Mental illness is frightening for some people in a way that physical ailments are not. While people are of course afraid of being hurt in a car accident for example, the shame associated with mental illness has no analogue in physical injuries. We sometimes associate mental illness with a moral failing, a bad background, or a lack of will power, and these reactions are simply unfair and unkind. We rarely blame someone who has broken a bone in a sporting accident on the weakness of their personality, or worry that this injury indicates that the person is no longer trustworthy.
These fears have three principal sources, 1) the general lack of understanding surrounding the symptoms of mental illness, 2) the long and complex history of psychiatry, and 3) the cultural myths around the behavior and treatment of the mentally ill.
When I first struggled with depression I went to see several different university counsellors. If you are a university student you should be aware that many campuses offer mental health counselling services to students free of charge. I was able to see social workers at various times during my studies who were happy to meet with me on a semi-regular basis. The counsellors that I saw essentially just listened to what I had to say, some offered more advice than others. My confusion and fear about what was happening to me left me unable to ask direct and clear questions. While I think these counsellors tried to help and were reasonable and decent people, given that my initial symptoms were rather vague, their advice wasn't very specific.
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| Rorschach Inkblot Image |
Free association, and its visual relatives, the Rorschach inkblot test, and the Thematic Apperception test, are all rooted in very early notions of diagnosing psychiatric patients. These methods are grouped under the title of projective techniques, and many people are familiar with them in at least a theatrical presentation of psychiatry. Everything I knew about psychiatry when in university I had learned from movies and television (I was majoring in mathematics and computers at the time), since what I saw on TV was usually some form of free association diagnosis, I thought that this was what I was getting from university counsellors.
The practice of letting a patient explain their worries and concerns, and talk about their past with little guidance from the therapist originates with Freud. In free association an individual lies on a couch, sometimes with the therapist seated behind them out of view, and says whatever comes to mind. In this model it is the therapist's job to help the client connect ideas and feelings that he or she was not aware of. Freud also analyzed dreams in this way. He developed this method in part because at the time hypnosis was being used as a therapeutic method to treat mental illness, and hypnosis did not always work. Freud found that many patients could not be hypnotized, and so he developed free association as a more general technique to explore the psyche of his patients. While some therapists still use a variation of this Freudian method, it is rarely used in this classical form today. In Mental Health through Will-Training Dr. Abraham Low has several very critical things to say about classical psychoanalysis, specifically that it is a very long and expensive process.
There is a recent BBC documentary discussing Signumd Freud's work and life presented by Bethany Hughes. While she credits Freud with inventing modern psychoanalysis she is also careful to point out that there were numerous flaws in how he treated his patients. She makes clear that today most people question the effectiveness of his methodologies and the utility of his basic theories as part of treatment.
The Thematic Apperception test (TAT) is composed of 30 black-and-white drawings of various scenes and people. Typically an individual is shown 20 cards, one at a time, and asked to create a story about what is going on in the picture. The idea is that by observing the character and themes of an individual's response that it is possible to gain insight into their thoughts. For example, if an individual often talks about one person leaving the other, the therapist might ask whether abandonment is an issue. The TAT lacks scientific evidence that might make it useful as part of developing a diagnosis.
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| Thematic Apperception Test Image |
While some professionals see the value in these projective techniques in terms of their ability to test how an individual responds to ambiguous stimuli, the major disadvantages of these methods center on questions of validity and the test's ability to tell us anything specific.
Because of the visual quality, mysterious character and history of these tests they are often featured in movies and television programs. Before meeting any counsellors or therapists I believed that psychiatry was about lying on a couch while talking about my childhood, my feelings and that as I responded to strange images I expected a therapist to write down lengthy notes. After some time the therapist would tell me something dramatic and enlightening about myself, and this would be my road to a cure. Despite meeting many psychiatrists and counsellors I've never had any of these experiences. Psychiatry, insanity, mental institutions, and treatments for the depressed or suicidal are a common trope of films and literature, and there was a time when this was all I knew about the treatment of mental health. Some of these films are great, truly terrifying, and fantastically suspenseful, but not entirely realistic or helpful for those who have an actual mental illness.
