It’s that time of year again—time to reread Edith Wharton’s second novel The House of Mirth (1905) and see no signs of ever tiring of doing so.

Doing so made me revisit an essay I’d written about it years ago—and rethink what I wrote back then.

Because rereading (or rewatching, relistening, etc.) is a strange thing. I mean, there’s so much content—stuff—in the world (I wish there were more content, said no one ever). Why would we ever re anything?

The House of Mirth’s protagonist Lily Bart is like no other heroine—beautiful, bored, proto-feminist, funny, false to others, smart, puerile, self-destructive, and doomed. Trapped in a society in which women are ostensibly forced to marry, Lily is twenty-nine—the point of no return lest she descend into spinsterhood—and must land a husband despite her independence and a fervent desire to be alone. Only rich widows and “unmarriageable” women get to be “free.”

But Lily doesn’t want to marry in the first place, and she’s not at all “unmarriageable,” i.e., she’s beautiful, charming, and knows how to “please” a man (i.e., when necessary she can act the part). She couldn’t be unmarriageable if she tried. Unmarriageable women devote themselves to helping the poor, live modestly, and become a saint. Lily likes to gamble and party (nineteenth-century style) and doesn’t have an altruistic bone in her body (though she tries). When another character mentions an “unmarriageable” woman who has her own apartment as an example of how Lily might live independently, Lily says, “But we’re so different, you know: she likes being good, and I like being happy.”

There’s more to Lily’s situation than the fear of being unfashionable. She doesn’t have an income. Being unmarried will relegate her to poverty.

But why reread it so often? (I think we’re getting on at least ten times.) Yes, Wharton’s prose is gorgeous. The characters are so real they seem to be physically in the room with you. But there are lots of books with those attributes.

I mean, I’m not a toddler. Why read the same story to myself again and again? (We all end up our own parents or guardians reading to ourselves in adulthood.)

And it’s hardly a feel-good story. Why put myself through it?

True, I love Wharton as a writer and for who she was as a woman. She writes almost exclusively about the upper classes, but readers and critics are mistaken when they call her full-length works “novels of manners.” No, Wharton was fierce, and her work exposes not just the falsity of America’s caste system, but how deadly (literally) it is to women.

I reread two other books every or most years—both downers as well: The Great Gatsby (not exactly a laugh riot) and Brothers Karamazov (hilarious—if you get the Peter Margasak translation; the others totally miss out on Dostoyevsky’s humor) but also violent, sad, and depressing.

Put a movie or TV show or song you have on repeat. Someone I know rewatches the Godfather trilogy every Christmas. Yet he loves it. But why that trilogy, on that day? It’s hardly Rudolph or Frosty.

I get the ritual factor. I’m a sameness enthusiast in all things. I eat pretty much the same three meals every day.

Though Mirth is brutally sad, rereading makes the misery familiar. Each time I delve in, it’s easier to recognize.

But that makes it no less sad. Maybe confronting Lily’s sadness in the safety of the novel’s pages makes my own more manageable.

Or maybe it’s more than that.

Maybe rereading (rewatching, listening over and over) can evolve us as humans. I’m not sure it can show us who we are or who we’re becoming but maybe it can help us glimpse who we aren’t anymore—and maybe that we’re lucky for it.

It’s Lily’s failure to take care of herself that made me weep the first time I read the novel in my twenties—sob, actually. Full, heaving sobs.

At the time, I wasn’t caring for myself—though not in the same ways. I was Lily then. I recognized in her my willfulness matched only by my self-destructiveness.

Reading it every year, I get to see how Lily has stayed the same, which means maybe I’ve changed.

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I’ve been thinking a lot about the interviews I did for in the 2000s—six total, including Nobel laureate Kenzaburo Ôe, Pulitzer-prize-winner Marilynne Robinson, National-Book-Award winner Ha Jin, and poet laureate Kay Ryan.

If you don’t know them, Paris Review interviews are it when it comes to author interviews. Since the magazine’s first interview with T.S. Eliot in 1953, they’ve featured everyone from William Faulkner to Toni Morrison to Stephen King.

That might sound dull to some of you, but Paris Review interviews are epic. The process is beyond lengthy. The author and interviewer meet over several sessions. (Marilyn Robinson and I had eight sessions.) Then the interview is heavily edited to read as a single conversation.

And then there’s everything that happens behind the interview, the strangeness of spending time with someone, hearing them talk for hours, but never really getting to know them or sharing anything about yourself.

I wrote a bit about my 2005 interview with the Spanish novelist Javier Marías a few years ago on and spent this morning writing through it again, trying to get at what else was happening during the three days I spent interviewing him.

I arrived at Marías’s apartment building just off the Plaza Mayor in Madrid at six in the evening. The light was just starting to fade. The doorman, an elderly Madrileño, ushered me upstairs. The enclosed stairwell was dark. I could barely see the stairs and kept thinking the Madrileño was going to trip and fall.

In Europe, Marías had the celebrity status of a rock star. His books had been translated into over thirty languages and had sold over five million copies worldwide. (He was also the king of Redonda, an uninhabited Caribbean island—long story.)

Earlier that day, while eating lunch at a nearby restaurant, the waiter asked what I was doing in Spain. When I told him that I was in Madrid to interview Javier Marías, he gasped and said, “Sometimes we see him walking down the street!”

I probably shouldn’t have been interviewing such a famous writer. I’d interviewed only one other writer in my life, also for the magazine: the extraordinary poet Jack Gilbert, and I’d talked my way into that one. (Longer story, which maybe I’ll also dig into.)

Marías answered the door and politely invited me inside. His eyes were puffy with dark circles under them, and though balding, he had a severe case of bedhead.

As we walked through the hallway of his apartment, Marías explained that Orson Welles’s Othello had been on television at three that morning, and he hadn’t gone to bed until six am.

He squinted apologetically and quietly mentioned that his father had passed away a few months earlier.

“I sleep badly,” he said, gesturing for me to sit on a puffy blue chair.

What the interview, later published in the magazine, won’t tell you is that I’d walked the streets the night before, homesick and alone, worried I wouldn’t be ready, that the batteries in my tape player would die.

I don’t remember exactly, but if someone had videotaped us, I was probably perched on the edge of the chair, so wanting to prove myself.

I was militant in my preparation for the interview—a habit I’d continue. I’d spent three months reading all eleven of Marías’s novels; his two collections of short stories; reviews of his work; and every interview with him that had been published in English.

The pressure came from the magazine too, not the editors but because of the prestige and the tradition I was now part of.

