From the Inside Out: New Insights

Where we are

When looking in from the outside, mental illnesses have many faces and present differently in different individuals. The current system for evaluating mental health status entails largely a set of diagnostic criteria that are designed to standardize diagnosis and treatment. As I wrote in an earlier paper, "The Diagnostic and Statistical Manual (DSM) in its current incarnation is a tome of symptoms, categories and diagnoses that are useful tools for mental health practitioners coming to grips with the varied presentation of behaviors that are characteristic of individuals with varying experiences" (1). But is this immense volume, the be all and end all, really the most conducive way to evaluate, understand and help those with mental illnesses?

A reading of five narratives of different people diagnosed with different mental illnesses reveals that the experience of mental illness is remarkably consistent across diagnostic categories. People feel the same way and think the same things, whether hearing voices in their heads, or purging. This means something and it means something important. We must not treat the symptom: depression, schizophrenia, bulimia, etc. We must restore the individual to a place where she has the capacity to be the driving force of change in her own life, without a prescribed endpoint, without limits. By recognizing the extent to which experiences overlap, mental illness is removed from the realm of the "sick" and placed squarely in the realm of "human," like the chicken pox or asthma. The brain in its efforts to resolved internal conflict produces similar responses, like the symptoms of a dust allergy may manifest similarly in different people. We all have these feelings; it is the degree to which we have them, which varies.

DSM IV
There is a vast difference according to all diagnostic measures, between anorexia nervosa, for example, and schizophrenia (2). Anorexia is defined as:   

1.   Refusal to maintain body weight at or above a minimally normal weight for age and height (eg, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
4. In postmenarchal females, amenorrhea ie, the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, eg, estrogen administration.)
(2)

On the other hand, the DSM IV describes schizophrenia in the following way:
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
* delusions
* hallucinations
* disorganized speech (e.g., frequent derailment or incoherence)
* grossly disorganized or catatonic behavior
* negative symptoms, i.e., affective flattening, alogia, or avolition
B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
(3)

As I wrote in an earlier paper, "This is the language of diagnosis. It is an attempt to measure, as an outsider, an approximation of the experience of another person. It is an effort to glimpse into the world of someone else and attempt to make meaning of behavior as viewed from the outside; but it is limited (2). These diagnoses often entail a process of 'ruling out' other diagnoses as a means of arriving at the appropriate one (4).  The question remains as to whether or not that which an outsider has determined to be readily definable and unique from others' experiences is, in the experience of the individual who receives the diagnosis, actually so starkly different? When the objective measures used to delineate between mental illnesses based upon symptoms, whether observed by an outsider or reported by the individual herself, are looked at in conjunction with the internal experiences of someone diagnosed with anorexia, someone diagnosed with schizophrenia, with bipolar disorder, with depression, and alcoholism, are the diagnostic categories so readily distinguishable?" (1). And what can be gleaned, which may be useful for rethinking the treatment of mental illnesses?

Internal experiences: what they tell us

In order to explore the relationships between diagnosis and the internal experiences of the people being diagnosed, I will examine five memoirs written by five different people, each diagnosed with a different mental illness (1). Those books are Darkness Visible by William Stryron (5), Unquiet Mind by Kay Redfield Jamison (6), The Quiet Room  by Lori Schiller and Amanda Bennett (7), Wasted by Marya Hornbacher (8), Dry by Augusten Burroughs (9) . In comparing the stories these individuals weave about their experiences with mental illness, this small sampling cannot and is not intended to be representative. However, there are undeniable parallels between these stories that need to be considered seriously, for they may serve as beacon in an often-murky field of mental health, where vague notions of treatment and outcome often fall short. This demands a critical reexamination of the diagnostic categories we use in order to take the working of the individual mind into account and deemphasize the external manifestations of illness, the symptoms, such as insomnia, psychosis, and purging, etc. Let us bring mental health to where it belongs, squarely in the realm of the individual, for she is not so different from you or me.

