing to note is that Cvetkovich’s work is theory-heavy and jargon-laden, which I think may be par for the course with cultural studies (I could be wrong about this, only guessing). Some parts of this text were difficult to decipher and persevere through. I found the introduction to be the most difficult part of the book to finish reading. In it, she touches on affect theory (which as I understand is a new school of thought in the humanities in which emotions or feelings are the privileged means of exploring cultural artifacts), critical race theory, and queer theory without going into much detail about each of these influences. The result feels like a deluge of names and ideas without very much substantive content.

The first half of the text is a memoir of Cvetkovich’s depression, which she calls “The Depression Journals.” The Depression Journals document the darkness of her life while writing her dissertation and her navigation through the academic job market. Her deepest depression comes on the heels of receiving both a book contract and a postdoctoral fellowship. She experiences a deep sense of dislocation—a disconnection from home and the familial histories it represents and an increasing unease with ordinary events of everyday life such as those of academic life, domestic life, social life, and self-care. As the depression stretches on for her, she follows up with therapists and eventually a psychiatrist who prescribes her antidepressants. She takes the drugs for a while, but eventually weans herself off after experiencing side effects. She chronicles her everyday boring and banal activities such as grocery shopping, going to the dentist, going swimming, doing yoga, and knitting and it is through these everyday rituals and habits that she eventually regains a precious sense of control over her life and body. She learns to cultivate habits and practices of physical movement, self-care, and creative expression in ways that make her life feel livable again. The Depression Journals are easy to read and are relatable. I think it’s important to point out that Cvetkovich’s type of depression is one that is not taken all that seriously in our culture. It is the sort of depression that brings your mood down low, but does not stop you from accomplishing what needs to be done in your life. Based on her description, I would not classify it as severe. This may be an unfair assessment on my part.

The second half of the book, “A Public Feelings Project,” takes the form of a critical essay in three chapters. These are interconnected reflections on her memoir form. The speculative essay that forms the second half of this book is meant to be an alternative form of tracing depression as a concept in order to resist the medicalization of it and to provide an alternative means for getting oneself unstuck.

In the first section of part two, Cvetkovich seeks alternatives to the neoliberal medical model of depression and she turns to the historical concept of acedia, an early monastic notion described as a “weariness or distress of heart” (p. 85). It is a spiritual crisis characterized by a lack of affect, but also by intense feelings of disgust, disdain, and dislike. This is an affliction that struck forth-century monks who found that they wanted to forsake the contemplative life in favor of sleeping or running away. Cvetkovich wonders if historical accounts of acedia can contribute to alternative, non-medical models of depression. This conception, she contends, can help us to understand depression as meaningful through the recognition of sadness as both “a normative part of cultural experience” and “a creative force” (p. 107). She notes that scientific accounts of depression lack a historical critique of the medicalization of depression which views depression as universal. In fact, this is a historical period that arose in the middle of the nineteenth century with the development of magic bullet medicine which was the idea that you could find a drug, target a molecular target and kill the disease. The turn to acedia and spiritual crisis provides a vantage point of depression that foregrounds matters of faith and hope as relevant to the experience of being depressed, which can manifest itself in psychic and spiritual ways in addition to biological and physical ones. Cvetkovich notes that she is not against science as a cause for depression, but she does not believe it is an either/or choice between biology and culture. Her interest in spiritual approaches to depression is a call for “more integrated relations between science and humanities in order to transform medical cultures” (p. 102).

In the second section of part two, Cvetkovich looks at race and the “emotional inheritance” of psychic trauma of a history of slavery and colonialism as well as the ordinary experiences of racism and alienation which are often omitted from a mainstream narrative of depression. Thus, Cvetkovich moves away from more popular memoirs and takes up the narratives of feminist scholars of the African diaspora as well as narratives dealing with class vulnerability and geographical displacement. Cvetkovich attempts to understand, not only how the symptoms and treatment of depression might differ for people from different racial, ethnic, or class origins, but also how North America’s history of genocide, colonialism, and dispossession engenders depression for some people in the working class, the African diaspora, and in Native American communities.

The third section of part two is dedicated to the art of crafting as an everyday sacred practice in response to depression. In a practice known as “craftivism,” she writes how feminist, queer, and disabled communities can come together and exercise their political agency in the face of racial, colonial, and neoliberal domination. She argues that the “cure” for depression resides in the art of everyday living and this is best achieved through the art of crafting. She writes:

Crafting practices inhabit the epidemic of feeling bad that is one form of insidious slow death spawned by neoliberal capitalism, especially among the middle classes, who, despite fewer material obstacles to thriving, are still bogged down by worry and—to invoke a concept that is both psychic and somatic—stress. Unlike forms of self-sovereignty that depend on a rational self, crafting is a form of body politics where agency takes a different form than application of will. It fosters ways of being in the world in which the body moves the mind rather than the other way around, or in which, echoing neurobiological views in another register, body and mind are deeply enmeshed or holistically connected. It produces forms of felt sovereignty that consist not of exercising more control over the body and senses but instead ‘recovering’ them from the mind or integrating them with it. Crafting emerges from the domestic spaces that are at the heart of women’s culture to provide a model for ways of living that acknowledge forms of structural inequality while also practicing modes of bodily and sensory life that incorporate or weave them into the fabric of daily life that literally includes texture, color, and sensory pleasure (p. 168).

Her prescription for getting out of stuckness is that of a life of contemplation and action as opposed to apathy and passivity. For her, this is achieved through daily activities that are meditative, like writing that focuses on paying attention to what is immediately present and valuing the ordinary and the detail (she mentions both Natalie Goldberg and Anne Lamott here), yoga, swimming, or crafting. She calls this spiritual practice, the utopia of ordinary habit, which transforms rituals into forms of embodiment or through creative enterprise. This, she acknowledges, may be hard to accept for those who are skeptical of spiritual or quasi-religious language. Indeed, her detailed excursion into the emotional and potentialities of crafting seemed to fall short of proposing a radical alternative model of cultural engagement with depression.

Also, surprisingly similar to Cvetkovich’s utopia of everyday habit and focus on spiritual practice is the teaching of dialectical behavioral therapy (DBT) developed by Dr. Marsha Linehan. DBT is a way for those in overwhelming psychic pain to learn life skills and ways of coping, such as mindfulness as well as self-care and compassion for self and others. The practice of mindfulness is nearly the same as what Cvetkovich refers to as a “slow living” (p. 167). For slow living, she turns to the art of crafting. What interests Cvetkovich in crafting is the process itself, the repetition it requires which is a special mode of attention similar to that required for meditation. She claims she writes “about crafting in the context of depression because, as a form of daily activity (whether individual or collective) that can sooth the mind and even raise the spirit, it presents an alternative to treating depression with drugs. It also reframes what we mean by treatment since crafting and other activities like it may not be cures or antidotes but ways in which depression and related affects are lived with rather than banished” (p. 189). This is similar to the idea behind DBT and many Buddhist views that suggest learning to become comfortable with and accepting of negative feelings and emotions instead of trying to drive them away is the key to becoming at peace. I am surprised that Cvetkovich does not make the link between what she is suggesting and the overwhelming influence of DBT on psychotherapy.

One thing that bothered me when reading this text was the “quality” of Cvetkovich’s depression. And I am bothered that it bothered me because I think perhaps this is too judgmental of a criticism to have. But as someone who has suffered from chronic severe depression, I cannot begin to describe the debilitating effects it brings to all areas of life. So when Cvetkovich writes that she is convinced that there are real and possible solutions for the depression that ails us, that “[t]here is nothing wrong with our biology or our intelligence; sometimes we are just stuck.” (p. 68), I am convinced that the depression that she describes is perhaps not the severest form of depression that is referred to in the DSM or in other memoirs of depression. Hers seems to be a low-lying depression that corresponds with feelings of hopelessness and apathy, but one that does not get in the way of her meeting her obligations in life and interacting socially. She also notes that her depression was alleviated with visits with friends, swimming, yoga, and crafting. She promotes the transformative power of daily habit as a way to combat depression. But for many, depression is not like this. For me, depression is a dark, inescapable place. It’s like being locked in a room with no light, windows, or door. It is so dark that you cannot even see your hands in front of your face let alone a way out. It is waking up each morning wishing you had died in your sleep. In depression such as this, maybe antidepressants or some kind of medical intervention is the only ethical answer. I tend to believe it is.

Another issue I had with this text is that Cvetkovich argues that mainstream depression memoirs by middle-class women are both fetishized and narcissistic which comes as a surprise considering Cvetkovich self-describes her work as confessional feminism. She also touches on the idea of gender resistance briefly, but does not say enough about depression as a means of resistance for daughters against their gender roles. These are gender roles that assume them to be passive, good, nice, and not exhibiting anger or violence. She also does not address how girls have traditionally been labeled as mentally ill when they did not conform to their gender roles.