Marías sat on the couch, and his eyes brightened. He described at length how honored he was to have been chosen as the subject for a Paris Review interview. He lit a cigarette and through the haze of cigarette smoke, said he had read the Paris Review interview with Vladimir Nabokov many times.

The interview also won’t tell you how sick I felt—not having eaten much, not being well mentally, and wanting so much to be impressive, liked, something. Or that—at the same time—I was totally enamoured of him and this incredible opportunity I had.

Marías and I met over three days. By the time we finished, the transcript of our sessions was 30,000 words long—the length of a novella—that the managing editor (also an epic editor) and I would curate and develop, keeping the his verbatim but moving sections around in chunks and simulating questions to get it down to 5,000 words that would make the reader feel like they’re in that smoke-filled room with us.

On the last day, during a rare lull, Marías stubbed out his cigarette, popped up, went to the kitchen, and returned with a thick bar of dark chocolate. After offering me some, he ate a few squares—like a mountaineer in need of an energy boost—and went on talking.

By nine o’clock, Marías’s energy started to fade. He said he’d promised to meet friends at the corner bar to watch fútbol. As he showed me to the door, he seemed exhausted. It was an expression of tiredness I’d see on other interviewees’ faces—the kind that comes from talking about oneself for too long.

The interview also won’t tell you what I mentioned before about how decentering it is to be with someone and never get to know them.

Maybe it was the wanting to prove myself. Maybe, if I’d been able to settle back in that chair, let it go a bit, I’d have learned more about him, maybe more about myself.

Or maybe not. That time was so foggy, so full of sweets (marzipan, lots of marzipan—and meringues, which I don’t really like but are like mainlining sugar) that I’d eat to try to calm myself down.

Or maybe that was the getting to know myself, a knowing that comes later, that feels too late but never is.

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After developing a rare neurological disorder in 2015, she turned her artistic focus inward, embracing stillness, intimacy, and relationship as the foundation of her work. In 2019, she launched Unfixed, a media project that now includes award-winning films, limited series, podcasts, memoirs, and live roundtables. Her work has been recognized by PBS, Harvard Medical School, and the Invisible Disabilities Association, among others.

Kim leads a larger advocacy role within the chronic illness community where she writes and speaks about her own patient experience.

Her forthcoming memoir, Unfixed: A Memoir of Family, Mystery, and the Currents That Carry You Home, will be published by Empress Editions in October 2025.

Pre-order Unfixed

Thank you, , , , , and many others for tuning into our conversation!

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.” Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not.

I.

My father stares pensively at his phone. We’re at our usual table in Starbucks. A water for me, ginger tea for him. I showed him how to download an app. He’s trying to do it. (He and my stepmother only recently agreed to get a cellphone.) He taps the screen and bites his lower lip.

My love for him encompasses me.

I still haven’t talked to my family about the fact that I’ve healed from serious mental illness. They were told I could only manage my symptoms. Healing actually feels like a betrayal. Will they think I faked it all those years? Will they think I’m lying about my recovery?

This morning, I sat at my desk and wrote the feelings and sensations that wreck me at worst or trouble me at best:

● Hollowness

● Vibration in my chest for no reason

● Pit in my stomach

● Insomnia

● Hypochondria

● Dislocation, feeling like I’m not in my body

● Panic attacks

● Needing to move

● Inability to stop moving

● Pessimism/negative thinking

● Hopelessness

● Inability to see the good

● Irritability

● Mood swings

● Negative self-talk

● Weighing myself

Before, these would have been symptoms; now, they just are.

He taps his phone, his forehead pinching in concentration.

To the sound of the barista calling out a double-skinny-iced something, the gravity of what I’ve done hits me: I’ve actually healed from mental illness—serious mental illness.

He looks up, defeated. “I can’t do this. Apple must only hire young people who hate their grandparents.”

I take the phone from him, feeling the smile on my face. We laugh together, not loudly but in a way we haven’t done in a very long time.

II.

I’m at my mother’s apartment. My sister’s sheepadoodle Augie follows her as she walks from the kitchen to the living room. A Kleenex dangles from my mother’s pants pocket. Augie eyes it greedily.

This has become a pattern. My mother takes care of Augie when my sister, brother-in-law, niece, and nephew go on vacation. It’s more stressful than fun. My mother loves Augie but being a dog sitter is a job best suited to, well, a dog sitter. Plus, Augie pooped on her rug. My mother worries she’ll do it again and won’t leave her alone in the apartment. So they’re together twenty-four, seven.

I come over every day to give my mother a break, taking Augie for a long walk to run with the dogs in the park—anything to tire Augie out so she’ll sleep, and my mother can read her books on Ancient Egypt and archeology.

Augie comes when I call her, trotting away from trailing after my mother in the hope of treats. I ask my mother what else she needs and what I can do.

“This is great. Just take her.”

Augie sits, her mouth moving in anticipation of a treat. She takes it from my hand as I clip her leash to her collar. “We’ll be back.” Augie gets another treat in the elevator and another once we’re outside and she pees.

My recovery feels almost complete: health, home, purpose, community. I live in a different brain. I have a home. My memoir, Pathological, will educate people about psychiatric diagnoses and save them from making the same mistakes I did. I have my family.

We walk—or rather Augie walks me. The air is crisp. Snow blankets the sidewalk.

How will I know when my recovery is complete? It’s been slippery and strange. What’s the you’ve-recovered benchmark? Do I need to have been happy for a year straight? Anxiety-proof and depression-free for a decade? Two years clean like in addiction circles? Five years without a trace of mental illness as with some cases of cancer?

III.

A few months before my memoir Pathological comes out, my father calls mid-morning on Sunday. I answer and ask how he is.

“Well, not very good.” His voice has the strain of someone who’s more confused than in acute pain. He tells me that he hurt his back. He fell but doesn’t remember falling. All he knows is that he fell and hit his head because there’s a wound on his forehead.

My father doesn’t have pain—or doesn’t talk about it; he complains only of arthritis in his hands. Even then, he minimizes it, saying it’s not that bad.

“I’m not going to be able to meet for lunch.”

His voice is so apologetic it makes me tear up. Then a pit forms in my stomach, the guilt for the way I treated him—and everyone—during the twenty-five years I struggled with serious mental illness.

Now that I’ve recovered, I look back on a lot of my life with regret, the feeling that I lost a quarter of it to psychiatry, the media, and so many clinicians perpetuating the myth that psychiatric conditions are biological, caused by a “chemical imbalance,” and lifelong. If only I’d known that none of these is true, I might have gotten well sooner. I might not have pushed my father away. I might not have become so hopeless I couldn’t live independently and was suicidal. That Sunday, I haven’t worked through the regret and grief that makes mental health recovery so hard.