There are common themes among the five stories that unite the five authors. The reason for the commonalities cannot be reduced to coincidence, rather must be seen as a similar mechanism by which the storyteller grapples with information and attempts to reconcile it in a meaningful way, using tacit knowledge and incoming sensory input (10). Mental illnesses are different ways in which the storyteller reconciles information, manifesting in many behaviors and ways of thinking that impinge upon individual flourishing. As I wrote in an earlier paper, "For many with mental illness, including the authors of the memoirs discussed here, there is a sense that 'it was not always like this,' something predated the mental illness, some sense, albeit vague of prior normalcy, of balance. There is also a shared internal experience of a second self, which overtakes a natural or more familiar self. And finally, one of the most striking features of similarities between internal experiences is a sense of helplessness to effect change in their situations, to restore themselves to health. One of the baffling qualitative observations one could make about behavior, and as an extension, mental illness, is that it is fraught with contradictions. 'I don't want to live,' in one breath, and 'Please don't let me die,' in another. These two sentiments are seemingly irreconcilable, yet elucidative of a deep internal conflict. 'Who am I? And what is my role in the world?' It seems these are questions with which many people wrestle, but with which those with mental illnesses may have more difficulty resolving" (1). That many people grapple with these issues along a continuum of experience, from a fleeting thought every now and again to the extreme of major depression, bolsters the argument that mental "illness" is more of a shared experience than we may be comfortable acknowledging, to the detriment of all.

Five narratives seep into one: The second self

As I wrote in a previous paper, "Styron's experience was a steep and slippery slide into depression and, as it unfolded, his descent was unpredictable and unstoppable in his mind. Upon emerging from depression, he looked back on it and was able to examine some factors that may have contributed to his mental state. However, it was, to the part of his mind that gave meaning to his experience, unexpected and extreme. And while he was vaguely aware that something was amiss, he could not know what that something was and wrote that no medication or therapy could have prevented the descent into depression that he experienced (5). He recalled experiences of joy he had in the past, but could not access that feeling, could not live it in the moment to such an extent that he contemplated suicide. The inability to experience the world, or oneself, as one had prior to illness is coincident with the feeling of being overtaken" (1). Styron writes, "...sense of being accompanied by a second self-a wraithlike observer who, not sharing the dementia of his double, is able to watch with dispassionate curiosity as his companion struggles against the oncoming disaster, or decides to embrace it..." (5, p.64).  This speaks to the conflicted nature of depression; Styron either fought against the impending storm or relented to the torrent within. With a sense of exhaustion and impending doom, and "despair beyond despair" (5, p.63) reorganizing one's thoughts can feel like an insurmountable, perhaps impossible task. As I noted in a previous paper, "This is an internal experience shared by all five writers in one sense or another, the crushing weight of their own thoughts and feelings seemingly impossible to navigate. This is of the utmost significance in understanding mental illness" (1). If someone feels trapped, someone needs to open a door and let him or her out.

Styron's internal experience can be compared to that of Kay Redfield Jamison, who has bipolar disorder. As from an earlier paper, "Jamison was somewhat aware that something inside of her mind had shifted, perhaps come into sharper focus, masking the parts of her by which she had come to define her existence," (1), such as her precocity, love of family, friends, etc. Even before becoming a teenager, Jamison writes of being in second grade, witnessing a plane crash about which she wrote, " From that afternoon on, I saw that death was also and always there" (6, p.13). As a second grader this is a tremendous burden to bear, thoughts of mortality without a clear contextual basis as to what those thoughts mean. Jamison's newfound awareness did not immediately translate into the behaviors that are associated with bipolar disorder, but she was aware of that moment in second grade as being a turning point. As the years passed Jamison wrote, "By the time I was sixteen or seventeen it became clear that my energies and enthusiasms could be exhausting to the people around me...after long weeks of flying high and sleeping little, my thinking would take a downward turn"  (6, p.35).