Unlike other contributions to the field, her memoir is not primarily an account of the effects of pharmacological treatment. Her text successfully formulates a new way of writing about depression and should prompt some introspection from those within academia about the value of combining critical analysis with personal accounts of emotional experience. Certainly there should be more to understanding depression than the medical model.

Price, Margaret. Mad at School: Rhetorics of Mental Disability and Academic Life. Ann Arbor: The University of Michigan Press, 2011.

Higher education often depends on the work of a rational mind. Aristotle’s famous declaration that man is a rational animal is so ingrained in our understanding of education and scholarship today that concepts such as reason, rationality, and critical thinking have infiltrated what we consider to be a good liberal arts education. The academy as a place of reason is a bellicose trope so familiar that it has become definitive of what it means to become an scholar. But what happens to those who are not rational animals? Margaret Price wants us to consider the flip side to Aristotle’s proclamation. What happens to those who do not always think rationally? What becomes of the faculty member who has such severe, crushing anxiety that she abhors teaching or presenting under the bright lights of a professional conference. What happens to the student who suffers from such debilitating chronic depression that he cannot make it to class on a regular basis? There is an obvious bias towards ableism in higher education and this is a book about the ways in which academic institutions, as they are currently designed and organized, exclude people with mental disabilities. Using rhetoric as the frame, each chapter outlines an area of institutional practice that needs to be reformed, rethought, reconfigured, and revised in order to provide all students, faculty, and staff with access and inclusion in higher education. In six chapters, this book covers a range of subjects pertaining to the erasure of the mentally disabled in academe. Price focuses on definitions of mental disability, how conceptions of space and time intersect with the work of mentally disabled students and faculty, the concepts of collegiality and productivity as they pertain to faculty roles, media representations of mentally disabled individuals in the wake of school shootings, mental disability as autobiography and memoir, and independent scholars and mental disability.

Price analyzes the rhetoric and discourse surrounding mental disabilities in higher education. She is interested in the ways that mental disability affect the lives of students, faculty, and staff and the ways that mental disability is identified and valued (or devalued) in this space. She notes that academics with mental disability are largely excluded from academic discourse: “The instruments of exclusion are not visible or dramatic—men in white coats dragging people away—but quiet, insidious: We flunk out or drop out. We fail to get tenure. We take jobs as adjuncts rather than tenure-track faculty. We transfer schools; we find a way to get a job or a degree elsewhere. Or not” (p. 6). Price reveals how individuals suffering from mental disabilities—which she defines broadly to include not only intellectual and developmental disabilities, but also autism, learning disabilities, and mental illnesses—are excluded, ignored, and targeted in higher education, which is an institution that privileges ableism through “the construction of rigid, elitist, hierarchical, and inhumane academic system” (p. 8). And those who are not excluded are “presumed not to be competent, nor understandable, nor valuable, nor whole” (p. 10). Persons with mental disabilities are often viewed as nonhuman. Not only are the irrational/the mad/the mentally disabled often barred from participating in academe, they are not rational animals in Aristotelian sense. They lose their personhood.

In the first chapter, “Listening to the Subject of Mental Disability,” Price introduces the topic of rhetoric and explains that it is not only the way that we communicate with one another, as in speaking and writing, but it also works in visual ways and even the subtle ways like the expression on our faces or the attitudes that we bring to each other. She argues that to be disabled mentally is to be disabled rhetorically. She asks us to consider “what happens to the rhetor who cannot be ‘listened’ to—because ze is not present, or fails to participate in discussions, or fails to ‘make sense’ on a neurotypical scale” (p. 44). Price is working from a perspective drawn from disability studies. She carefully deconstructs the values that are privileged and embedded within the academy. Among these are the idea that all educated minds are rational and are able to “make sense” of the world around them. Price argues that many individuals who are mentally disabled lack rhetoricity, the ability to be received as a valid human subject, barring them from fully participating in the institution. She contends that the mentally disabled are viewed as “Other” in academic discourse because academe is premised on the idea of reason and rationality as normality.

The second chapter, “Ways to Move: Presence, Participation, and Resistance in Kairotic Space,” examines what Price deems “kairotic spaces,” which draw on the rhetorical concept of kairos, a Greek word that is often translated as “the opportune moment” or “the right time.” Kairotic spaces are informal sites of close personal contact (often face-to-face, but not always) in which power (she draws on Foucault) and knowledge are exchanged, and which have high stakes for one or more of the participants. She argues that these spaces are made even more challenging for those suffering from mental disabilities. Kairotic spaces are marked by “the real-time unfolding of events; impromptu communication that is required or encouraged; in-person contact; a strong social element; and high stakes” (p. 61). In this chapter, Price also calls into question the unstated assumption of what it means to be “present” in the classroom. Price raises paradigm-challenging questions, for example, asking how do we accommodate students whose participation in the classroom falls outside of normative expectations. Often composition instructors will assign group work in the classroom to give students more opportunities to engage with the material and to create a participatory space, but students who are anxious and neuroatypical may find that group work produces barriers to engagement with ideas and texts. These small groups may be fraught for students with mental disabilities rather than offering greater opportunities for participation. Price calls for professors, campus administrators, and staff at universities to imagine that students who do not attend class, do not send emails, do not register with the office of disabilities may be students with mental disabilities. Rather than assuming these students are merely lazy or unmotivated, we might think that they are being denied access to the classroom through the assumptions about rhetoric.

The third chapter, “The Essential Functions of the Position: Collegiality and Productivity,” focuses on the ideas of collegiality and productivity in the context of faculty expectations. Price discusses two kairotic spaces: the job interview and the academic conference and how those faculty with mental disabilities may find themselves punished in these spaces. The pressures associated with academic life, especially the triumvirate of “teaching, scholarship, and service,” make academic life more stressful for members of the professoriate with mental disabilities. She asks whether people with schizophrenia or agoraphobia can be professors. It is clear that she wants to answer yes to this question, but she admits that the institutions and structures “will require enormous, paradigm-shifting changes to some of the academe’s most dearly held tenets” (p. 112). In the classroom, she suggests that we look to the principles of Universal Design to reform the structures that keep the mentally disabled from being fully accepted.

In the forth chapter, “Assaults on the Ivory Tower: Representations of Madness in Discourse of US School Shootings,” Price looks at representations of “madness” in reports of school shootings. She focuses on Cho Seung-Hui (who killed thirty people at Virginia Tech in 2007) and Steve Kazmierczak (who killed seven people at Northern Illinois University in 2008). In both cases, the academy is represented as a “sanctuary of reason” (p. 145), while the shooters were clearly demarcated into the realm of insanity against the normality around them. She shows how representations of Cho and Kazmierczak relied on stereotypes of mental disability in order to explain the violence. She addresses the faulty causal link between madness and violence instead promoting accurate statistics that show how individuals with mental disabilities are more likely to be victims of violence than perpetrators of it. This chapter should be mandatory reading for college administrators and college public safety departments.

The fifth chapter, “Her Pronouns Wax and Wane: Mental Disability, Autobiography, and Counter-Diagnosis,” examines how pronoun references in three autobiographic texts from writers with mental disabilities challenge the conventions of the autobiography genre and challenge the relationship between ableist and mentally disabled perceptions. Price examines three “memoirs of affliction” for her analysis. She claims that these are examples of counter-diagnosis, narratives “that claim authority not in spite of, but through and because of, their mental disabilities” (p. 179). Counter-diagnosis produces narratives through a couple of strategies. The first of which is called creative coherence which generates dissembling and structural features of a text that work against the usual ways we rely upon disability narratives. The second strategy is proliferation which tells a story through multiple voices. Counter-diagnosis is a way of challenging, attacking, and queering standard institutional mental disability narratives.

The book’s penultimate chapter, “In/ter/dependent Scholarship with Leah (Phinnia) Meredith, Cal Montgomery, and Tynan Power,” examines independent scholars “whose views are not readily accessible through conventional academic scholarship” (p. 201) because they do not teach, because they do not publish in academic journals, or because they are outside of the conventional academic norm in some other way. Much of the writing done by independent scholars is viewed as only personal and not scholarly. It may be assumed that many independent scholars have chosen a life outside of the academy. “However,” Price points out, “given the inaccessibility of teaching (and speaking, and writing) spaces available in academe, it becomes evident that avoidance of these spaces may be a survival strategy rather than a true choice” (p. 228). Price proposes that we rethink scholarship from both inside and outside the academy as interdependent scholarship.