I ask if he needs anything and I’ll miss seeing him. My stepmother is with him, so I don’t worry too much about him going through this alone. I tell him I love him.

“I love you too, hon.”

My chest surges with love, and the pit of regret hardens.

*

Hours later, he texts me. He’s in the ER. Immediate Care sent him there because his condition warranted more serious treatment. They’re going to keep him overnight for observation.

My sister calls. He actually fell yesterday. He’d been in the basement. Suddenly, he woke to find himself on the stairs, having fainted on his way back upstairs. He didn’t notice the gash on his forehead until a woman at the desk of his health club told him he was bleeding. Then, that Sunday morning, his back started to hurt.

The doctors diagnose him with bradycardia. His heart beats too slowly. A slow heart rate is typically a sign of good health. It’s the goal of exercise, meditation, and good sleep hygiene. But bradycardia is life-threatening. Not enough oxygen-rich blood pumps through the body. Undiagnosed, it can lead to cardiac arrest and death.

My father will have surgery the following day. The pacemaker will send electrical signals to his heart to make it beat faster. It’s a routine procedure. Minimal risks include infection, blood clots, and maybe a collapsed lung, but there are always risks.

That night, he texts. He says he doesn’t like being in the hospital. The next line practically breaks me: It’s lonely. I call and tell him I love him. He says he loves me too, his voice brittle and weak.

My father’s surgery goes well. He says he feels fine, except he’s hungry from not having eaten all day. I google visiting hours, which are almost over, and ask if he wants me to bring him a sandwich. He says the nurses are going to bring him something. He’ll be discharged by this evening.

The next day, I visit him and my stepmother. He answers the door. His cheeks are sunken, his skin wan. He looks very, very tired. As we walk inside, he’s unsteady on his feet. When we sit, he has to ease himself onto the chair.

He points to the part of his back that’s most painful and tells me that the doctors don’t know what he did to injure it. The cut on his forehead is already starting to scab. He shows me the scrape on his elbow. He’s never looked so fragile.

Something rises up in me, a pleasant vibration in my chest. Gratitude. I’m sure of it. I’m grateful he’s okay, so I can have more time with him.

Eventually, I start listening to a gratitude meditation on my walk each morning that asks me to think of three moments from my past that maybe I wasn’t grateful for then but could be now. Moments, not things. Scenes. Experiences. It takes a while—a year or so—but the regret I feel for the years I spent living with mental illness starts to fade.

A few months later, after my book has come out, my father leaves a message while I’m teaching a class on Zoom. I listen to the message after we finish.

He says he’s reading my book. “I love you,” he says. “I just want you to know I’m here.”

That same pleasant vibration fills my chest. It fills me to the point that my eyes brim with tears. Gratitude. It’s too late to call, but I text how much I love him and how grateful I am that he’s my father.

IV.

At our annual appointment, Dr. R asks how I’m doing. I went from weekly visits to monthly to bi-monthly to every few months, then every six months. I’ve since graduated to once a year.

I’m not sure what to say: I’m okay. Teaching is going well. I love my apartment. My family’s all healthy. I got a cat. Oh, and I totally healed from mental illness without telling you. And I wrote a book exposing the flaws in the Diagnostic and Statistical Manual of Mental Illness (DSM), psychiatry’s bible, and psychiatric diagnoses, and you’re in it. How are you?

Instead, I tell him I’m doing really well.

He bobs his head the encouraging way he does. “Good. Good.”

Gingerly, I tell him about getting an agent and selling the book. Even more gingerly, I explain that it’s about my years in the mental health system. More gingerly still, I mention my research on the DSM. “But I’m not anti-psychiatry. Not at all.”

He bobs his head knowingly. “Oh, yeah. The DSM? It’s just a mess. I tell my residents at the hospital, Don’t even go there. Stay in the real world. It’s a guide. Stay with your patient. I’m a biologist. I believe in science, but that’s not science.”

We talk for some time. I ask him questions about his experience with it and how he uses it.

“Well, it’s easy for me,” he says. “I don’t take insurance, so I don’t need to tell my patients they have the worst disorder so I can get reimbursed.”

His response to my book and honesty about the DSM fill me with trust—again.

He says, “Every medical resident should read your book, so they know what it’s like to be on the other end of the DSM.”

I want to tell him about my recovery. Instead, I stare out the window and become increasingly self-conscious. How am I “presenting”? How do I seem to him? What diagnosis do I embody? Would someone who’s recovered from mental illness stare out the window? Maybe she would. Maybe she just did.

We sit without speaking. How can I prove I’ve recovered? I don’t have any data marking how well I’m “managing” my symptoms. Anxiety is still an abiding part of my existence. Sometimes, it’s debilitating. Whirling dervishes of depression and darkness take hold. The sodden pit still comes. There’s no avoiding them.

Emotions and thoughts aren’t easy to manage. I wish there were an “atlas” of emotions, but it’s taken learning my bodily sensations and understanding which thoughts cause those sensations, and even then, I’m often puzzled because emotions don’t simply arise due to external events. There’s affect and mood, the ways that physical health and equilibrium—hunger, tiredness, blood sugar level, level of caffeine and other stimulants, etc.—create emotional responses. Our evolutionarily driven thoughts trigger them too.

As evidence of my recovery, could I present the way my self-talk isn’t cruel anymore? What about how strong I feel because I paved my path to recovery? Or how I wake each morning with a sense of purpose because I know my book will someday help improve the mental health system by giving patients the information they need about diagnoses? Or how when I’m at home, I still occasionally stop mid-kitchen or mid-living room or out on the balcony, amazed that I live in such a beautiful apartment with a view?

Could I use as proof my lunches with my father and phone calls with my mother and visits with my sister and brother-in-law every Saturday at 4 pm to walk Augie? What about how incredible it felt to hear my nephew introduce me as his aunt and realize, Yes, I’m an aunt, not a diagnosis?

Could I describe my love for my cat Sweets, who is so set in his ways? At night I lie in bed, and he lies ten feet away on the floor. It’s a kind of cuddling. The closets and under the bed are his territory. When he stretches out, exposes his belly, and gives me a haughty look, the likeness to Henry VIII (not the Buddha) is unmistakable.

Would my gratitude practice count toward my recovery?

What if I told Dr. R I’ve recovered, and he disagreed?

Maybe he already knows.

V.

On Sunday, my father and I have lunch. We sit on stools at a bar table at the Japanese restaurant where we eat each week. The waiter, who knows our order by heart, comes to the table to confirm. (Routine: I eat the same thing almost every day, and it’s rubbed off on my father—at least during our lunches.) It’s early, and the restaurant is practically empty.

