Vague Recriminations Can't Fix American Mental Healthcare

the absolute last thing our system needs is more entitlement and demonization

This piece is a response to someone writing about their sick child, which is obviously a matter of great sensitivity. I intend to be careful and sympathetic. But I’m afraid I do think that Jane Ehrenfeld’s essay in Slate, about her child Ash’s battle with a disorder with no name, is badly mistaken about mental illness and its treatment, self-defeating as a matter of advocacy, and in fact reflects a common but incoherent set of complaints that are filled with internal tensions and bad assumptions. And I fundamentally believe that the only way forward for mental healthcare is for people who really want to expand access to that care, as Ehrenfeld does, to understand that the system came to them pre-demonized. Our culture already does the job of indicting our psychiatric establishment, every day. There is no more fruit to be picked in the branches of this tree of inchoate resentment, though Ehrenfeld goes reaching for it. Grinding the same fucking axe that I’ve seen ground so many times is not the revelatory or progressive act she thinks it is. She’s on the side of the angels in every way that doesn’t matter and doing the devil’s work in every way that does.

Let’s start where Ehrenfeld starts. Her essay opens with a set of vague complaints about the inpatient experience that I’ve heard many times before. The facilities are cold and so are the staff. Access to programs seems arbitrary. The care Ash receives in various facilities and programs, Ehrenfeld is sure, is both inadequate and too hard to get. (There is a “the food’s terrible and the portions are too small” element to the whole piece.) She talks about a lack of personal communication from doctors, inconvenient scheduling, the “liability-based, anti-therapeutic approach” of the hospital approach. (Elsewhere in the essay Ehrenfeld brags about the lawyers she’s hired to enforce her daughter’s rights; perhaps she might consider the possibility that the hospitals are fixated on liability because of people like her.) She doesn’t like the American mental healthcare system and is unsatisfied with the various options for care. Her descriptions grow florid; an encounter with a bare mattress in an empty concrete room, in a school program, strikes me as unbelievable, in that I don’t believe it happened. But either way, the reader has no sense of how badly Ash is being treated because there’s no discussion of either that treatment or her ailment. It’s impossible for me, as someone who knows these waters, to really assess Ash’s circumstance at all, since Ehrenfeld tells us nothing about the diagnosis. Ehrenfeld wants us to understand how badly her daughter has been failed, but won’t share the engine of her ruin.

There is, of course, no obligation for a mother to divulge sensitive details about her daughter’s mental illness. But without that information, with no sense of a diagnosis, the essay is too unmoored to work as a piece of advocacy. For example, Ehrenfeld complains about expensive private hospitals, and that and her other advocacy for more equitable medicine are admirable. But there’s a dirty secret about those ritzy hospitals: there’s no reason to think that their care is any better. They focus on amenities in their literature, advertising themselves as exclusive resort hotels plus meds, because there’s no silver bullets that they can sell. The trouble, you see, is that while modern psychiatric treatment is far more effective than its reputation, there are no cures. Ehrenfeld speaks vaguely about the superiority of a therapeutic approach, but the reality is that the severely mentally ill almost always needs meds. And the fundamental problem is that the meds are life-saving but not good enough. There was a gold rush with psych meds after Prozac hit, that money dried up, and now there’s precious little pharmaceutical industry interest in developing better medications. That is a bigger problem than any of the problems Ehrenfeld has with the administrivia of the programs she derides. Yes, rich patients could get access to on-patent antipsychotics like Latuda or Lybalvi, which cause less weight gain, which is nice. But there’s no magic cures to be had, and there won’t be until our society generates the will to find them. Sadly, in that regard, Ehrenfeld is part of the problem.

Here’s a central issue for expanding access to mental healthcare: we have a large and vocal anti-psychiatry movement in the United States that has successfully agitated against the very concept of treatment. They helped dictate the sixty-year-long drift against involuntary care, which has resulted in untold thousands of deaths from suicide, substance abuse, and death. They’ve filled the public imagination with the assumption that inpatient care looks just like One Flew Over the Cuckoo’s Nest, a 50-year-old work of fiction written by a man who never saw the inside of a psychiatric hospital and was explicitly using mental illness only as a metaphor for his juvenile take on SOCIETY. They reflexively and unthinkingly report that “there’s no such thing as a chemical imbalance,” overgeneralizing an exaggerated critique of the serotonergic theory of depression that they don’t understand in the first place. And they fill my inbox, every time I write about this stuff, as they surely will again soon. I beg Ehrenfeld and the rest of you to understand: essays like this contribute to a knee-jerk rejection of all psychiatric medicine that badly deepens the very crisis of access Ehrenfeld laments. What do you think happens when you write pieces like this? That the average reader will say “we need to better fund these systems that the author has spent thousands of words savaging”? Or will they decide, as so many have, that psychiatry is all a scam, and that it should simply be erased from the earth?