I found this book to be powerful and relevant because I am a graduate student with a mental disability who strives to be a part of and endeavors to carve out an academic career in an academic institution. As compelling as I think this text is, I also find it difficult to imagine what the alternatives to some of the issues she raises are. One powerful suggestion she made was that of creating a collaborative environment in the classroom for those with mental disabilities. Instead of simply meeting the legal obligation of putting a statement on disabilities within the syllabus, Price suggests that we invite all students to consider how class assignments might be modified to accommodate and encourage their access and participation. At the same time, as funding for public education is being cut and as high-stakes testing is becoming the pinnacle of assessment, it is difficult to see how things can drastically change. Instructors who are committed to accommodation and access for those with mental disabilities may have their hands tied by administrative forces. I am left wondering in what ways might instructors organize their classrooms, class activities, assignments, and policies to recognize and be inclusive of students with disabilities? In what ways might students with disabilities approach faculty about their disability (how much is too much to share) and what might they expect in return?  I am also wondering how do we critique the biomedical model of psychiatry that fetishizes genes, brain structure, and neurochemical chemistry over the lived experience of individuals with mental disabilities. I believe this plays a huge role in how we think about the “Others” with mental disabilities.

Johnson, Merri Lisa. Girl in Need of a Tourniquet: A Memoir of Borderline Personality Disorder. Berkeley, CA: Seal Press, 2010.

“Stories are the self’s medium of being” writes Arthur W. Frank.[ref]Frank, Arthur W. The Wounded Storyteller: Body, Illness, and Ethics. Chicago: University of Chicago Press, 1995.[/ref] Illness narratives do not simply recount someone’s life experience, according to Frank; they enact selfhood, bring a version of identity into being, and as a result, have the potential to undo the stigmatizing prejudices that attach to many forms of illness and disability. Storytelling thus acts in revolutionary and empowering ways, allowing the memoirist to present a version of self that might directly counter the authority of medicine. Personal stories also individualize, offering discrete perspectives against the anonymity of symptoms or etiologies.

With raw honesty, Lisa Johnson tells of her lived experience with borderline personality disorder (BPD) in Girl in Need of a Tourniquet. She recalls her path through a dysfunctional and destructive relationship with a married colleague, recounting the experiences that brought her to her breaking point. In recognizing her struggle with BPD, Johnson is eventually able to reach out and seek help. She embarks on a soul-searching, psychological healing process. It’s a process that is painful, difficult and, at times, heart-wrenching, but ultimately makes her better able coexist in healthy relationships with others.

For the majority of this text, Johnson focuses on the confusion, panic, and chaos that characterizes an affair with a woman, Emily. Johnson recognizes this relationship as co-dependent and unhealthy yet she finds she is unable to break free. Somewhere along the way, Johnson conducts a Google search on her issues of self-mutilation, relationship drama, estrangement from her mother, her addictive personality and is directed to a page on BPD. Johnson immediately recognizes her symptoms are consistent with this diagnosis. Her diagnosis is later “officially” affirmed by a therapist.

In an effort to understand herself and her behavior, Johnson immerses herself in research on BPD, drawing heavily on psychological research in her text. Her writing is spliced with excerpts from various scholarly sources on BPD and personality development, citations from major works in both psychology and self-help literature, various relevant definitions, song lyrics, quotations, poetry, and graphic black slashes (likely representing self-injury, which is often a feature of this disorder). Johnson’s style choices reflect the disorganization of the borderline experience. Chapters are highly fragmented, comprised of chunks of text with frequent interruptions in different fonts and type sizes, capital letters, indentations, and alternating spacing. Overall, this makes for a unique reading experience about a very serious illness. Her writing is figurative and lyrical. This is a very artful memoir.

Despite this being a text about BPD, it takes Johnson about two thirds of the book to start divulging any real information on the disorder. When she does so, she begins with the criteria for a diagnosis of BPD from the Diagnostic and Statistical Manual (DSM). She then goes on to conceptualize the illness as:

A form of madness made of mood disorders and neurological malfunctions. People with borderline personality disorder heat up fast and have trouble cooling back down. Emotions run high. Impulse and inhibition run together like hot and cold water from a tap. Once the borderline body reaches this place of hypervigilance and despair, every day presents new evidence of apocalypse and new opportunities for hysteria and resignation (p. 159).

Johnson pays a lot of attention to the stigma attached to BPD, describing how the media portray women with this disorder as “beautiful sociopaths.” According to Johnson, most therapists and people in general are afraid of those diagnosed as BPD. She recounts an experience that gives a clear indication why there is such a negative connotation with the term:

I had heard of borderline personality disorder when I worked in the university counseling office as a undergraduate English tutor. A woman walked in one day, a streak of dark hair and an open black raincoat. She asked to see one of the graduate-student counselors. No one would tell her anything. Everyone just wanted her to leave. When she left the office, the student worker staffing the front desk turned to me and said, “She’s a borderline. They’ll stalk you.” That’s the start and finish of what most people know about borderline personality (p. 138).

She writes that a diagnosis of BPD “is medical shorthand for patients who make their doctors uncomfortable. Unstable, mercurial, self-injurious, contradictory, seductive, clingy, the term borderline personality has borderline personality. It is in crisis. It is poised to self-destruct” (p. 197). Johnson’s memoir is something of an open invitation to readers to change how they think about people with BPD. Many people have called for the name of the disorder to be changed to “emotion regulation disorder,” renouncing the label of borderline as insult, injury, and outdated bias on par with hysteria. Madness is a word that has been historically used to tie a woman’s arms and legs to a bed in an asylum. There is a radical tradition in psychoanalysis with its roots in the work of R. D. Laing, who questions the social construction of mental illness believing that we sustain a fantasy of being whole if we set apart those who are sick. The idea that anyone is mentally well all of the time is a delusion that may get in the way of asking for help when we find ourselves falling away from our stable minds. Marsha Linehan, the brains behind Dialectical Behavioral Therapy and once a sufferer of BPD, describes this as the borderline patient’s first dilemma: Am I vulnerable and sad or undisciplined and bad? I believe that proposing that the label of BPD is inaccurate or artificial is very risky. It may further undermine the very real needs for therapeutic support and corresponding eligibility for medical insurance claims. Johnson writes that such “pragmatic concerns cannot be overstated, yet as psychiatric knowledge steadily evolves, identity categories give way to more subtle models that conceptualize mental illness as dimensions—continua or spectra without clear separation from normalcy, and with less separation from each other than we think” (p. 201). It’s important to point out that Johnson does not use the term “disorder.” She believes that while BPD is a serious condition, it also seems to be a collection of unhealthy behaviors that many people exhibit at some point in their lives. She writes:

A personality disorder is not the foreign presence of demonic possession or a cancerous cluster of cells spreading among the internal organs. It is a pattern of cognition and reaction that impairs the capacity to be productive, happy, and generally at ease. It is a fractured sense of self giving way to the weight of stressful interpersonal dynamics (p. 203).

In other words, personality disorders are “as common as dirt” (p. 203).

One of the most intriguing things about this memoir is the trustworthiness of the author. I think this comes from her intense self-reflection and compelling honesty about her fractured relationship with Emily as well as her behavior in subsequent relationships (including a fling with one of her students). Johnson also delves deeply into her family life, describing how she was raised by a serious of stepmothers after her father left her “careless and selfish” mother. She focuses much of her attention on her two younger sisters who had the misfortune of being raised by their neglectful mother after Johnson and her father left the household. She describes the guilt she feels for not being there for her sisters, who both also have the diagnosis of BPD. As she gets better, she describes how the illness has manifested itself in different ways for them. She describes her attempts to reconcile with them and help them through their diagnosis. It becomes painfully clear that Johnson has a better handle on her illness than either of her sisters do.

A criticism of this text is that Johnson abruptly shifts from her breakup with Emily to a scene where she is at peace with her new wife, leaving the reader to wonder how she got from Point A to Point B. Johnson makes it clear that even in the her newfound stability, she will always continue to struggle with the instability that comes along with being borderline. However, she does not make it explicitly clear how she reached this stability and I think that is of interest to the reader. Overall, I found the book to be an engaging read with a fast flowing and interesting narrative. This book is clearly written with the intention of offering solace to others diagnosed as borderline and understanding to those who are not.

North, Carol S. Welcome, Silence: My Triumph Over Schizophrenia. Lima, OH: Academic Renewal Press, 2002.

