Tuesday, May 31, 2011

Down With Psychiatry

I have to admit that I don’t always use my subscription to The New Yorker to full effect, but sometimes an article appears in the pages of a new issue that lets me know with its subtitle that it is something I have to read and give my fullest attention.  Yesterday’s issue contains such an article.  The piece by Rachel Aviv is called God Knows Where I Am, and beneath that title on the table of contents, it reads “A patient rejects her diagnosis.”  That is a meaningful subject to me, because everywhere I look, I see people not only accepting psychological diagnoses, but accepting them unquestioningly, and courting them as if by sworn duty.

I leapt eagerly into the article because I am opposed to much of what mental health professionals do.  While I allow for the greater demands of extreme cases, I reject the impulse to treat most any diseases of the mind with medication, and to a large extent I am opposed to the entire culture of diagnosis in general, which has no reliably objective means of disembedding concepts of mental illness from aspects of an individual’s personality.  I want to see more people take their mental struggles into their own hands, and I hope that the public will come to take a more comprehensive view of treatment, which leaves off the expectation of a quick fix.  So I was thrilled by the prospect of a story that told of a person dismissing an overreaching diagnosis and proving herself capable of compensating for deficiencies and flaws without damaging her personality.

This, however, did not turn out to be such a story.  Instead, it a tragic tale detailing how the sufferer ended up dying alone in a vacant home as a victim of her own delusions.  Still, the author did not take this as grounds for suggesting that the patient was wrong to not submit completely to the authority of a mental health center.  Instead, Ms. Aviv astutely demonstrates the flaws and failings on the part of both the patient and the system that is meant to help her.  In the end, Aviv seems to make no argument and take no position on the general veracity of diagnoses or the emphasis on medication as treatment, but she does raise a variety of serious questions, and for that I am truly grateful.

Aviv does also seem to strongly suggest that there’s something definitely not right with our current approach to mental health, and in particular she details the ways in which current U.S. law and the policies of mental hospitals make many relatives of the mentally afflicted feel excluded from the medical decisions that those patients make.  This strikes me as particularly tragic since it is my belief that mental troubles can be seriously exacerbated by the lack of positive input from friends and loved ones.  Alienation obviously can be a major driving force behind mental disorders, and treatment that does not address this is foolishly shortsighted.

Aviv speaks to this when she points out that the patient being profiled in this article was made to feel more alienated by the fact that she saw all of her interactions with psychiatrists as being efforts to convince her that aspects of her personality constituted mental illness.  She goes on to generalize the topic and point out:

“People recovering from psychotic episodes rarely receive extensive talk therapy because insurance companies place strict limits on the number of sessions allowed and because for years psychiatrists have assumed that psychotic patients are unable to reflect meaningfully on their lives.”

This is one of those instances where professional consensus seems to fly in the face of common sense.  Anyone who has spoken to a psychotic or delusions person, or who has been close to insanity himself should know that mental illness does not have to result in a complete lack of cohesive thought or a lack of engagement with one’s own life.  Quite to the contrary, delusions can serve to compensate for a severely upsetting lack of personal significance or ability to relate to the world.  Where that is the case, the effort to medicate seems to be a way of simply suppressing the effort to construct meaning through unsuitable means, without providing any alternative way of making that effort.

In what may be the most important comment in the article, Aviv says of the patient profiled in her article:

“With medication as her only form of treatment, Linda was unable to modify her self-image to accommodate the facts of her illness.  When psychotic, she saw herself as the heroine in a tale of terrible injustice, a role that gave her confidence and purpose.”

And so rather than helping to provide her with another mode of access to that confidence and purpose, the mental hospitals that she drifted in and out of strove only to convince her to admit that she was sick and to take medication for it.  At least one relative tried regularly to keep updated on Linda’s situation and offer her help, but she became one of those loved ones who feels excluded by the way the system currently operates.  If not for that, perhaps she could have aided Linda in building that news self-image sans medication.  It would be a long, difficult process, but it may have been effective, though now we never can know.

It is my belief that that is exactly the way to counteract psychoses and delusions, if they do not constitute a serious threat to the person around the sufferer.  I am pleased to know that I am not entirely alone in this.  Aviv’s article describes something that is known as the “c/s/x movement,” which stands for consumers, survivors, and ex-patients, and criticizes the unquestioning acceptance of biological explanations for mental disorders.  Such explanations are horribly disempowering, and lead to the perception that there is nothing to be done about mental illness other than to artificially modify brain chemistry.  But I cannot accept that claim.  No person’s mind is an island that is immune the influence of external changes.

Aviv also describes the establishment, rise, and ideological fall of New Hampshire Hospital, which, way back in 1866, had a superintendent who “described psychosis as a waking dream, which, if not broken in upon, works mischief to the brain,” and stated that the purpose of treatment was to “interfere with this world of self – scatter its creations and fancies and people it with objects and thoughts foreign to its own.”

You see, a genuine solution is out there.  That quotation sounds so appropriate to me, so comprehensive, and so forward-thinking.  And it seems like that process would be awfully gradual, requiring patience and commitment, nothing like the quick fix promised by medication.  And that is of course why this ideological mission of the hospital failed, with this method of treatment being incapable of keeping up the demands of an increasingly large patient population, so that today the hospital is run just the same as any other mental health facility in the country.

It is my thinking that the system does not take the right approach to these matters because it cannot.  And no system could unless it grew to encompass all of us.  So long as we try to shut our problems away and trust in trained professionals to take them up so that we don’t have to think about them, they will go unsolved.  But when all take the responsibility to provide our parents, our children, our friends, and our neighbors with the structures that might help them hold themselves up, then we can call it real treatment.

But what breaking point will it take to get us to collectively accept that kind of empathy, confidence, and discomfort?  Will it come only once we’ve all gone mad?

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