It’s time to tell him—someone—I’ve recovered, but I don’t know what to say.

My father tells me a story he’s told before. I love to hear him tell it. He and my mother lived in Addis Ababa, Ethiopia in the 1960s. My father helped translate the government documents written in French into English. (He’s fluent in French.) One night, my father and mother had some of his Ethiopian colleagues over for dinner. My father is a masterful cook and dinner-party host. He served doro wot (spicy Ethiopian curry) as well as French pate and cured meats. He also put out a jar of Dijon mustard.

“Just regular Dijon,” he says. “Nothing special.” He smiles and tells of how his colleagues had no reaction to the spicy curry. “But the Dijon made their mouths burn. I hadn’t thought about it. The spice in mustard seed affects a different part of the mouth.”

It’s a story he delights in, likely because the years he and my mother lived in Ethiopia were some of their fondest together. Travel brought and kept them together for twenty years.

Our food arrives. My father opens his chopsticks. I do the same.

“Dad.” I hesitate. “I think I’m well. I mean, I think I’m cured. Not sick anymore—at all.”

He nods, certain. “I know.” He smiles. “I know.”

Support my work by buying a copy of Pathological. If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

Buy Pathological

Listen on the Substack app or on Spotify to hear:

• Why psychiatric diagnoses aren’t scientifically valid or reliable—and what that means for recovery

• How I spent 25 years in the mental health system and eventually recovered from serious mental illness

• Why GPs are being asked to diagnose conditions they’re not trained to treat

• The role of evolutionary psychiatry in understanding our brains are designed to freak out

• How I relaunched Pathological on Substack and hit the USA Today bestseller list

Tori describes herself as a full-time therapist, part-time Spiritual Director/Minister, and everyday Mystic.. Her writing (specifically on her Substack, Love, Tori) and public speaking frequently bridge the gap between clinical therapy and theology, often focusing on “everyday mysticism” and contemplative practices.

Jonathan is a former pastor who left the institutional church and whose work now centers on “love-centered theology,” often deconstructing traditional views of God in favor of a non-violent, relational perspective. On his Substack, , he points people dealing with change toward a more sustainable theology.

It was such a pleasure, and I’m so grateful to Jonathan and Tori for spending time with me and supporting my work.

To support my work, purchase or gift a copy of my memoir Pathological: The True Story of Six Misdiagnoses. You can donate the copy to your local library or favorite used bookstore.

Buy or gift Pathological now

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Voices come from the hallway outside my office. I sit at my desk, staring at my laptop screen, my mic in front of me, waiting for my portion of the Zoom conference to begin. Onscreen is the name of my talk—Pathological: What 25 Years of Living with Mental Illness Taught Me About Self-Stigma and How to Eradicate It—and the conference title—On Our Own of Maryland: Celebrating 30 Years of Peer Empowerment.

The phrase On Our Own should mean a lot to me, but it doesn’t. It’s emblematic of the recovery movement, which I still haven’t heard of. On Our Own is the title of Judi Chamberlin’s memoir. Chamberlin is one of the movement’s most pivotal figures. Her book was one of the first to call for patient-centered mental health services.

When the organization asked me to be one of the conference’s keynote speakers, I had no idea that On Our Own of Maryland (OOMD) is the oldest and most respected recovery-oriented, peer-run organization in the country. It defines itself as “a statewide peer-operated behavioral health advocacy and education organization which promotes equality, justice, autonomy and choice about life decisions for individuals with mental health and substance abuse needs.” But it’s so much more than that. It’s the epicenter of the future of mental health: recovery and peer support.

The afternoon session begins. Two hundred people are on Zoom. I think I understand the meaning of the word peer in the field of mental health—but I don’t. Peer, I think, means friend. Or maybe more like colleague. Either way, I think I get the gist of it.

Onscreen is Rowan, a recovery peer support specialist, who’s there to introduce me and be in conversation with me after my talk. She has a round, sweet face. I presume to know what a recovery peer support specialist is. Supporter. Good person.

Rowan begins the introductions. “For many folks in our community,” she says, her voice deep and genuine, “our first experience of a behavioral health challenge or crisis resulted in a diagnosis.”

Our community—something about how she says it, with such warmth and ease, strikes me. She uses the pronoun we in the same way. It’s clear she’s not just talking about the organization and the people it serves.

Rowan continues: “That diagnostic label might have been a relief, a scar, or a fundamental shift in our identity. We may have taken those labels at face value, or we may have wondered where they came from.”

As Rowan talks, I become deeply embarrassed for not knowing more about the organization. How could I not have done my homework? I prep for all appearances.

I give my talk, complete with a PowerPoint presentation, briefly telling my story and how over-identifying with a diagnosis ultimately caused me to stigmatize myself to such a degree that I limited myself and my life.

My presentation doesn’t mention recovery—or that adopting a diagnosis at face value almost prevented me from doing so. Recovery still seems like a secret, something I can have but have to hide.

No one recovers from mental illness. Everyone knows that.

As Rowan and I talk, on the right side of the screen, in the chat, come reactions: virtual hands—of all skin tones—clapping, smiley faces, thumbs upses, streamer-streaming tada’s. I only see them because Rowan mentions them to alert me to how those in attendance are relating to what I’m saying.

Psychiatry has welcomed Pathological and my message, but some members of the public and the media have been wary, shying away or raising concerns that people won’t get help if they know the truth about diagnoses. This fascinates me. Why do we want people to get treatment, which often entails potentially harmful medications, without having the information they need to get better?

This community is different. These people are aware of what psychiatric diagnoses are and what they aren’t, and they’re empowered by that knowledge. They’ve been through some version of what I have—though many had it much, much worse than I did—and they recovered.

Recovered.

Peer Support.

Recovered.

It takes a second, but I realize I’m with hundreds of people who’ve recovered from mental illness and substance abuse. Soon, I’m talking about how I healed. In the chat appear clapping hands and tada’s and thumbs upses—one after another.

A few evenings after the On Our Own of Maryland Conference—where I’ve discovered that many, many people have recovered and are recovering from mental illness—I sit at my computer, researching recovery and peer support. It’s painful to discover that recovery is an actual stage of mental illness that many people suffering from psychic and emotional distress transition into. More painful is that there’s a whole community—a lifeforce—dedicated to it. There’s been a we out there all this time.