This remarkable memoir tells the story of Dr. Carol North’s phenomenal recovery from schizophrenia. North was chronically psychotic for almost eight years and yet during this time she was not what one would consider a typical schizophrenic. While she was often debilitated by her delusional thinking, she was also highly motivated, driven, and goal-oriented. Despite severe and crippling psychotic symptoms, she continued to achieve academically in college and in medical school. North graduated from the prestigious Washington University School of Medicine in St. Louis, Missouri and went on to do a residency in psychiatry.

What is most astounding though is her determination and will to succeed in the face of seemingly insurmountable odds. It is not merely the description of going psychotic that makes this book memorable. It is also the fact that while North was going crazy, she was also going through college and two years of medical school. This academic pilgrimage is extraordinary in itself, but to go through it while fighting off hallucinations and delusions is almost unimaginable. Even after being barred from medical school during her second year (most likely due to stigma), she tenaciously found another medical school to attend and flourished academically.

Early manifestations of her disease began in childhood, but its full flowering awaited her late teens. There were voices—advising, criticizing, confusing, suggesting, interfering, commanding—one, many. Her characterization of the voices she heard during this time suggests a deeply disturbed mind: “The voices knew the truth: my schoolteacher was indeed a kidnapper, sparrows were really attack birds, my mother was a mind reader. No, nothing was quite what it appeared to be on the surface. All existence was merely a thin membrane covering a greater, hidden reality” (p. 62). She also experienced visual hallucinations of patterns in the air, paranoid delusions that people were reading her mind, trying to kill her, periods of catatonic immobility and multiple suicide attempts. North vividly describes her auditory and visual hallucinations and the book shows her courageous attempts to make sense out of what is happening to her. During her first year of college, she was hospitalized and officially diagnosed with schizophrenia and it was here that she slid further into psychosis and finally succumbed to the inexorable incapacitation that is so often characteristic of the disease.

Her descriptions of her delusional thinking during the prodrome to her first hospitalization are extraordinarily vivid. To have someone who has actually lived through psychosis describe with clarity not only what her thought process was, but the emotions she experienced truly enables the reader to gain a sense of what suffering from schizophrenia is like. Accounts of schizophrenia are often clinical, a story told from the outside looking in. That is why it is so rare to have the raw diaries of a person with schizophrenia that are so accurate, sensitive, and eloquent. This is a book that forces us to confront our stereotypes. The media all too often portray people with schizophrenia as homicidal maniacs or paranoid outcasts. The fact that North is a successful and respected physician demonstrates that there are high-functioning individuals with this disease. It is also exceedingly brave of North, who is in a profession where the slightest hint of being mentally unstable is viewed as a liability, to be so open about her history. Welcome, Silence was published two weeks before the end of her residency program in psychiatry. Knowing the risks she was potentially taking with her career and credibility as a psychiatrist, she decided to go public anyway because “it was the right thing to do” (p. 318). She hoped her story and experience would reduce misunderstanding and stigma surrounding schizophrenia.

During medical school, North was fortunate to find a skilled and sympathetic psychiatrist in “Dr. Hemingway” who understood her dedication to becoming a physician and who worked with her to stay well enough to remain in school. However, her illness progressed and when it seemed as though all hope was lost, her doctor enrolled her in a controversial and experimental kidney dialysis program. This is what cured her.

One minor criticism of this book is that it does not emphasize enough the rarity of North’s outcome. The chance for recovery from schizophrenia without medication is almost unheard of. Even more unusual is the way that North was cured. She was one of the first people to participate in renal dialysis for schizophrenia. The theory behind dialysis is that it removes some unidentified substance from the blood, presumably a chemical responsible for producing schizophrenic symptoms. This is a controversial treatment that is based on reports of success from a small number of patients and not on any rigorous scientific study. As of now, there has been no documented improvement in schizophrenic patients on chronic dialysis. Even today, North is unable to explain why she was successfully cured of schizophrenia and she openly admits that she has never recommended dialysis treatment for any of her schizophrenic patients. This is because newer medications have been developed that are more effective in treating the symptoms of schizophrenia while minimizing the side effects.

North’s story is buttressed by her recollection of fleeting symptoms and medical records obtained subsequently by her treating physicians. The illumination of the mysterious process of psychosis is facilitated by North’s familiarity with the subjective and clinical aspects of the illness. We should be thankful that North was cured so that she could share her story. Most of those living with schizophrenia must suffer in silence. Many have little means of appreciating their own private hells. North offers us a rare look inside.

Slater, Lauren. Prozac Diary. New York: Random House, 1998.

Lauren Slater became one of the first people to take Prozac in 1988. Prozac marked a revolution in psychopharmacology because of its selectivity on the serotonin system. In Prozac Diary, she chronicles her experience with the drug and her shifting identity from one based on illness to one based on health. Although Slater has a master’s degree in psychology from Harvard and a doctorate in psychology from Boston University, her account of life on Prozac can hardly be considered clinical. She intertwines her ongoing antidepressant use with memories of an unstable childhood and an emotionally distant mother. She also explores basic questions of selfhood in a society in which people increasingly turn to pharmaceuticals to improve their feelings about themselves. She questions what it means for the definition of self when someone is happily taking antidepressants and claims they feel “more like themselves” when they are on the drugs as opposed to when they are not.

Slater’s diary is a mediation on what it is like to take Prozac. Slater is open about her long psychiatric history. She has attempted suicide and engaged in self-mutilating behaviors, including anorexia, that resulted in five psychiatric hospitalizations. She has carried the diagnosis of Borderline Personality Disorder since she was nineteen and has battled with severe and recurrent depression. She tried many forms of treatment and nothing had been successful. Then she tried Prozac. Her reaction to the drug was miraculous. She marveled at her quick response: “It was as though I’d been visited by a blind piano tuner who had crept into my apartment at night, who had tweaked the ivory bones of my body, the taut strings in my skull, and now, when I pressed on myself, the same notes but with a mellower, fuller sound sprang out” (p. 24). She felt like an entirely new person yet she also noted that she was finally feeling like the person she was always meant to be. This brings up all kinds of issues and questions about identity, mental illness, and medication. For example, if you have been mentally ill and suddenly feel like yourself taking a medication, who is the real you? For Slater, Prozac took away her obsessive compulsions almost immediately, but she also noticed that it appeared to tweak her personality, noticeably her lack of creativity. While she always considered herself an intense writer, for the first year on Prozac she found that she could not write a short story or a poem. Still, Prozac appeared to be a success for Slater. She describes how it changed her, made her feel normal, and after a period of adjustment, she began to enjoy her life. During this medicated time, she finished a Ph.D. in psychology, went on to become a psychotherapist, was gainfully employed, and developed a relationship with a chemist. However, after an extended period on the drug, she noticed that the initial euphoria had worn off and eventually she needed higher quantities of the drug to get any positive effect. This lack of efficacy after long-term use brings into question the ability of Prozac to be a continual cure for depression. Eventually, her love relationship with Prozac ends and she begins to question her chemical and psychological dependency on the drug. Slater begins to be in awe and envious of “regular people” who live their lives without a chemical crutch. In the end, she sums up her relationship with Prozac explaining that it “is a medicine that takes much away, but its very presence in my life has been about preserving as well as decaying” (p. 200).

Slater has a gift with the English language. The text is elegiac and poetic. The flood of lovely phrases and descriptions had me in a state of admiration. She puts into words and prose what I can only feel. Without question Slater is an amazing writer, but at the same time, it didn’t feel as though there was enough here for a book. I think this would have been better constructed as a literary essay for a magazine such as the New Yorker. Obviously a lot of information in this book is dated which brings its relevancy into question. Prozac Diary was written shortly after the FDA approved the use of Prozac in the late 1980s. Additionally, the interest for this book seems limited. I would think that unless one has tinkered with pharmacological chemicals at some point in their life, then this ethereal and sometimes random memoir would likely have not much resonance. As much as I enjoy memoirs about individuals living with mental illness, there were times when I found this book less than gripping. The second half of the text especially felt full of moments where the content added nothing to my understanding of Slater’s mental illness or how Prozac helped her. Reading this book was certainly not a waste of time, but I do think there are better memoirs on psychopharmacology out there.

(While doing some searching about Slater, I found an article in which Slater is accused of making up quotes in a book she published in 2004. I take it with a grain of salt.)

Jamison, Kay Redfield. Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. New York: Free Press Paperback, 1994.