And, as with Styron, the realization that something was amiss did not translate readily into a set of tools to employ to prevent the overwhelming internal experiences. Jamison, too, shares Styron's sense of being overtaken by something or someone other than who she knew herself to be, "However lodged within my mind and soul the darkness became, it almost always seemed an outside force that was at war with my natural self" (6, p. 15). There is on the one hand a sense that one cannot escape the thoughts and feelings and on the other a profound realization that the thoughts do not define her entirely. The task of the mental health professional is to help the individual navigate the tangle of simultaneously feeling trapped, yet paralyzed to effect change. Schiller and Hornbacher share this sentiment, too.

As I wrote in an earlier paper, "Lori Schiller writes about her ups and downs with schizophrenia, in terms of how much the voices were present and how able she was to function in the world to the extent that she wished" (1). The goal of mental health treatment need not be assimilation, rather enabling the individual to reach her potential, not fully determined, but influenced by her genes, her environment and the bridge between the two. This would create a space in which mental illness were not so foreign to those experiencing it or those who bear witness. It is not possible to make someone something they are not, but it is possible to make someone who they have yet to become. The fewer constraints we place on each other, the fewer constraints we place on ourselves in the context or alleviating mental distress.

Of her experiences, Schiller writes, "By summer's end, I was sick, without any clear idea of what was happening to me or why. And as the Voices evolved into a full-scale illness, one that I only later learned was called schizophrenia, it snatched from me my tranquility, sometimes my self-possession, and very nearly my life" (7, p.7).  As I wrote previously, "This, too, suggests that Schiller did not see the illness coming, and as such, while aware once it struck, did not have a way to guard against it. This is similar to the experiences of both Styron and Jamison, a sense of surprise at how strong and tormenting the internal experience had become without a sense of what to do to overcome those thoughts. Schiller goes into detail about the voices feeling as though they were inside of her, but identifying them as other than her. This theme of mental illness as 'other' is a strong one in the experiences of those who have them" (1).

Hornbacher writes primarily about her experiences with bulimia and anorexia. She writes of a time when she first became aware of the changes in her internal experience, "Through the looking glass I went and things turned upside down, inside out," (8, p.123). She went from a life she recognized and clung to, to the life of someone with an eating disorder, a stranger to herself. This was not a choice she made with complete awareness, rather a slow movement towards one thing and away from another. This, ironically, may be the role of the mental health professional, to guide the development of those with mental illness without delineating an endpoint. However the ability of one to create a new scenario for oneself is hampered when one has become alienated from oneself. Hornbacher writes of bulimia, "...it is at once tempting, seductive and terrifying. It divides the brain in half: you take in, you reject; you need; you do not need. It is not a comfortable split even early on...You have a specific focus. Your thoughts do not race as much." (8, p.42) This "split" to which Hornbacher refers is similar to the experiences written about by Styron, Jamison and Schiller. For Styron, like Hornbacher, there are times during which the strength of the storyteller's "depression story" is overridden by an alternative story that is less deleterious. The task is to hold onto the vision of another story, which is one way in which a mental health care worker can help. Hornbacher writes:

I felt like I was going out of my mind. My head was never quiet. ...the strange blackouts I began to have - pure silence, not sleeplike but deathlike - and the hellish shrieking jumble of my own thoughts and the voices of the world. And the sharp hiss of one voice that started out softly, as though below layers of moss, or flesh, and gradually became so loud it drowned out everything else: Thinner, it said. You've got to get thinner.
(8, p.69).

Here Hornbacher refers to a voice, which in her experience refers to her as "you" not as "I," which indicates that her internal process was such that the voice felt like an intruder. Styron, Jamison and Schiller all recount a similar sense of an "intruder." This internal experience, a world within a world, where "I" is at war with "other" is a common thread throughout the six stories.