A fly has gotten into the apartment, and Siddhi is on the hunt. Siddhi moves his body at warp speed (for him) onto the counter and off, onto the kitchen table and off, onto the sofa, and up his cat tree. Twenty minutes later, he’s still at it. It’s like watching Ahab go after the white whale. Siddhi clumsily dashes from one end of the apartment to the other, meowing, lunging, and leaping at the fly. He won’t give up.

I’ve just finished reading Thomas Insel’s Healing: Our Path from Mental Illness to Mental Health. In it, Insel writes that mental illness isn’t chronic and declares that the future of mental health is the recovery model and peer support. During his time at the NIMH, he was known as “America’s psychiatrist.” To have someone with such authority tell us that it’s time to let those of us who’ve experienced mental illness recover is revolutionary. The recovery community and the lessons it has to teach psychiatry, families, and the public are key.

Siddhi comes barreling through the living room. I can’t see the fly he’s after, but he does. And that’s all that matters.

I start researching Peer Support Specialists. In their contemporary form, Peer Support Specialists have been around since the 1980s and 1990s. It’s taken nearly half a century, but mainstream medicine, psychiatry, and policy have finally started to see their value.

In a couple of months, I’ll enroll in my first Peer Support Specialist training course and understand why. The facilitator will explain the primary role of a Peer Support Specialist: to model recovery by sharing the parts of our experience that might help the person.

Peer Support Specialists don’t give advice. We listen and support—hence the name Peer Support. We’re there to draw them out, to help them establish goals, exercise decision-making skills, and develop action plans. Our role is to listen and guide as the client (or consumer) comes up with practical ways to improve wellness in all aspects of their lives: emotional, financial, social, spiritual, occupational, physical, intellectual, and environmental. We empower—we don’t instruct—and appreciate of every step they take (“baby steps” is a degrading term).

Ideally, we join the clinician and care team. Non-diagnosed clinicians and staff are experts in treating a mental health condition; we’re experts in living with and overcoming a mental health condition. Sometimes, we provide support when the staff doesn’t believe in people with mental illness.

In working with someone with mental illness, we listen to their self-talk, their possible goals, and the barriers they think prohibit them from achieving them. It’s about finding out their thoughts, emotions, and behaviors without using technical language (like self-talk, goals, and barriers). In this, we play various roles:

• Motivator and cheerleader

• Ally and confidant

• Truthteller

• Role model and mentor

• Resource broker

• Community organizer

• Lifestyle consultant

• Advocate

• Friend

• Assistant in goal building

• Collaborator in establishing overall wellness

(I tried to be all of these to myself; it barely worked.)

What amazes me most about peer support is that diagnoses aren’t mentioned. As Pat Deegan puts it: “We can never and must never reduce a person to being a diagnosis.” As a peer support specialist, diagnoses don’t matter. We aren’t clinicians and don’t pretend to be. All that matters is where the person is in the process of recovery and what we can do to help. We talk about experience, emotions, thoughts, their home and environment, if they have work and purpose, their personal medicine (including psychotropic drugs but also whatever else helps—walking, listening to music, playing with their dog), their social support network of family and friends. We help a person stop using a diagnosis to limit themselves.

In the stages of recovery, we have different jobs. In stage 1, we refer them to services that can help them decrease distress and symptoms. In stage 2, we instill hope and a sense of possibility, along with ways to improve their self-image. In stage 3, we (gently) encourage the person to see their lives as limitless. In stage 4, we help them identify their strengths in terms of skills, resources, and supports. In stage 5, we help them build self-trust and take full responsibility for their lives.

Throughout, we try to bring them from hopelessness to hope. As Deegan writes in Recovery: The Lived Experience of Rehabilitation, “All of the polemic and technology of psychiatry, psychology, social work, and science cannot account for this phenomenon of hope. But those of us who have recovered know that this grace is real. We lived it. It is our shared secret.”

There’s warmth in the group on the first day of my Mental Health Peer Support Recovery Specialists training. Our facilitator speaks slowly. It’s comforting. He tells us that the training will be intense, personal, and fun and that it’s a privilege for him to guide us through this process of becoming Mental Health Peer Support Specialists.

This is one of many courses I’m taking for certification to support those with mental illnesses as they move toward recovery. One course is eighty hours; the other is one hundred and ten hours plus three hundred hours of an internship. This course is partly self-directed, culminating in an intensive series of workshop days; the other meets every Saturday for seven hours for months and then sends us out to work with mental health organizations, where we meet with clients, helping them define their definition of recovery, assisting them in developing a plan, and giving them resources. Other courses are three days or two days or a few hours long. The Depression and Bipolar Support Alliance (DBSA) runs this certification. A local university holds classes for the other.

The government fully funds the university program. Tuition is waived, and the internship is paid. As many in positions of authority, including Tom Insel, have said, peer support is the future of mental health. It’s the answer to all those community centers that were never built. Who better to help those struggling with mental health conditions and substance abuse issues (both much more encouraging ways of referring to people in crisis and in challenging situations) than those who’ve been where they are? Who better to set them on a path to recovery instead of a lifetime in the mental health system?

The problem is that our mental health system is designed to keep people in treatment, and peer recovery support specialists and the recovery model are still in the nascent stages of being integrated. In the university course, the professors discuss the mental health system’s response to the recovery model and peer support. They warn us about what we’ll face when we set out to work with an organization. Likely, organizations will try to have us do paperwork, which isn’t what we’re there for. It’s not an insult; it’s just that without systemic change on a state and national level, the role of peer support specialists is a bit ambiguous. We’re left to convince others—one organization at a time—of the value of peer support and the role we can play.

To move away from the biomedical model, which entails a clinician seeing people for fifteen or thirty minutes and prescribing psychotropic medications and maybe recommending some form of therapy, to a recovery model, which views healing as the end goal and assists people in developing a personal treatment plan as the way to get there, will require a systemic shift unlike any our mental health system has seen. Institutions and organizations will have to accept that healing isn’t just possible but the goal. They’ll need to see mental health treatment, particularly for those with serious mental illness, as a three-step process: pre-recovery support (awareness of where to get help and options for assistance), treatment (peer recovery & other means), post-treatment (recovery support services, including checkups, monitoring, transitioning).

This shift in thinking has been met with resistance from pharmaceutical companies, biopsychiatrists, clinicians, insurance agencies, and legal institutions. Aside from the profit-motive aspects, change is hard for individuals, let alone systems, institutions, organizations, and the public at large.

In both trainings, the people there to become Peer Support Specialists are of all races, ethnicities, genders, religions, and socio-economic backgrounds. Many are veterans, primarily because the Veteran’s Administration has been at the forefront of adopting the recovery model and peer support into its services.