Robert Burton wrote in the seventeenth century that “all poets are mad.” Many people have long shared Burton’s suspicion that genius and insanity are entwined. Kay Redfield Jamison is a psychologist and a highly regarded researcher of bipolar disorder (also known as manic-depressive illness) and has been eloquently open about her own struggles with the illness in her memoir, An Unquiet Mind: A Memoir of Moods and Madness. In Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, she turns her attention to the specific relationship between creativity and bipolar disorder. Jamison uses a blend of modern psychiatric diagnostic criteria, illness-outcome data and research, and genetics to examine the lives of writers, artists, poets, and composers for evidence of bipolar disorder all the while speculating about the possible ties between the disease and success in the arts. Touched with Fire is a beautifully written book that poetically weaves the strong links between psychopathology and creativity with first-hand accounts about their mental illness from famous artists, writers, poets, and composers. Because Jamison so skillfully illustrates the psychopathology of bipolar disorder by discussing specific creative individuals, often presenting quotations from them or their work, the book is interesting to read and gives the reader a concrete feel for the ideas presented.

Jamison provides a thorough and accurate description of bipolar disorder and cyclothymia. A full description of the types of mood swings that can occur, from depression to normal functioning to hypomania (a milder form of mania) and manic states is given. Mild mood elevations are thought to be the most facilitative for creative thinking therefore hypomania is thought to be the most useful state for creative work because it is characterized by mild mood elevations, risk taking, and fluency of thought. Hypomanic or manic individuals “usually have an inflated self-esteem, as well as a certainty of conviction of correctness and importance of their ideas” (p. 13). After defining mood disorders, Jamison reviews the research and biographical literature that finds an association between creativity and mood disorders.

For years, scientists have documented some kind of connection between mania, depression, and creative output. In the late nineteenth and early twentieth centuries, researchers turned to accounts of mood disorders written by prominent artists, their doctors, and friends. This research is largely anecdotal and is thus not representative of a scientific study, but it strongly suggests that artists and writers and their first-degree relatives are far more likely to experience mood disorders and to commit suicide than the general population. Jamison reviews empirical studies on the incidence of mood disorders among living writers and artists. She also reviews the historical records of numerous deceased artists and writers using information from their medical records, their personal letters, their art, and from their biographers. She makes a compelling case that the incidence of bipolar illness in these groups of artists is staggeringly high, especially for poets, in comparison with the rates in the general population. Judging by current diagnostic criteria, it seems that many famous artists suffered from one of the major affective (mood) disorders, namely, bipolar disorder or major depression. Major depression includes intense melancholic phases, whereas bipolar disorder, a strongly genetic disease, cycles between depression and hyperactivity, euphoria, or intensely irritable states (also known as mania). In its milder form, cyclothymia, bipolar disorder causes changes in mood, behavior, sleep, thought patterns, and energy levels that are not completely debilitating. People who suffer from bipolar disorder and those who are creative appear to share certain features: the ability to function well on a few hours of sleep, the focus needed to work intensely, bold and restless attitudes, and an ability to experience a profound depth and variety of emotions. The review of biographical research indicates that there is a higher rate of mood disorders in artistic populations than would be expected by chance. Jamison then introduces her own study of British and Irish poets born between 1705 and 1805 and she finds that this population was thirty times more likely to have symptoms of bipolar disorder, ten to twenty times more likely to have milder forms of bipolar disorder, more than five times as likely to commit suicide, and twenty times more likely to have been committed to an asylum than the general population.

Jamison builds the link between bipolar disorder and creativity with biographical details about the gifted as well as evidence culled from life-study investigations conducted over the last century and a half and some recent diagnostic and psychological examinations of living artists and writers. While most of the studies being cited suffer from a variety of problems—questionable selection of subject populations, inadequate sample size, lack of meaningful control groups, and ambiguous diagnostic methods—two conclusions emerge: (1) the symptoms of bipolar disorder are disproportionately encountered in higher socio-economic classes and upper levels of educational achievement and (2) poets, writers, artists, and composers give evidence of higher rates of mood disorders than the general population.

The excerpts of personal letters and original work of great writers, composers, poets, and artists of the past are enlightening, inspiring, and often devastating to read. For example, the suicide letter by Virginia Woolf is heart wrenching:

Dearest,

I feel certain I am going mad again. I feel we can’t go through another of those terrible times. And I shan’t recover this time. I begin to hear voices, and I can’t concentrate. So I am doing what seems the best thing to do. You have given me the greatest possible happiness. You have been in every way all that anyone could be. I don’t think two people could have been happier till this terrible disease came. I can’t fight any longer.

–Virginia Woolf

Another telling example is a suicide note written by American artist Ralph Barton detailing the plights of his life and why he can no longer bear to go on living is heartbreaking:

Everyone who has known me and who hears of this will have a different hypothesis to offer to explain why I did it. Practically all of these hypotheses will be dramatic—and completely wrong. Any sane doctor knows that the reasons for suicide are invariably psychopathological. Difficulties in life merely precipitate the event—and the true suicide type manufactures his own difficulties. I have had few real difficulties. I have had, on the contrary, an exceptionally glamorous life—as lives go. And I have had more than my share of affection and appreciation. The most charming, intelligent, and important people I have known have liked me—and the list of my enemies is flattering to me. I have always had excellent health. But, since my early childhood, I have suffered with a melancholia, which, in the past five years, has begun to show definite symptoms of manic depressive insanity. It has prevented me from getting anything like the full value out of my talents, and, for the past three years, has made work a torture to do at all. It has made it impossible for me to enjoy the simple pleasures in life that seem to get other people through. I have run from wife to wife, from house to house, and from country to country, in a ridiculous effort to escape from myself. In doing so, I am very much afraid I have spread a good deal of unhappiness among the people who have loved me.

Barton’s letter exhibits things most people fail to understand about the seriously mentally ill. Despite increased awareness, there is still a need for empathy among much of the world’s population. This book is a contribution to raising awareness and erasing stigma associated with mental illness, supplying vital details of the lives of the creatively revered that carry over to the lives of millions enduring similar situations today.

Jamison devotes an entire chapter to Lord Byron as an example of an intense, changeable, and complex temperament. In another chapter, Jamison intimately presents short biographical overviews of a number of creative individuals including Alfred Lord Tennyson, Robert Schumann, Herman Melville, Ernest Hemingway, and Vincent van Gogh. Through a thorough examination of artists’ famous writings, diary entries, medical records, family trees, and personal writings, she dissects the history of the disease. This interweaving of quantitative research and case study illustrations is the most compelling part of the book and is surely a major contribution to the fields of both psychology and creativity.

This book concludes with a discussion of the medical and ethical concerns raised by the study of bipolar disorder. For example, Jamison asks us to consider the potential consequences of effective treatment of bipolar disorder on the quality of literary and artistic production from those who suffer from it. Moreover, with the prospect of identification of the gene(s) responsible for bipolar disorder, the question is posed about what to do with those who test positive for this disorder. The question is likely to impact medical intervention in the form of gene therapy, prenatal testing, voluntary abortion, and sterilization.

Jamison’s review of the research literature that supports a link between bipolar disorder and artistic creativity is comprehensive although she does not go into much detail regarding the methodology of past studies or possible methodological flaws that come with studying a deceased population for a mood disorder that is conceptualized completely differently today than it was in the day of these artists. The fact that the subjects of this study are all dead invites certain difficulties. It means that most of what can be said about the lives of these people has come from secondary sources and what are often fragmentary and passing observations made by the subjects themselves and their family and friends. The fact remains that the pronouncements of the famous dead were made in a context of cultural assumptions that were quite different from those of our contemporary society.

As a psychologist and an authority on mood disorders, Jamison identifies bipolar disorder as the clinical label best suited to the explanation of the afflictions and erratic behaviors commonly associated with artistic and literary creativity. Jamison succeeds in making a strong argument for this association. For those suffering with bipolar disorder, the book is both disturbing and strangely comforting. Knowing that many of the world’s greatest artists and writers suffered from debilitating conditions, yet were able to contribute immortal novels, poems, paintings, and symphonies to the world provides a sense of great hope. Anyone loving or living with a person coping with a mental disorder such as bipolar disorder often finds the emotions and experiences of the sufferer difficult to handle and impossible to comprehend. Jamison clarifies what it means to feel something one cannot control.

Whybrow, Peter C. A Mood Apart: Depression, Mania, and Other Afflictions of the Self. New York: Basic Books, 1997.

Dr. Peter Whybrow attempts to explain to the lay reader the physical causes of depression and mania and the way psychiatric drugs such as a Prozac and Lithium work to keep these illnesses under control in his book, A Mood Apart: Depression, Mania, and Other Afflictions of the Self. Whybrow examines mania and what he calls melancholic depression (severe depression) generally, but thoroughly. Much of the book is concerned with brain chemistry and therefore it is clearly promoting the biomedical paradigm of mental illness. Whybrow’s writing is clear, concise, descriptive, and charming and the book avoids the feeling of a science textbook. He successfully writes to a broad audience of scientists, psychiatrists, therapists, laymen, and persons who suffer from the afflictions of mood. Whybrow produces empathy for the etiologies of illness and the persons they afflict through case studies that weave scientific descriptions into moving subjective accounts of what it is like to experience depression and mania. Despite the emphasis on the science of mania and depression, he believes emphatically that human experience is just as important as biology in understanding mood disorders. Singular views regarding medication or talk therapy have been put to rest with his careful insights and reasoning.