Augusten Burroughs' memoir, at once hilarious and bitter, is fraught with his struggles to overcome his divided self. As Burroughs' tale unfolds, it is evident that he feels detached from his sense of "self" and from the world whether drunk or not. It is, however, with alcohol that the dull, aching, loneliness dissipates, hence, in part, his continued return to alcohol to distance himself from his detachment, to feel less trapped, like Hornbacher with bulimia. Burroughs' writes, "I finish the bottle and still do not have that sense of relief that I need. It's like my brain is stubborn tonight. So, I have some bottle of hard cider and these gradually do the trick and I get my soft feeling," (9, p.18). The only way Burroughs' knows to alleviate the sense of alienation he has from the world is to use alcohol to allow his "other" self to emerge. It is not that there is truly another self, rather that the predominant story that shapes his "reality" is not one that is constructive for Burroughs' in his aim to live a life he desires. It is so for all of the other writers, too. Burroughs' further writes,

I'm not anxious. I'm lonely. And I'm lonely in some horrible deep way and for a flash of an instant, I can see just how lonely, and how deep this feeling runs. And it scares the shit out of me to be so lonely because it seems catastrophic-seeing the car just as it hits you. But then all of a sudden, that feeling is gone and I'm blank. So it's like a door quickly opened, just a crack, to show me what a mess I was inside. But not enough to really stare long and absorb all the details. Just enough to know the room needed a major spring cleaning.
(9, p.30-31).

In moments, Burroughs', like the other writers, is able to recognize that the story being crafted to reconcile his experiences, is itself transient and possibly illusory. If we can begin with an underlying premise that reality is, in fact, fluid and ever-changing, the ability to replace a story with one that is more conducive to life suddenly becomes plausible; there are a multitude of possibilities. Sometimes people need to be reminded of this, urged to consider the alternatives and even helped to create an alternative. Thus, Burroughs' sense that there may be something amiss is "real" to the extent that his mind is showing him that there may be another possibility. For to recognize something is amiss, is to acknowledge there are other "less wrong" (14) possibilities. This is a critical component to mental illness, as evidenced by all of the narratives herein discussed and something to which more attention must be paid, in an effort to truly untangle the web.

You see me differently than I see myself & agency

As I wrote in a previous paper, "Other similarities in stories stem from the ways in which the authors present themselves to the world and how presentation can differ from one's internal sense of one's world. Styron did not explicitly try to mask the way he felt during his depression, though did not realize how far he had slipped into depression until outsiders noted it. One feature of internal experience is that one either explicitly attempts to mask one's anguish, or one is so completely detached that one is not even aware how far one has slipped" (1). Styron writes, "One does not abandon, even briefly, one's bed of nails, but is attached to it wherever one goes...the walking wounded" (4, p.62). Because the "murk" of depression leads to "minds turned agonizingly inward," (4, p.47). Styron went from seeing the world in color and with texture to being inside of his mind feeling as though he could not escape. Styron writes that he was not aware that others could recognize his pain, until a photographer takes his picture and urges him to "smile" and Styron recounts having obeyed this request. The photographer later telephones Styron to say the photographs must be retaken because they are "too full of anguish" (4, p.58). Styron's felt so trapped that he did not see how depression had changed him nor did he realize it was something of which outsiders might be aware. This sense of isolation and desolation is powerfully consistent across the five stories, whether the efforts to mask one's internal world are direct or not.

While Styron did not realize how strongly his turn inwards was visible to others who  observed him, Jamison, as she became more aware of her illness, did attempt to hide it from others. This creates another layer of torment, as she describes it. She made a great effort to keep her internal experiences from other people. In part, this shame and guilt is an internalization of societies general distaste for and discomfort with extreme behaviors. For mental illness to be more effectively ameliorated, we must confront our prejudices about mental illness to wipe away the layer of guilt and shame atop the mental distress that further complicates matters for the individual. Jamison writes, "I made...an enormous effort not to be noticed" (5, p.39). The feeling that one must hide one's pain is closely related to a feeling that one cannot change one's circumstances, that one is powerless. Of her handling of her vacillations in mood Jamison writes:

I had learned to accommodate quite well to them. I had developed mechanisms of self-control, to keep down the peals of singularly inappropriate laughter, and set rigid limits on my irritability. I avoided situations that might trip or jangle my hypersensitive wiring, and I learned to pretend I was paying attention or following a logical point when my mind was off chasing rabbits in a thousand directions.
(5, p.82).  