This is maybe my simplest and most important gloss on psychiatric medicine in the last quarter-century: patients and families who demanded more and better care spoke a language that played right into the hands of our large and influential anti-psychiatry movement, which does not want to improve care or expand access to it but to destroy the institution of psychiatric medicine. And Ehrenfeld, like so many other anguished parents, seems not to have the slightest idea which dog she’s lying down with by publishing this essay. Go look for the reaction to the piece, go ahead. It’s all the same familiar characters, the people who think you can cure schizophrenia with a keto diet and that antipsychotics are a government mind-control scheme. That’s whose water Ehrenfeld is carrying.

The palpable question that stems from reading this essay is, what does Ehrenfeld really want? Like so many people working in this genre, she’s far more coherent and compelling in describing what she doesn’t want than she is in describing what she does. Every approach tried seems inadequate to her, but I see no definition of what good treatment looks like. Ehrenfeld writes that “our old systems… never worked and still don’t work.” But what does this mean? How don’t they work? Certainly, the sheer agony of finding care is awful, and there’s a real and important service performed in the essay in that regard. But throughout the piece I’m far more clear on what Ehrenfeld finds superficially stupid than on what she thinks would be effective treatment; this is also, I’m afraid, a commonplace in the genre. “I am sure there is no double-blind study proving that Fun Fridays are an effective treatment for suicidal depression,” she writes. Well, OK. It’s a constant complaint in these pieces that psychiatric facilities are too cold and unwelcoming, but OK. The question is, what does pass that double-blind standard? Less than you might think, and despite the constant scaremongering of antidepressants, they have a far better research record than you may believe. Ehrenfeld mentions medications in her piece twice, both times to complain about them. This is very, very common from parents of the mentally ill - they reflexively dismiss the potential of medication but cling to the notion that there is some perfect therapy regime that will cure their child. But it just doesn’t work that way.

I’m afraid that, in glomming on to the now-inescapable theory that mental illness is the product of a harsh world - a world that is, somehow, suddenly far harsher than it once was, in spite of all the evidence - Ehrenfeld contributes to the immense expansion of the definition of the mentally ill. And what you have to ask someone who does that is this: how can you think, realistically, that we can expand access for the people who need it, if we relentlessly increase the number of people we say need it? We live in a world of limited medical resources. We can and should and will fight for more funding for medical treatment generally and psychiatric treatment specifically. But there are limits to how much treatment we can provision; that is the way of things. Almost no one in this conversation seems willing to have a hard conversation about the connection between stretched and strained systems and the unspoken ideology that holds that mental illness has no true diagnostic criteria, includes more and more of what was once considered the ordinary unhappiness of life, and spreads via social media.

Ehrenfeld writes

Swirling through all of this, I think about what Ash and thousands of other children like her are trying to tell us: That the world that we have created for them does not work for them. That the world we have created, plus a global pandemic and so many other unaddressed crises in public life, does not work for them … or anyone.

But because they are children, and because it is clear that we are not wise elders, but just flawed people stumbling in the dark, the way that this all plays out is that they are destroyed from the inside, and that explodes outward in a myriad of terrifying ways—suicide, self-harm, school avoidance, failure to launch, school shootings, and on and on and on

To fix things, in life, we must first think clearly. Ask yourself: is it really credible to suggest that we live in a more psychically-damaging time for young people than, say, the 1910s, when the world was wracked with the bloodiest war to date, when the Spanish flu killed perhaps 50 million people out of a world population of 1.8 billion, when the global infant mortality rate was something like 10 times what it is today, when women in the United States didn’t have the right to vote, when the end of Jim Crow was a half-century in the future, and when almost no one had access to any psychiatric care whatsoever? Is it really credible to suggest that there’s greater stress on teens now than there was in the 1930s, when the Great Depression crushed the economy to the extent that the federal government defined 60% of Americans as living in poverty, when fascism was on the march in Europe, when more than 650 out of every 100,000 mothers died in childbirth, when the widespread acceptance of psychotherapy as a legitimate medical practice was still 40 years away? Really? I find these constant claims that we live in a period of unique psychic damage for adolescents powerfully unconvincing, and this distortion has consequences, given how often it’s drafted into service as justification for whatever perspective on psychiatric care. And to the extent that I’m ready to believe that things really are uniquely hard on kids today, it’s because of the advent of smartphones and social media, which have the power to scramble a child’s brain and which Ehrenfeld doesn’t mention.

People are made profoundly uncomfortable by the possibility that the human brain itself can become disordered, and they hide in the social theory of psychology to avoid the frightening implication that, someday, their brain might go bad too. I quote the abstract of a 2021 article by Jonathan Sadowsky, which does the unpopular thing by suggesting that psychiatry is a form of medicine, medication a form of care, and the brain an organ that can go wrong.