In the preface, Whybrow explains how this book is about mood and human emotion and about their function and purpose in our life. In particular, it is about what happens when moods go wrong and turn into emotional disorders such as mania and depression. The importance of this text is in its intimacy to the majority of our lives. The chances are overwhelming that during the span of a normal lifetime, we will come face to face with some manifestation of mania or depression, either in ourselves or in somebody close to us. Whybrow writes:

Mania and melancholic depression are intensely personal illnesses. Although they stand as true aberrations of thought and feeling, extending the range of what we consider “normal” emotional experience, they remain accessible to all of us through empathic understanding and thoughtful dissection of such common mood states as profound grief and great joy (p. xviii).

Changing moods and the emotions that trigger them are central to being alive and as a result, mania and depression are more than illnesses in the everyday sense of the term. They cannot be understood like other disorders of the body. This is because in disturbing the function of the brain, the illness enters and disturbs the person—that collection of feelings, behaviors, and beliefs that uniquely identify the individual self. Mania and depression are afflictions that invade and change the very core of being.

In the first chapter, “A Glimpse of Melancholy,” Whybrow explains that although we call mania and depression mood disorders, they go beyond mood. The essential elements of thought—memory, concentration, and decision-making are disturbed as are many of the “housekeeping” functions of the brain (sleep, sex, eating). The disturbance of emotion is what lies at the center of mood disorders. Emotion can be thought of as an ancient signaling system that we share in common with many mammalian species living in social groups. In fact, Whybrow takes an evolutionary perspective in discussing emotion, drawing on the work of Charles Darwin to suggest that emotion is both hardwired in our heads and shaped by our experience. Darwin found that emotions are remarkably uniform across cultures. Such is the case with primary emotions—pleasure, grief, joy, and fear. Whybrow writes that “[t]he changing behavior we call emotion reflects a homeostatic system of brain activity that has been shaped by evolution to increase successful adaptations, especially in complicated social groups” (p. 8). Moods develop from our emotions and because emotional life lies at the very core of being a person, the idea that emotion and moods can be disordered calls into question the very experience of being that most of us take for granted, “the presence of a defined, predictable, and unique subjective entity that we fondly refer to as the intuitive ‘self’” (p. 7). In the rest of the chapter, Whybrow focuses on depression and describes how sadness is only the visible core of the disruptions that it can invoke. The functions of daily living are rapidly engulfed and become seriously disorganized. Changes in the regulation of energy, sleep, appetite, and sexual behavior are profound. The skills necessary to adapt to changing circumstances are lost. Social responsibilities are forgotten and life becomes a burden.

In the second chapter, “Darkness Visible,” Whybrow works to give the reader a sense of the indescribable despair of severe depression. He beckons the words of William Styron who is quoted from his book:

Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes manifest to the self—to the mediating intellect—as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.

Whybrow writes that sadness does not have to be the precipitating factor to a diagnosis of depression, but that a loss of emotion may take place. The diagnosis of depression and manic-depressive illness are also notoriously difficult to pin down for many mental health professionals and many patients may go years before getting the proper diagnosis and treatment for their disorder if they get treatment at all. Whybrow argues that this is partly because “it is difficult to differentiate the changes in the person, seen later as illness, from those naturally present in the emotional ebb and flow of daily life” (p. 24). The triggers to depression are many and Whybrow even refers to it as “the common cold of emotional and mental life” (p. 25). He presents a compelling patient vignette of a woman named Claire DuBois who suffers from severe depression. In presenting such a personal glimpse into the illness, he reiterates the fact that the only way to understand what has the power to kindle and precipitate a depression is to know the personal story that lies behind the experience and the illness. In this chapter, Whybrow discusses his preference for the term melancholia to depression because “in reality, the portrait of severe depression is complex and varied and many have been misled by its common name” (p. 32). However, he uses the terms melancholia, melancholic depression, and depression interchangeably throughout the text.

The third chapter, “A Different Drummer,” Whybrow examines mania and its dimension of personal suffering through the vignette of another patient, John Moorehead, whose manic-depression went undiagnosed and unrecognized by the hospital staff who saw him after he had a severe psychotic episode. Mania often goes undiagnosed by mental health professionals and even unrecognized by the sufferer and those around her because, as a culture, we have an appreciation for those who are upbeat and have lots of energy. Many successful, creative leaders have these traits and they are qualities that most of us covet. Many of those who are in the early stages of mania, called hypomania, do not complain, but instead live their experience fully. However, while early mania may be exhilarating and even a desired state of being, mania in full flower is confusing and dangerous, seeding social violence and sometimes self-destruction. All too frequently those suffering from acute mania find themselves in jail before they find themselves in a hospital.

In the fourth chapter, “A Mind of One’s Own,” Whybrow believes that it is an understanding between experience and biology that is essential to comprehending mood disorders. As a result, he looks at some of the ways that learning from experience molds, and is molded by, the genetic instructions that each of us carry within us. Again he takes an Darwinian perspective in stating that the human capacity for emotion is innate and is molded by what we learn:

Infants have a core repertoire of emotional behaviors present at birth, which they put immediately to work letting their mother know the state of their inner feeling. Anger, fear, surprise, and disgust—as in identifying a bad taste for example—are primary emotions, obvious in the first weeks of life. These behaviors are comparable to the sucking reflex, genetically programmed and expressed in response to the environment. They are part of an innate pre-verbal signaling system that we share with other primates and many other social mammals. Human emotion is rooted in this mammalian heritage, but because of language and our extraordinary capacity to learn from experience, we have also developed a complex range of secondary emotions (pp. 71-72).

Some of these secondary emotions include pride, embarrassment, envy, shame, and guilt. He argues that the Cartesian distinction between mind and body is unfortunate because the two are interdependent and indivisible.

In the fifth chapter, “Unique and Similar to Others,” Whybrow describes the importance of psychiatrists in capturing accurate case histories of patients in order to best understand and diagnose them. He distinguishes signs from syndromes. Signs are what the doctor observes and the clustering of particular symptoms and signs is called a syndrome. A syndrome is really just another name for a category, a cluster of symptoms or pathological signs which consistently occur together. The first step in developing a diagnosis from any syndrome is to accurately describe the individual symptoms, how they cluster together, and how that clustering evolves over time. While it is not necessary to know the cause of a syndrome to successful describe and diagnose it, to call something a disease does require that we understand it sufficiently well to predict its course and perhaps say something about the pathology that determines it. Mood disorders are episodic illnesses which ebb and flow with time. People who suffer from manic-depressive illness, especially if the episodes are infrequent, experience little to no residual signs of illness after they return to normal health. Both depression and manic depression repeat themselves at intervals, frequently in association with stressful events, although sometimes with apparent autonomy. There is evidence that bipolar and unipolar depression are different disease entities that are born of a specific genetic vulnerability, have distinct natural history, and respond differently to treatment. Because these disorders often present as similar in the initial stages, diagnosis can be tricky, commonly vague depression is the first sign of illness. This means that people can go years being undiagnosed properly and receiving the wrong treatment or no treatment at all.

In the sixth chapter, “The Legacy of the Lizard,” Whybrow leads the reader into the biological chamber of mood by exploring the limbic system and its importance in regulating emotion in individuals. In ultimate development, the brains of different creatures are different. However, in general, the genetically programmed stages through which they pass have similarity. We share in common with other creatures such behaviors as sexual courtship, pleasure-seeking, aggression, and defense of territory. In the human brain, the bulk of the reptilian structures are found in the medulla which houses the homeostatic mechanisms that regulate the activities of breathing, heart beat, and digestion. Mammals have family and the capacity to learn, from parental guidance and then from the behavior of others. The prerequisite for the development of all these mammalian behaviors in the evolution of the brain is the great limbic lobe. An alternative designation of this lobe is the limbic system or the limbic alliance (Whybrow refers to it as the limbic alliance). The limbic alliance generates emotional behavior and has three major functions—functions that become disturbed in disorders of mood. The first is to ensure the development of the next generation through attachment, nurturance, and learning new skills; the second is to monitor the changing social environment and communicate need; the third is to oversee the smooth running of the body’s physical machinery, “continuously tuning it to sustain optimum physical vigor and harmony with the planetary environment (the housekeeping functions of the body)” (p. 129). It is the limbic alliance that primarily dictates our behavior. The principal brain centers participating in the limbic alliance are the thalamus (the center of the limbic alliance), hypothalamus (which orchestrates the body’s housekeeping needs with the exception of spontaneous heartbeat and steady breathing), hippocampus (thought to be the center of emotion, memory, and autonomic nervous system), and the amygdala (the centers that assign emotional significance to experience).