Recently I watched the "Mind-Hunter" series on NetFlix that chronicles the development of the early behavioural sciences unit at the FBI and focuses on the personal difficulties that the investigators have as they learn about the unusual behaviour of serial killers through one-on-one interviews. Another film I enjoyed recently was "A Cure for Wellness", which tells the story of an executive who is sent for an unusual therapy in the Swiss Alps, and learns that once patients enter this idyllic sanatorium they are reluctant to leave. In a "Clockwork Orange" drug based conditioning is used to modify the violent behaviour of Alex, a young gang leader. After a failed suicide attempt Alex takes a version of the TAT test to measure the damage that resulted from his behavior modification. In "Harold and Maude", an affluent teenage boy fascinated with suicide falls in love with Maude, a 79 year old survivor of a concentration camp. Harold's therapist accuses him of sexual perversion, while Maude teaches him about the joys of life. The "Hannibal" TV series as well as its original source material "The Silence of the Lambs" present variations of the fantastical Dr. Leckter, who uses his knowledge of the human psyche as a weapon. "12 Monkeys", staring Bruce Willis and Brad Pitt, is another great example of thriller science fiction that features macabre scenes set in psychiatric wards where the stresses of time travel cause Willis' character to be unsure about reality. The contemporaneous "Fight Club", starring Brad Pitt and Ed Norton has an entire sub-narrative devoted to group therapy meetings, and formed my initial expectation of what I would find at Recovery meetings. These expectations where entirely inaccurate as I learned when I first attended a meeting.
The most famous story featuring a psychiatric ward is perhaps "One Flew Over the Cuckoos Nest". The film version is an adaptation of a 1962 novel by Ken Kesey of the same title and is considered by many to be one of the great films of the 20th Century. Wikipedia summarizes the plot thusly:
In 1963 Oregon, recidivist criminal Randle McMurphy is moved to a mental institution after serving a short sentence on a prison farm for statutory rape of a 15-year-old. Though not actually mentally ill, McMurphy hopes to avoid hard labor and serve the rest of his sentence in a relaxed environment. Upon arriving at the hospital, he finds the ward run by the steely, strict Nurse Ratched, who subtly suppresses the actions of her patients through a passive-aggressive routine, intimidating the patients.
I think of Nurse Ratched as the ultimate evil movie villain. In rewatching this film it is Louise Fletcher's performance in the role of Ratched, the sadistic psychiatric head nurse who employs shock therapy to control patients, which I found both brilliant and riveting. Her endlessly cool control of the ward and her conflict with Jack Nicholson's character McMurphy as he escalates his disruptive behavior are what make this film a masterpiece.
I believe that it is important to be able to enjoy media and remain critical of it at the same time. Having recommended all these films as great examples of modern television and cinema featuring scenes of psychiatric wards and people suffering from mental illness, I think it is important to point out that while these films borrow from the truth, they don't tell an accurate story about either mental illness or its treatment. In all of these examples the mythology of psychoanalysis and its associated treatments are used to create suspenseful and intelligent narratives based on the truth, but not necessarily fully representative of the truth.
These good stories create real stigma for people seeking mental health treatment, and they also create confusion about what one might reasonably expect as treatment. Electro-shock therapy or as it is more formally known, Electro Convulsive Therapy (ECT) was used widely in the 1940s and 1950s before anti-depressants drugs were developed. The treatment is still available today in a somewhat modified form. The modern version is usually coupled with muscle relaxants and is only recommended in extreme cases for people that don't respond to other therapies due to its rather nasty side effect of memory loss. What some people know about ECT comes from Nurse Ratched's abuse of her patients in "One Flew Over the Cuckoo's Nest". Setting aside the complex question of ECT's benefits versus its hazards, many people are terrified of the treatment, and by extension those who have received it, because of this film. This film is extremely realistic, and while the author may have been telling a very legitimate story about the abuse of power through medicine, the impact that this story has had on those suffering from mental illness has not necessarily been positive. This particular story has become "the" narrative of psychiatric wards for many people.