From this adaptability to the norms of society, to her expectations of herself comes a conflict between what Jamison's life was from the inside and what she projected to the outside. An extension of this was a deep sense of inescapability. Jamison writes, "At one point I was determined that if my mind...did not stop racing and begin working normally again I would kill myself" (5, p.83). Jamison over and again describes feeling that she was not herself and did not know how to return to herself, to reclaim what she had lost and this was a source of tension and fear. This is an essential commonality between the stories of many with mental illness, which is a complete sense of either paralysis about how to resolve internal conflict, or inability to even fathom a way through the labyrinth of one's internal experiences. Styron , Schiller and Hornbacher  and Burroughs write about arriving at the brink of life and death and questioning their ability and desire to live as a result of the anguish of their internal experiences, their sense of helplessness almost overwhelming their desire to live. The extent to which people feel these ways could be mitigated with a more forgiving mental health system.

As I wrote in a previous paper, "Schiller writes about her internal experience, feeling as though nobody else should know about her struggles. She feared she was mentally ill, knew herself to be at some level, but felt the need to hide it from her family" (1). She writes, "...I suddenly had a new task: keeping my terrible secret. It took all of my determination, and all of my drive. I was putting on a super performance nearly every day. I was pretending that nothing had changed, even though nothing at all was the same" (6, p.15). The internal experience for Schiller had transformed her, but these drastic changes in her experience were not visible to an outsider, hence the dilemma of being stuck inside of one's mind, while one's distress is not readily visible to anyone else. Schiller further writes about finally meeting with a psychiatrist:

Week after week I met with him, yet I couldn't speak. I couldn't talk about the Voices. It was too dangerous. The Voices were twisting themselves around me. It was hard to tell where they left off and I began. They threatened me and I believed them. If I squealed on the Voices, they might kill me. If I ratted them out, the person I told would have to die
(6, p.25).

It is this "secret" that keeps her trapped. She writes of feeling unable to communicate the depth of her struggles, even as they became apparent to outsiders The perception of lack of agency is potent and severe, leading many to take drastic measures to alleviate that feeling.

Hornbacher's desperation lessened when she hid inside of herself. She writes, "I was not as I appeared. I liked that. I was a magician. No one could see what I hid underneath, and I didn't want them to, because what I hid seemed raw" (7, p.32). Furthermore she writes, "I had a secret. It was a guilty secret, certainly. But it was my secret. I had something to hold on to. It was company. It kept me calm. It filled me up. It emptied me out (7, p.42).

The conflict of being someone inside that only you can know versus the "you" that is seen by others runs deep and is a source of anguish for all five of the writers. Hornbacher writes about protecting the internal experience because she felt it to be the only part of her world over which she reigned. Her sense that her internal experience was her only source of worldly power, in the absence of meaningful relationships and connectedness to the world. Hornbacher retreated further inside until she had lost site of the exit. Here, again, is the theme of agency: the idea that nobody is allowed to know one's internal experience, nor is it possible for one to escape one's internal experience. When one's internal experience is frightening, anguishing and not conducive to continued personal progress, this feeling of lack of agency is a source of great despair. Hornbacher writes of her internal experience and her simultaneous feeling of needing it and fearing it:

The sickness occupies your every thought, breathes like a lover at your ear; the sickness stands at your shoulder in the mirror, absorbed with your body, each inch of skin and flesh, and you let it work you over, touch you with rough hands that thrill. Nothing will ever be so close to you again. You will never find a lover so careful, so attentive, so unconditionally present and concerned only with you.
(7, p.125).

For Hornbacher, the outside world did not seem one in which she was able to flourish and so the "turning inwards" of Styron's world was a way to create order out of seeming disorder, to feel important, empowered and in control inside of herself.  The effect, however, was further isolation and a feeling of intense loneliness and despair.