Far from solidifying the medical status of depression and psychiatry’s treatment of it, the spread of pill-oriented depression treatment strengthened social researchers’ emphasis on psychiatry’s social nature. The article further argues that a depiction of psychiatry as mainly a social phenomenon both unduly diminishes its status as medicine, and implicitly underestimates the social in the rest of medicine. This matters if people can benefit from psychiatric treatment. Put another way, if people taking psychiatric medications are indeed ill, and taking medicines that can help them, social analysis should acknowledge this, even as it rightly investigates psychiatry as embedded in social and cultural contexts, as all of medicine is. Doing so means treating psychiatry, whatever its limitations, as a kind of medicine, not as a special case.

I would very much like to ask Ehrenfeld if she’s considered the possibility that this vibes-based approach to diagnosing mental illness, the endlessly expanding definition of who is sick and the totally-unjustified assumption that the contagion is caused by vague social environmental factors, is part of the problem. What if the extremely-unfashionable notion that mental illness is a result of problems in the brain is, in fact, correct? That there’s a neurological defect at play? And what if insisting that your daughter suffers because of convenient and conveniently vague cultural factors is in fact underwriting your resistance to the idea that this problem is a chronic tragedy that has no parenting fix? If Ash had been diagnosed with cancer or MS or another disease of the body, her mother would still rage against it, still battle for better treatment, still search for a cure. And she would have every right to, just as she has every right to demand more when confronting her daughter’s mental illness. But a disease of the body might at least force Ehrenfeld to confront the limits of the possible in contemporary medicine. Psychiatry always leaves people insistent that more can be done, and the notion that teens are sick because teens are sad and teens are sad because the world is suddenly hard has only deepened the refusal to ever confront the awful notion that maybe this is the best that can be achieved, right now.

And, again, those resources. Everyone who contributes to the current vogue for seeing mental illness as the result of how the world is fucked up and bullshit contributes to the endless expansion of who qualifies as mentally ill and the vision of mental illness as an “identity.” And what no one seems willing to countenance is the possibility that we can devote greater resources to the mentally ill or vastly expand who counts as mentally ill, but not both.

At the heart of all of this, there’s something I’ve tried to point out again and again in my writing about mental illness: sometimes things are just bad. Childhood mental illness is a tragedy. And what I find both tragic and deeply wrongheaded about Ehrenfeld’s piece is her dogged determination that, somehow, she is in this awful position because the system has failed her, and not because of the cruelty of fate. I referenced her dark wave at the attorneys she’s hired, and there are many more assertions of her child’s rights and what she’s entitled to…. What Ehrenfeld seems not to understand is that mental illness isn’t obligated to give her or her daughter anything. Ash is indeed entitled to certain rights under “the system.” But psychiatric illness is sublimely indifferent to what we think we are entitled to, and it cannot be controlled by the system. There is so much lawyering going on in Ehrenfeld’s essay, so much white-knuckled grasping for an administrative solution, so much unthinking demand to be let out of this hell through special pleading and a very contemporary form of aggrieved, social justice-inflected entitlement. Ehrenfeld and her daughter deserve every possible medical intervention; in fact, they deserve an instant cure. But deserve has nothing to do with it. This thing has taken her child. It will set her free or it won’t. And while every effort must be given to help her, there is no cosmic authority to whom we can petition for relief or recompense. Ash will get better, or she won’t. And I know that’s a terribly cruel thing to say. But it’s a terribly cruel reality.

“There is no help,” Ehrenfeld writes. There is no help. This is a very understandable thing to say. It reflects her deep anguish, and I am very sorry for it. But it’s also, I think, a cruel and insulting thing to say. Throughout the essay, there are people attempting to help. Ehrenfeld just finds those attempts inadequate. She is entitled to do so. But the notion that professionals in psychiatric medicine just generally don’t care, that they’re unfeeling, unsympathetic functionaries - this is a constant casual slander, and one that does not match my own experience at all. There are a lot of people in the field who care. Some of them saved my life. Again, let me ask: how is this essay helping the problems it describes? We have a deep psychiatrist shortage in this country. Why? Well, why not? Compared to other physicians, psychiatrists are not paid well, and the high-end salaries are either found in courtrooms as professional expert witnesses and thus not as healers, or at the high-end clinics that Ehrenfeld resents. But at least we give them so much respect! Oh, no, wait, we do the opposite. We constantly publish essays like this. We let the witless and conspiratorial voice of the anti-psychiatry movement flourish in our discourse. We undermine the profession while we make more and more extravagant demands of what it might accomplish. Well… maybe we have to choose. Maybe we have to choose to support the mental health system we have while demanding it improve, or choose to wash our hands of it and stop expecting it to work miracles.

What’s happened to Ehrenfeld has been very, very hard. The dark but necessary point to make is that nothing will get better until people like her learn to be hard on themselves.