We then talk about our relationship with peer support. Some have been working in peer support for years. Many work for the VA or want to work for the VA. Some want to start their own nonprofits. A few had the benefit of peer support in their recovery. We all want to give back by helping others in the mental health system understand that recovery is possible before it’s too late for them.

Getting a formal certification is a relatively new thing. There are various levels: human-to-human peer support (i.e., no formal certification), some sort of credential, and state and national certification. To even test for state and national certification, you must complete one hundred and ten hours of coursework and two to three thousand hours of work experience.

We go around and share our experience of recovery—briefly. Not one of us heard the word recovery when we first entered the mental health system.

Their experiences and the fact that they recovered astounds me and fills me with admiration: foster care, homelessness, diagnoses, psychoses, hospitalizations, addictions. They speak of loneliness, despair, and frustration. One woman cries as she tells of how she hurt her family, and I want to tell her I understand. Some have had milder experiences: struggles with depression or anxiety or obsession and compulsions or distractibility, limited quality of life, inability to achieve their goals or take pleasure in what used to bring them joy.

The facilitator says that it’s time to turn our story into a dynamic skill set that will help others.

For the third time in my recovery (the first being when my psychiatrist said he didn’t know what diagnosis to give me, the second upon hearing that one of his patients had fully healed and gone on to become an executive at Google when I thought mental illness was lifelong), I feel a shift.

“You’re going to move from an illness story to a wellness story.”

Later, I’ll learn that in the recovery community, symptoms aren’t important. Our symptoms are part of what it means to be human—maybe not for everyone but for us. Psychiatric disorders are extreme occurrences of basic thoughts, emotions, and behaviors. Intense anxiety. Punishing depression. Dangerous risk-taking and grandiosity. Severe distractibility. Excessive rumination and compulsive behaviors. Even hearing voices seems to organically occur. Ever had a song stuck in your head?

As Allen Frances, once named the most powerful psychiatrist in America, said in a 2018 interview, “We’re taking everyday experiences that are part of the human condition and we’re overdiagnosing them as mental disorders, and way too often providing a pill when there’s not really a pill solution for every problem in life.”

For many in the recovery community, the absence or even lessening of symptoms is neither possible nor the goal. The goal is to build resilience and then a life with what some call “symptoms.”

Clinicians see it differently. They take the presence of any “symptom” (i.e., depression, anxiety, ruminations, obsessions, manic energy, hallucinations, and paranoia) as proof of illness. They categorize us as asymptomatic (within the normal or clinically acceptable range and consistent with the absence of disorder), fully symptomatic (indicating full syndromal expression of the disease), and partially symptomatic (everything else). We’re then viewed in terms of severity, duration, and functional impairment and placed on a scale of acute, maintenance, or continuation with no hope of escape.

The biomedical model trains clinicians to view remission and recovery as uniform and determined by the complete absence of symptoms. A landmark 1991 paper, published during biopsychiatry’s brain-disease heyday, set the parameters for the operational criteria for remission and recovery. The patient must experience x number of symptoms in y number of weeks. For those diagnosed with major depressive disorder, to be asymptomatic we must have fewer than x symptoms present and receive a score of less than seven on the Hamilton Rating Scale for Depression and less than eight on the Beck Depression Inventory.

Recovery, for the traditional bio-psychiatrist, is a linear process. Each day brings improvement. The patient strives for and achieves partial remission (critical symptoms abate and treatment must continue) and then full remission (asymptomatic and no increase in treatment are required). It’s as if they’ve never spoken to someone who’s recovered, who could easily explain that recovery is nonlinear and redolent with instability and inconsistency.

Based on the amount of time spent without symptoms, remission is declared if the clinician sees fit. If a patient is christened recovered, there are two options: discontinue or continue treatment. (And what if we want to recover and continue treatment? Many of us will remain on medication indefinitely.) But neither entails fully graduating from the mental health system. The inevitable next episode still looms.

We already have one potential career path for those with lived experience of mental illness: mental health peer support specialists. Peer Support Specialists are those with lived experience of mental illness and/or substance abuse who have fully recovered and now support patients move toward wellness by helping them access resources, decide what recovery will look like for them, and develop their own recovery plans. Instead of hearing only from “experts,” patients get the perspective of someone who’s been through what they’re going through and has fully healed.

Physicians and mental health professionals are overworked and already don’t have time to meet with many in need of care. Employ those with lived experience of mental illness to be part of the clinical team. One caveat: the Peer Support Specialist has to be welcomed onto the team, which hasn’t always been the case.

I don’t worry about “getting sick again”—whatever that means. There will be depression and panic attacks. (I also get migraines and don’t see them as a sign that something is chronically wrong.) Unsettling, even excruciating anxiety will thrum in my chest for days. Certainly, I’ll ruminate and have insomnia and the sodden pit in my stomach will make it hard to eat. Or I’ll eat too much or not enough. But I’ll never think of myself as a diagnosis and won’t fall into the trap of believing there’s no hope.

Around me will be those who’ve recovered, examples of what’s possible; their voices will be in my head.

Thank you for reading!

Buy Pathological

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.” Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not.

If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

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A white, speckly light flashes across my line of vision. Soon, I can only make out part of the computer screen and the talking points I’m writing up. A migraine I don’t have time for.

I go for a walk. After a mile, the aura fades and is replaced by what feels like a dense plate in the center of my chest, making it hard to breathe. Bikers speed by me too fast. The trucks on the street are too loud. The dense grey plate in my chest expands and shifts, making it feel like a shard of glass is cutting my chest.

I’ve been invited on National Public Radio to discuss my memoir Pathological. Two people will be joining me: Thomas Insel, former director of the National Institute of Mental Health (NIMH) and Paul Appelbaum, director of the Steering Committee of The Diagnostic and Statistical Manual of Mental Disorders (DSM). While preparing for the interview, I assume Appelbaum will respond to me and my book negatively, given that I heavily criticize the DSM.

For days, migraines with auras and panic attacks the intensity of which I’ve never known come and go. Tom Insel and I did another interview together, and he’s been very supportive of my work; I’ve never met Paul Appelbaum and my mind paints him as an enemy. He isn’t, of course. I have great respect for him. His specialty is ethics in psychiatry. He’s about as upstanding a psychiatrist as one can find.

The cut-glass feeling turns into an unsettling vibration. This is an emotion: anxiety. Or panic.

I thought mental health recovery would mean being immune to painful emotions, especially anxiety. Mental health is actually the ability to fully feel those emotions and keep going.

Researchers and mental health professionals refer to state versus trait anxiety. State anxiety is passing anxiety in response to a situation. Trait anxiety stays with you, always under the surface. For some, trait anxiety can be debilitating. It leads forty million Americans to get professional help and a diagnosis of anxiety disorder each year.