My grandmother received ECT treatment in the 1960s. All I know about this part of my family history was that despite being an intelligent and productive individual in her youth and middle age, she fell ill in her later years and my father and grandfather argued at length about the decision to give her this treatment. I don't recall meeting her, she died when I was very young. I just had this basic information from my siblings that the treatment didn't go that well, and then I saw the Jack Nicholson film at some point, and this is what I knew about mental health treatment growing up. This wasn't a nice picture.
The other issue with the dramatic presentation of mental health cures is that they create the notion that psychiatry, and mental health treatment are complex and unreliable voodoo like procedures. My father certainly thought this way about psychiatry. He expressed a great deal of suspicion about doctors, and especially psychiatrists while I was growing up. In Abraham Low's interviews with patients he often comments on how patients distrust his recommendations and expect to be probed with complex methods. In the chapter "Simplicity Versus Complexity In Combating Fears", Low, as the examiner (E) recommends that the patient (P) command their muscles to do what they fear to do.
P: Frankly, that sounds a bit too easy. It doesn't just seem possible that I should cure my fears by moving my muscles. It should take more than that.
E: It will be difficult for you to convince me that it is "a bit too easy" for persons to command their muscles to move if they feel paralyzed by the fear of making another step. You did not mean to say that my suggestion sounds too easy; you thought it sounds too simple. I shall not enter into a detailed discussion of this very important distinction. I shall merely tell you that I do not want my patients to believe that cures and remedies must necessarily be complex, involved and timeconsuming. It is easy to sit in a chair and to be given lengthy and interesting explanations about how fears arise and develop. That is complex but easy. But if a boy is afraid of swimming or diving it is not at all easy to make him move his muscles for the purpose of a resolute jump. That jump is simple but difficult. Do you realize that you expect to be cured of your fears by means of complex but easy and sometimes glib explanations instead of by means of simple but exacting directions? You want to be studied and analyzed and discussed but you do not want to be told what to do and how to act. What will the most lucid explanations profit you if you are seized with a deep anxiety or a paralyzing panic? In a condition of this kind you are utterly unable to make use of the ingenious and fascinating explanations you may have been given. If in a panic you try to remember what you learned and to reason out what is the sensible thing to do your mind will fail you disastrously. The panic weakens your memory and blots out your reasoning power. All you will be able to do in a commotion of this sort is to apply simple rules. Their very simplicity renders them capable of being employed in a situation in which complex thought is impossible.
P: I do not mean to be contrary, doctor. But it seems to me that when I get into a panic I will not be able to carry out even simple rules.
E: That may be correct for the first and second trial. But if you continue to practice you become ever more proficient in the application of these simple rules.
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Recovey methods are not complex, they do not require a deep understanding of one's history, motivations, or the basic causes of an illness. Recovery methods are exercise for the mind, and have a similar effect that exercise on the body can have, in that they provide general strength and an overall sense of well being if practiced regularly. It can be difficult to get into a routine of physical exercise. Despite the simplicity of going for a walk every day, many people will not find the time to develop this basic habit, preferring to drive or stay indoors. Practicing Recovery methods is as simple as taking a daily walk, although reaping its benefits can be as difficult because it requires work and consistent effort.
Movies and television often present mental illness as terrifying. The underlying themes show mental health professionals as cruel, incompetent, or abusive individuals who are applying cures that are hideously complex, ineffective or dangerous. While there are real life examples of this conduct, and the mental health industry has numerous issues, most practitioners are genuinely concerned about the people that they are attempting to help. While the mythology around mental illness is fascinating and fun from a theatrical perspective, if one finds oneself suffering from mental illness the many untrue and confusing ideas gleaned from modern media don't provide much helpful or accurate information. At Recovery meetings we emphasize the use of simple tools, these tools can help anyone regardless of the degree of their illness.
Cognitive Behavioural Therapy techniques, like Abraham Low's very simple recommendation to do the things that you fear and hate to do so long as there is no danger, are safe, effective, and not complex. These methods do require sustained effort, and this is one of the reasons that we hold Recovery meetings every week. We provide support for those who want to learn better habits. We are always happy to meet new members, and we encourage you to come to a meeting.
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Suicidal Ideation, Helplessness and Hopelessness
Effectiveness of Peer Support for Depression
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