Boroughs', too, attempts to create a world for himself in which he is able to drink frequently and to excess, while still maintaining a job and relative "stability." The too aims are at odds, as Boroughs eventually comes to understand, but he is not deterred in his efforts to convince himself that he can hide his alcoholism from the outside world by pretending it is not a problem He thus maintains the stability of his story. Boroughs fears facing "responsibility" as he puts it, so hides from it either by denying it or by drinking, so he does not have to grapple with the anxiety that his daily life engenders. Burroughs writes, "...I know I drink too much, or what other people consider too much. But it's so much a part of me, it's like saying my arms are too long. Like I can change that?" (9, pg.16). A feature of all of the stories is a limited vision of  an alternative story, a sense that each individual is inescapably defined by her behaviors without other options.

Representative?

There are many other factors, which are not within the scope of this paper that are important in understanding the faces of mental illness. These factors are largely the external factors, things outside of ourselves that are an integral part of identify-formation, the definition of "I" for each of us. These are variable such as familial factors, namely the role of the environment in which we are raised and the role of genetics (11). Of note, which makes the stories of Styron, Jamison, Hornbacher Schiller and Burroughs different than many other people with mental illnesses is that they were able to seek help and achieve some sort of resolution. They each achieved some measure of control over their internal experiences, where they previously felt they had none. This is not always, or even often, the case with people experiencing mental illness. Why not?

As I wrote in an earlier paper, "To suggest that any two human experiences can be the "same" is to suggest the impossible, but also implicitly, to negate the observations that suggest genes and environment together contribute to our behaviors, to our internal experiences, thus to how a person experiences her world. However, to reduce human experiences to the sum of its parts, to schizophrenia, to eating disorders, depression and bipolar disorder, is to overlook the similarities in the ways in which those diagnosed with mental illnesses experience the world and themselves in the world. This is an argument for greater sensitivity to the individual and her experiences from the inside and decidedly not an argument for homogenization or conflation of mental illness diagnostic categories. Styron writes, "It is of great importance that those who are suffering a siege, perhaps for the first time, be told-be convinced, rather that the illness will run its course and that they will pull through" (76).  Having experienced depression, lived through it and returned to a more balanced internal experience, who better to describe the needs of those "under siege" than Styron. Styron writes that there is a "...basic inability of healthy people to imagine a form of torment so alien to everyday experience" (4, p.17). There is no way to know the experience of another and especially in the case of mental illness in which the person with the illness often has trouble communicating her internal experience. On the subject of communicating her internal experiences, Hornbacher writes, "But the part that kept lurking, unarticulated, in the back of my head wasn't discussed" (7, p. 206). If there are more similarities across diagnostic categories than the categories themselves reveal, there is a need to bring to light the internal experiences of those with mental illness, to free them from the sense of helplessness and lack of agency, by making the internal experiences shared knowledge. This is not a solution unto itself, but one piece of a multi-faceted puzzle, a piece that may well prove useful in understanding mental illness" (1).

Mental health an alternative view

Mental health is a human project, not the domain of the "sick." Mental health must be reconceived as a journey fundamental to the shaping of every human story. Thus, the health and illness paradigm would dissipate and make room for the possibility of growth, change, and actualization of potential that is not associated with any particular endpoint, rather is geared toward the individual journey. That all five stories discussed in this paper share a sense of a second self, a memory of or hope for another possibility and a simultaneous feeling that one cannot change one's circumstance, the challenge is to see these as human experiences, not just products of illness. In so doing, one can work with the story without restricting oneself to the categories of schizophrenia, depression, alcoholism, etc. And such categories are restrictive in that they have become associated with certain features that are symptoms of an illness, just like the flu is associated with fever, nausea and a sore throat. This narrow symptom-based definition leads to a narrow-symptom-based treatment. We are overlooking the forest for the trees.