The etymology is telling. Anxiety stems from the Latin verb angor, meaning to constrict. Some languages equate it with anguish while others see the two—anxiety, anguish—as different: anxiety is a mental state like worry whereas anguish is a physical feeling that results from such worry. The American Psychological Association defines it as “characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure”—which makes it sound tame.

Many have written powerfully about living with debilitating anxiety, like Scott Stossel in My Age of Anxiety, describing it as an all-encompassing physiological, mental, and emotional torment.

We try to avoid anxiety—eat, drink alcohol, numb out with drugs, shop online, binge on Netflix—but historically, it’s been seen as a normal, human, even beneficial emotion. To the existentialists, it was an essential part of our humanness. The philosopher Soren Kierkegaard thought it was crucial for success in life: “Whoever is educated by anxiety is educated by possibility.” Studies have since shown this to be true. Anxiety actually makes us perform better. It motivates us.

Evolutionarily speaking, it’s vital. As leading anxiety researcher David Barlow puts it, without it, “[t]he performance of athletes, entertainers, executives, artisans, and students would suffer; creativity would diminish; crops might not be planted. And we would all achieve that idyllic state long sought after in our fast-paced society of whiling away our lives under a shade tree. This would be as deadly for the species as nuclear war.”

For decades, scientists and researchers have tried to determine what anxiety is and how it’s produced in the brain. Although we tend to talk about “anxiety” as a single entity, the New York University neuroscientist Joseph LeDoux explains that there are two mechanisms at play: survival circuit activity and the feeling of anxiety. One is unconsciously enacted by what he calls our defensive brains; the other is consciously thought by our mental processes. Many position anxiety in the amygdala—a mass about the size of an almond in the temporal lobe, the area just behind your ear—but we now know it’s more complex than that. The amygdala alone isn’t responsible. Anxiety arises because of the constant conversation going on among different areas of the brain. Neurotransmitters form an anxiety network.

Much of our understanding of anxiety as a bad thing comes from Freud. He invented pathological anxiety and made it the centerpiece of mental disorders. For Freud (and the Ancient Greeks), anxiety differed from fear in that it was about expecting and dreading danger that may or may not come, whereas fear was in response to an actual threat. (LeDoux says that anxiety and fear are inextricably intertwined.)

Freud is just one part of the short history of why we think of anxiety as a mental illness. In antiquity, some thought it was a sickness, others simply an annoyance. The Epicureans and Stoics offered a simple cure for it: stop regretting the past and fearing the future. In the sixteenth, seventeenth, and eighteenth centuries, it was seen as a symptom of other mental conditions. In the nineteenth and early twentieth centuries, it was the core feature of “nervous disorder” (neurasthenia), manic-depressive illness, and Freudian neurosis. In the DSMs I and II, anxiety, phobias, and obsessive-compulsive thoughts and responses were considered neurotic conditions. The DSM-III defined two types of anxiety: generalized anxiety disorder (GAD), which cognitively manifests as worry, and panic disorder (PD), which produces physical responses.

Over the various editions of the DSM, it’s become easier to diagnose. The DSM-III stipulated that to be considered “disordered,” your worries had to be “unrealistic.” This meant that worrying excessively, even to the point of excruciating anguish, about losing your job after making significant errors on a year-end report, for instance, wouldn’t qualify for a diagnosis. The DSM-IV loosened the criteria by removing the term “unrealistic,” which meant any worry was fair game. As diagnostic criteria loosened, the number of people diagnosed increased. Generalized anxiety disorder (GAD) went up by almost 20 percent. The DSM-5 has also helped make it the most common mental health diagnosis. The DSM-5 decreased the amount of time a person had to experience anxiety to qualify for a diagnosis from six months to three months.

Today, anxiety disorders are the most common mental health diagnosis, and the “anxiety product economy” is a multi-million-dollar empire.

There are days when anxiety doesn’t harrowingly vibrate in my chest and create in me a sense of being dislocated and of being so inside my head that I feel like I’m trapped, but those days are rare. Yes, anxiety interferes with my quality of life. But I’ve healed from mental illness and know real disability; this is more along the lines of something I’d much, much, much rather not experience.

The interview won’t take place in the studio. I’ll be doing it from home. That morning, I’m shaky and nauseated. My uneasiness is accompanied by diarrhea and then heartburn.

I go through my morning gratitude routine, which helps. While actively grateful, it’s impossible to be simultaneously sad, upset, angry, anxious, etc. But this morning I can’t concentrate.

I get on the Zoom call early and study my key points again. What if I get another migraine? What if I can’t breathe?

The Zoom app spins to life. Three boxes line the top of the screen. One is black with the radio station’s letters: WMAU. In another, a woman sits behind a soundboard. The other window is black with just the engineer’s name.

I’m not ready. I can’t do this.

The engineer welcomes me and asks me to test my sound. I do. He says it’s good and instructs me to get as close to the microphone as possible. He says I can turn off my camera. I do.

Sarah, this is happening. Let’s go.

Paul Appelbaum comes on. His face is the epitome of kindness. His beard and glasses make him seem avuncular. Should I say hello to him, my adversary who’s not my adversary?

I sweat. My mouth is dry. I want this to be over with. I want this not to start.

You’re anxious. You can be anxious and do this anyway. These thoughts seem impossible and stupid. Naïve. Are you kidding? My heart pounds.

The engineer says Paul Applebaum can turn off his camera, and he does. I focus on the screen, on Paul Appelbaum’s name. P-a-u-l. We wait. Tom Insel comes on with his camera off too. It’s just his photo along with his name. In his photo, he’s smiling. I stare at his image—smiling, calm. We’re all here for the same reason: to help those with psychiatric conditions and their loved ones.

The woman behind the soundboard raises her hand, cueing us that the show is about to begin. Tom Insel’s smiling picture stares back at me. My book will help people. It will give them the information they need about psychiatric diagnoses, so they and their children don’t make the mistakes I did.

During the interview, I make my points. The interviewer asks Paul Appelbaum if the public deserves to know what psychiatry knows about the invalidity and unreliability of diagnoses. In a turn I don’t expect, Paul Appelbaum agrees: Yes, patients deserve to know the truth.

I fist-pump the air. It’s a triumphant moment—not for me but for all patients.

Afterward, people I haven’t spoken to in years text and email to say they heard the interview and how illuminating it was. Never have I felt so strong, so purposeful, so able to feel the anxiety I feared for years, the anxiety that’s part of my recovery and my life.