In the seventh chapter, “The Vital Balance,” Whybrow looks at the role stress and homeostasis plays in the regulation of moods. Whybrow writes: “Any challenge to a living system that perturbs (causes a deviation from the resting state) will induce a correction (adaptation) designed to maintain the internal balance (homeostasis) and reestablish the system’s preferred relationship, or set point, with the environment” (p. 152). A normal amount of stress is necessary for healthy adaptation and we can learn from it and grow stronger. On the other hand, prolonged exposure to physical or emotional stress can lead to exhaustion or death and, in such circumstances, the stress response goes beyond simple coping or adaptation and becomes itself a damaging agent. The study of hormonal stress response and the psychology and physiology of adaptation have become important research areas in understanding how mood disorders can be kindled by the apparently mundane things that happen to us in everyday life.

In the eighth chapter, “Of Human Bondage,” Whybrow continues his discussion of chronic stress and mood disorder. He states that the similarities between the behavior experienced as depression and chronic stress are reflected in common neurobiology. A major focus of research has been on the endocrine system, particularly the hypothalamic-pituitary-adrenal system and the emergency messenger, cortisol. Cortisol manufacture is homeostatically controlled, switched on and off by cortisol in the blood “feeding back” information to the pituitary gland and centers of the limbic brain, particularly the amygdala and hippocampus. This system of orchestrated feedback becomes disorganized during periods of depression. A critical variable of stress is the level of psychological uncertainty we feel. Many of the early depressive behaviors (sadness, anxiety, disorganization, sleep, tension) mimic the symptoms of chronic stress. Whybrow then discusses the importance of human connection. He writes that bonds of loyalty and attachment lie at the core of our humanity and social organization. If these bonds are damaged or disturbed, normal development is profoundly affected. Strong attachment bonds, especially to dominant members of the community, and social networks among peers reduce the uncertainty we feel by providing social support and potential assistance. Whybrow writes that “stress, genetic predisposition, learning, and social networks weave a dynamic tapestry in determining vulnerability to mood disorder” (p. 189).

In the ninth chapter, “Pills to Purge Melancholy,” Whybrow discusses the pharmacological treatment of mania and depression. He argues that the turn to medication is a story intertwined with a revolution in understanding brain biology. As we have gained more insight about the inner workings of the neuron and about the mechanisms that regulate behavior, this has stimulated the development of new drugs, more precise in action. There are three neurotransmitters thought to be important in the chemistry of mood: dopamine, norepinephrine, and serotonin. When, for whatever reason, the balance of these neurotransmitters is disturbed, emotional regulation becomes unstable and in those individuals genetically predisposed to bipolar disorder, the syndromes of depression and mania may develop. In severe mania it is the neurotransmitter, dopamine, aided and abetted by norepinephrine that appears to dominate the pathways of limbic communication. Many antipsychotic drugs are used in the emergency treatment of mania because they are pharmacological antagonists of dopamine. Once mania abates, depression usually settles in and this requires the use of either an antidepressant or a mood stabilizer. In people with bipolar disorder, mood stabilizers are often used because in many antidepressants can trigger a manic episode. Lithium is still the gold standard in care of mania though we really do not understand how lithium works other than it alters the balance among neurotransmitter operating systems of the limbic alliance. There is growing confidence that serotonin is an important modulator in depression and this has led to the development of pharmaceutical companies of antidepressant drugs that specifically target the serotonin system of neuronal communication (e.g., SSRIs like Prozac). The bottom line is that there are no magic bullets for the treatment of these illnesses and that medications work as an insurance policy, but not as a cure.

In the tenth and final chapter, “Thoughtful Reconstruction,” Whybrow explores self-knowledge through psychotherapy as another key to regaining one’s health from the grips of mood disorder. Psychotherapy is to be used in conjunction with medication in order to be most effective. Whybrow writes: “Given the present tools available to help those with mood disorder, the evidence is overwhelming that judicious pharmacological intervention plus a program of self-education—which is the core of any psychotherapy—is the best approach to treatment and prevention” (p. 235). The “dynamic” therapies, which originated with Freud, consider emotional attachment—specifically the relationship between the person and the therapist—as the fulcrum of change. The behavior therapies consider the paradigm of learning as paramount in modifying behavior and believe attachment to be of little consequence. Research has found that individuals with recurrent depression who have the best outcomes are those who receive interpersonal psychotherapy in addition to medication.

One thing that struck me in this text, for such a biomedical perspective, is the decision to refer to mania and depression as illnesses rather than diseases. Kimberly Emmons in her book, Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care, decided to write depression as an illness rather than a disease because the term illness encompasses more of the experience of the individual. I wonder if this is the same logic for Whybrow. It is something that he does not discuss. He does however tell of what he believes constitutes a disease, which is an understanding of a condition sufficiently well to predict its course as well as an understanding of the pathology that determines it. It seems as though throughout the book that Whybrow has been establishing that there is a sufficient understanding of the etiologies of depression and mania so his use of the term illness over disease is a bit baffling. I also do not believe there is enough emphasis in this book on how much is unknown regarding the specific molecular causes of depression and mania. Many studies have shown that the “dopamine hypothesis” and the “serotonin hypothesis” do not measure up. Otherwise, I find that this text is a good resource for those suffering with bipolar disorder or depression, those who know people who are, or those who are interested in learning more about the illnesses.

Watters, Ethan. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, 2010.

“Cultures become vulnerable to new beliefs about the mind and madness during times of social anxiety and discord,” (p. 249) writes Ethan Watters in his book Crazy Like Us: The Globalization of the American Psyche. Watters sees social anxiety and discord as making cultures “vulnerable” to new beliefs about mental illness rather than simply receptive to them. Specifically, he looks at the ways the West, and particularly the United States, have been exporting their understandings of the diagnosis, symptoms, and meanings of mental illness around the world. In doing so, we have failed to see that individual cultures have ways of dealing with mental illness that are local and specific and in some cases, more effective than ours. At the same time, in promoting our ideas of mental illness, we may even be causing harm.

Crazy Like Us is a thought-provoking, well-written, and challenging non-academic book that attempts to draw more attention towards global mental health concerns and the impact that our own cultural understanding of the mind and the self is having around the world. The book is personal and human and each chapter provides a look into the lives of individuals and their families who suffer from mental illness as well as those who are tasked to treat them. The patients and professionals portrayed in the book are poignantly described and the material presented is informative and detailed. The book is divided into four main chapters. Each of these focuses on a country and a particular mental illness and describes how local understandings of the mental illness have been modified as a direct result of the exportation and adoption of our predominantly biomedical paradigm of mental health. Watters defines this paradigm in the concluding chapter:

The ideas that we export to other cultures often have at their heart a particularly American brand of hyperintrospection and hyperindividualism. These beliefs remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and the unconscious, as well as teeming numbers of self-help philosophies and schools of therapy that have encouraged us to separate the health of the individual from the health of the group. Even the fascinating biomedical scientific research into the workings of the brain has, on a cultural level, further removed our understanding of the mind from the social and natural world it investigates. (p. 254)

In Chapter One, “The Rise of Anorexia in Hong Kong,” Watters explores the history of anorexia in China and finds that, prior to the 1990s, the disease was relatively rare, with just 10 reported cases in psychiatric journals between 1983 and 1988. Those who did have anorexia prior to the 1990s had a different symptomology than those in the West. Notably missing in Chinese accounts were the fear of gaining weight and the body dysmorphia which characterize the disorder in the DSM. In fact, on the contrary, Chinese girls had an accurate body image of themselves and they often attributed their lack of eating to somatic symptoms such as abdominal pain. Watters describes the research of Dr. Sing Lee, the leading expert on eating disorders in China. In the rare cases he studied, it appeared as though he had found a rare form of mental illness that was unique to China, which resembled anorexia, but was itself a distinct disease entity. Similar to R. D. Laing, Dr. Lee believed that the only hope of finding a cure for this mental disorder was in developing a deep understanding of each patient’s subjective experience. In the 1990s, however, things began to change and the incidence of eating disorders in Hong Kong began to rise. What has often been attributed to this increase has been the belief that Western body ideals were influencing adolescent girls through popular culture. But this was not the case. Instead the rising rates of anorexia in Hong Kong were due to the imported Western template for the disease. As Western views of anorexia took hold in Hong Kong, the disease presentation among women began to change. Watters writes: “Amid all the finger-pointing at fad diets and the influence of Western fashion and pop culture, few considered the possibility that the idea of anorexia nervosa itself—prepackaged in its DSM diagnosis and explained by readily available Western experts—might have been part of the reason the disorder caught on so quickly in Hong Kong” (pp. 48-49). In other words, the incidence of anorexia increased in Hong Kong when the media and the psychiatric community adopted the American conception of the disease. Watters believes that the new public discourse on anorexia contributed to its incidence as Chinese girls unconsciously mimicked the behavior of the disorder in order to call attention to their private distresses.