How we can help

If an individual experiences hopelessness, it is not necessarily relevant that said individual has "depression." In that, an alcoholic who feels helpless may benefit from the same modifications to their story without receiving a particular diagnosis. The category does little to elucidate an appropriate treatment. There are a number of ways in which the mental health system could be modified to better facilitate the flourishing of all people. It is possible to tell one's story and from the telling receive help in assigning new meaning to the same story. This is a revision of story that can be facilitated by a mental health worker. This opens up a world of possibility because it gives agency to the individual. One is no longer blamed for behaviors, but instead undertakes an active role to reshape her own world, while maintaining a sense of "self." Styron alludes to this in his story. He knew something was amiss and that he had to make change but could not do it alone. Few people can. And this is something that makes mental health a universal project, for all who wish to engage and everyone should be encouraged and helped in their efforts to do so. This is not an impossible goal, though it may seem improbable. The revision of stories is an essential tool for all people to cultivate, whether diagnosed with a mental illness or not. If people are presented with possibilities for a story other than their current story, one that is less anguished, more engaged in the world that can be enough to serve as a catalyst. When one is "stuck" in a particular mindset, if a mental health worker listens to the individual story and helps craft meaning that is life-affirming, this is a tremendous step towards a new vision of the world, a new way to be in the world.

If someone has the sense of a second self, one that is not who they really are, as did all of the individuals in the five stories discussed here, diagnoses are not necessarily prescriptive. The second self may well be the mark of a conflict in story. When the brain reconciles information from tacit knowledge and sensory input, there is more than one possibility for story generation, though those possibilities may elude the individual. For some people, part of therapy is not just assigning new meaning to the same story, but generating a new story. It may be the role of the mental health worker to listen to the story of the individual and create a new story along with the person. This is often, as in the case of Hornbacher and her eating disorder, something the therapist may have to continually reinforce in order to supplant the old story with the new. It is the apparent and temporary lack of agency that eventually restores agency to the individual. Repetition of any story lodges it more firmly in the mind, thus the more the new story is affirmed, the more strongly it takes hold, first as a seed in tacit knowledge and eventually as it is blossoms in consciousness as a new story. Many people need to be given an alternative, a vision of something else other than their story as well as permission to engage in revision of their story.

There are times that one is deeply entangled in a particular story, such that the feedback loop between tacit knowledge and the story-teller continues uninterrupted, without assimilating a new story that is presented by an outsider. During such times, agency must, paradoxically, be removed from the individual in order to eventually restore it to the individual. Although it was of his own volition, Styron went to a hospital to seek help as an inpatient as did Burroughs and in so doing, had many "choices" taken away from him, so that he could relearn how to make different choices, ones that were more positive in his life. When dealing with the story-teller, the "symptoms" of depression will go away if the story can be adequately replaced.

The same, but different

Certainly, there are differences in experiences of mental states that need to be recognized, so that any "system" of dealing with mental health must be an adaptive one. It must be adaptive to different people and their needs, and to the changing needs of the individual, as her journey is ongoing. In a tangible way, this means being open to many different therapeutic modalities and to a more inclusive understanding of health that is a project, a journey, not a specific endpoint with strictly definable goals. As Justin Smith writes in an article about depression, "I am a depressive, which is to say a person who experiences the world in a certain way" (12). And because there is always potential to view the world in more than one way, the mind of someone with depression is as fertile ground for change as anyone else. If depression and other illness categories are as a way to understand the story of the individual rather than as a means of treating a set of symptoms, the categories may prove more useful. This also entails flexibility to recognize differences amongst people who may fall into the same "category" and similarities between people in different categories. Another person diagnosed with depression writes, "But I doubt that their reduction to medical conditions like any other is what best helps us to understand them, or to live with them" (13).

The journey continues...

So, in the interest of "getting it less wrong" (14) where mental health/illness are concerned, let's release ourselves from the chains of the health/illness dichotomy entirely and infuse the system with a more realistic continuum that exemplifies the range of human behaviors and mindsets. Thus, touch the mental health system with humility and engagement. Humility is required to acknowledge that the individual mental health journey is a universal project, not to be feared, which has the potential to be one of continued personal refinement and self-actualization. And a sense of committed engagement is also needed to insist that everyone has the ability to create meaningful change.

References

1. /exchange/node/3295

2. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry/eat  ing/table1.htm accessed 24 October, 2008.

3. http://www.counsellingresource.com/distress/schizophrenia/dsm/schizophrenia.html        
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