In Chapter Two, “The Wave That Brought PTSD to Sri Lanka,” the export of Western conceptions of mental illness occurred on a much wider and more dramatic scale. In December 2004, a tsunami struck Sri Lanka and caused the death of over a quarter of a million people. As a result, Western therapists and traumatologists flocked to the country, convinced that PTSD cases were about to rise exponentially. Watters describes scores of mental health workers arriving in Sri Lanka to conduct “Critical Incident Debriefing,” to train local people in identifying PTSD, and to encourage those who had survived the horrors of the tsunami to “open up” about their experience in order to properly heal. Once in Sri Lanka, Western counselors and traumatologists used PTSD checklists that were developed from the DSM and neglected to take into account culturally distinct reactions to traumatic events and culturally specific modes of healing. Through his research, Dr. Gaithri Fernando, an assistant professor at UCLA, found that Sri Lankans’ experience of trauma differed from that of Americans in two important ways. First, Sri Lankans felt more physical pain after experiencing a trauma and reacted to disaster “as if they had experienced a physical blow to their body” (p. 91). Second, Sri Lankans did not report pathological internal states of suffering such as anxiety, fear, numbing, and the like. Instead, they reacted to trauma in terms of the damage it did to their social relationships. Thus, they conceived of the damage done by the tsunami as occurring not inside their mind but outside their self. This led Watters to conclude that there is not a human universal when it comes to reactions to trauma and the process through which damage to the psyche becomes an outward symptom is a reflection of cultural beliefs in a particular time and place. Therefore, the only way for Western mental health professionals to be effective in their aid is for them to recognize the local idioms of distress—the particular ways psychological trauma is understood, experienced, and expressed in specific cultural contexts.

In Chapter Three, “The Shifting Mask of Schizophrenia in Zanzibar,” Watters focuses on anthropologist Juli McGruder and her ethnographic study of schizophrenia in Zanzibar. Her interest originated from two World Health Organization studies that showed that individuals diagnosed with schizophrenia in developing countries fared better in their long-term prognosis than those in the industrialized developed world. However, recent research indicates that this generalization may be too simplistic. McGruder thought that what was missing on studies of schizophrenia was an on-the-ground examination of the ways that patients in the developing world were treated by their family members. Again, like R. D. Laing, McGruder wanted to get at what the experience of madness felt like for those suffering from it or around it. In Zanzibar, she found that family members of an afflicted person took a relaxed and non-judgmental view towards schizophrenia. In her research, she found that family members rarely pressured sufferers to engage in “normal” behaviors. Importantly and in contrast to the American view, family members did not assume a cause and effect relationship between productivity and wellness. Although the family saw the sufferer’s productivity as a sign of health, they did not pressure her to continue to be productive with the assumption that it would be curative. Watters demonstrates the direct connection between what is called high expressed emotion and poorer outcomes for schizophrenia. Expressed emotion (EE) is a measure of the family environment that is based on how relatives of a psychiatric patient spontaneously talk about that patient. Family members with high expressed emotion are thought to be hostile, critical, and judgmental of the patient and this experience tends to parallel the experience of schizophrenia itself. In other words, it is not merely coincidence “that one of the central symptoms of schizophrenia is hearing demanding, critical, or disparaging voices” (p. 153). Patients who live in high-emotion households experience higher relapse rates across cultures. McGruder found that religion is one factor that is responsible in keeping a low-emotion household. The belief in spirit possessions is another factor. According to local culture, spirit possession is not seen as something uncommon or even an extreme experience. The application of this belief to schizophrenia actually has the effect of lessening the stigma attached to the disease because “it [makes] bizarre or disruptive behavior more understandable and forgivable” (p. 157). The point that McGruder and Watters are both trying to make in this chapter is that a culture provides its members with a variety of affective and behavioral responses to mental illness. Watters writes, “Because different cultures around the world view mental illness in different cultural contexts, the intensity of emotions attached to these experiences often varies” (p. 160). However, Western psychiatrists and mental health professionals have promoted the biomedical model of schizophrenia around the world. “Mental health literacy” was coined by the West to describe the set of ideas that Western mental health professionals have promoted around the world. Populations that adopt Western ideas are considered more “literate” than those that do not.

In Chapter Four, “The Mega-Marketing of Depression in Japan,” a more sobering and disturbing picture is presented. This chapter catalogues the rise in depression in Japan in the 1990s. Watters argues that this increase resulted from the intentional and deliberate actions of GlaxoSmithKline, the producers of Paxil, seeking to introduce the billion dollar industry of SSRIs to Japan by importing new conceptions of sadness and depression from the West. Previously, the incidence of depression in Japan was low and some of the symptoms of depression—sadness, grief, and melancholy—were seen as a natural part of human life and even a source of strong moral character. Japanese psychiatry did acknowledge a rare and severe form of depression which often required long-term institutionalization, but the everyday variety of depression that was standard in the United States was not present in Japan. However, social upheaval and anxiety made individuals “vulnerable” to new beliefs about depression. At the end of the twentieth century, the country was in economic crisis. Bankruptcies were common as were divorce and unemployment. Then came the devastating earthquake in the city of Kobe in January 1995. With this disaster came an influx of Western mental health “experts” who claimed that the population needed not only basic food and shelter but also psychological intervention. A critical turning point came when Peter Kramer’s bestselling book, Listening to Prozac, was produced as a special on the nation’s largest television network. Millions watched and praised the program. Japanese psychiatrists were taken by surprise at the interest in depression due to the fact that up until that point the public had pretty much eschewed the intrusion of psychiatry into their daily lives and like many people in the country, these psychiatrists did not consider unhappiness to be a mental illness. This is where multinational pharmaceutical companies came in to lend a helping hand in creating depression in Japan. The major problem GlaxoSmithKline faced was that Japanese psychiatrists and mental health professionals still translated the diagnosis of “depression” as utsubyô, which retained its association with an incurable and psychotic form of depression. In the hopes of softening the connotations of the word, marketers used the metaphor of kokoro no kaze, a “cold of the soul.” The image of depression that was marketed to Japan was left deliberately vague so as to encompass the widest possible population and the widest possible range of discomforts. The metaphor of a cold suggested that taking medication for depression was as simple as buying a cough syrup. It also suggested that, like common colds, depression was ubiquitous. What followed was an advertising campaign that featured “ask-your-doctor” commercials about new medications and symptom checklists for depression. To garner even more media attention for depression, the drug companies leveraged the population’s growing concern over high suicide rates. The advertising and public service announcements were a success. There was also the belief that the United States represented the pinnacle of scientific research and moral authority on mental illness. However, there was widespread corruption in scientific studies that were purported to have been conducted by independent academic scholars but were actually being ghostwritten by the drug companies. There was also the problem of drug companies touting depression as an imbalance of serotonin in the brain, a claim that has no current scientific consensus. Additionally, scientific research was finding evidence that Paxil’s effectiveness in treating depression was flimsy, incomplete, and inconclusive. These findings were not publicized and the side effects, ranging from nervous system problems to increased rates of suicide in adolescents, were downplayed and underreported.

The Western biomedical model of mental illness is important and a familiar one. Watters cites key research from the field of cross-cultural psychiatry to suggest that the biomedical paradigm of mental illness only compromises a narrow view of the psychological life of individuals. Our conceptions of mental illness are reflective of our values and these vary from culture to culture. Watters presents good evidence for why we should question the biomedical view and its supposed universalism. At the same time, it’s worth considering that as we have exported the American psyche to the world, it is possible that in some instances we have also managed to export treatments that have drastically improved the lives of people. On the one hand, if a person does not feel as though she is suffering from a mental illness, then chances are she is probably not and there seems to be something inherently wrong about persuading a person otherwise. In this book, Watters argues that many people of Hong Kong, Sri Lanka, Zanzibar, and Japan are better off without us and he very well may be right. However, we cannot rule out the possibility that the biomedical model of mental illness could be beneficial to people in these and other countries.