Thank you for reading!

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.”

Buy Pathological

Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not.

If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

Subscribe now

My experience in the mental health system is that most of those working in it—especially those who’ve devoted their lives to helping those in need—are to be thanked and admired. Not everyone shares this view. We’re asking so much of them: Here, solve my mental and emotional pain, even though we really don’t know how to do that on a grand scale. There are bad apples—in every profession.

But we’re failing people with mental illnesses. We fail them when we 1) don’t give them the care they need and 2) tell them that their diagnoses are chronic (they’re not), purely biological (definitely not), and the best they can do is manage their symptoms (not even close).

We fail them when we don’t center mental health treatment around recovery.

The 2000s could have been the decade of recovery. It included the President’s New Freedom Commission Report on Mental Health (2003), the National Consensus Statement on Mental Health Recovery (2006), and SAMHSA’s Recovery to Practice Initiative (2009). The 1990s, which had been hailed as the “decade of the brain,” had produced lots of misinformation: the mistaken ideas that psychiatric diagnoses are biological, valid, caused by a “chemical imbalance,” and lifelong. The government, it seemed, was finally going to move away from the biomedical model and adopt the recovery model.

The President’s New Freedom Commission sought to transform mental health care. It had six goals:

1. Americans understand that mental health is pivotal to health.

2. Consumers and their families become the center of mental health care.

3. Disparities in mental health services no longer exist.

4. All Americans have access to screening, assessment, and referrals.

5. People receive services and research increases.

6. Technology is used to full advantage.

But the commission did so much more.

It gave those with lived experience of mental illness a voice. Dr. Dan Fisher, who recovered from schizophrenia, was on the Commission. The Commission sought out feedback from consumers, as we were referred to in the report. We were experts too.

In February 2006, SAMHSA officially endorsed the recovery model. The press release announced, “Recovery must be the common, recognized outcome of the services we support.” It called for the mental health system to “move towards operationalizing recovery from a public policy and public financing standpoint.” It outlined ten core components to recovery: self-direction, person-centered care, empowerment, holistic care, non-linearity, strengths-based treatments, peer support, respect, responsibility, and hope.

Almost as a reminder, as if to say, Hey, it’s been a decade since we made recovery the most important part of our mental health care system, and yet it still isn’t, SAMHSA adopted its Recovery to Practice Initiative in 2009. It sought to provide training and resources on recovery to clinicians. Headed by Larry Davidson of Yale’s Program for Recovery and Community Health, it didn’t take root though not for lack of trying.

The 2010s could have been the decade of recovery, too. Psychiatry was besieged by controversy. The insidious relationship between psychiatrists and pharmaceutical companies reached the public. Publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) brought protests not primarily from patients and consumers and their families but powerful biopsychiatrists, two of whom essentially wrote the DSM.

In 2011, Marcia Angell helped bring the nefarious relationship between psychiatry and pharma to the public. The former editor of the esteemed New England Journal of Medicine published a two-part review/outcry. She highlighted the scathing criticisms of psychiatry put forth in three books: Irving Kirsch’s The Emperor's New Drugs: Exploding the Antidepressant Myth, Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, and Daniel Carlat’s Unhinged: The Trouble with Psychiatry—A Doctor's Revelations About a Profession in Crisis. Others had tried to blow the whistle, but Angell’s critique appeared in a lay albeit literary media outlet. The three books might otherwise have been viewed as fringe, anti-psychiatry diatribes, but Angell, because of her status in the medical community, legitimized their findings and critiques.

Though Angell’s aim was to make people aware of the dangers in the ways psychiatry was being practiced and its reliance on psychotropic medications, her review brought to light the many ways the biomedical model was failing the American public, primarily because of the influence of pharmaceutical companies. They paid academic psychiatrists, referred to by drug companies as “key opinion leaders” (KOLs). Angell writes: “[T]hese are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs.” One-fifth of the American Psychiatric Association’s funding came from pharma, which also subsidized psychiatric meetings, conferences, and research studies. These biopsychiatrists in pharma’s pocket, Angell writes, “largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them.”

In 2013, the most recent full edition of the DSM sparked a veritable uproar. Criticisms ranged from the authors’ ties to Big Pharma to the way the DSM pathologized normal thoughts, behaviors, and emotions and invented new diagnoses to how criteria were loosened to make disorders easier to diagnose to the fact that political wrangling, not science, dictates the diagnoses we receive.

The DSM-5 professed to be more “scientific” than the previous editions. It rebranded with the Arabic 5 instead of the Roman numeral V to signal a “new” approach that distinguished it from previous editions and said to the public, yes, this time, these diagnoses are scientific (for sure) even though they weren’t. Everyday behaviors like childhood temper tantrums (disruptive mood regulation disorder), mood changes before menstruation (premenstrual dysphoric disorder), and overeating (binge eating disorder, which states that anyone who has “binged” and felt bad about it once a week for the past three months has a mental illness) became mental illnesses.

*

In mainstream media outlets like The New York Times, powerful biopsychiatrists, including former DSM Task Force Chairs Robert Spitzer and Allen Frances, filleted the DSM-5. They tried to inform the public that the DSM doesn’t define what a mental disorder is. It doesn’t provide a measure to gauge if a person’s symptoms are severe enough to qualify as being labeled “disordered.” Its authors can’t show at what point normal thoughts, feelings, and behaviors cross over into abnormal. Frances writes: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.”

In his 2013 book Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life, Allen offered a kind of mea culpa for the mistakes made in previous editions of the DSM. He acknowledged the DSM-IV’s role in creating the false epidemics of bipolar II, autism, and ADHD. The DSM-IV could have prevented those “epidemics” by requiring more symptoms of longer duration with greater impairment. In 2019, he explained, “[T[he diagnostic exuberance of DSM-5 confuses mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition.”

Scholars documented the prejudice in the DSM—how, historically, diagnoses have served to try to help some people and control, alienate, and persecute others—setting off a practice of viewing the psychiatric diagnoses not through a lens of biology but social injustice. In his 2011 book The Protest Psychosis: How Schizophrenia Became a Black Disease, the psychiatrist Jonathan Metzel meticulously outlines how schizophrenia, one of the most stigmatizing diagnoses, has been used as social control over Black men. Andrew Scull would later document the many brutal and unproven experimental therapies—lobotomies, forced comas, and the removal of internal organs (really)—inflicted primarily on women. Add to this the long history of “mad women” being exorcised, raped, and burned to death. Scholars would continue to explore the contradictory and damaging reasoning that allowed the American Psychiatric Association to pathologize homosexuality as a mental illness until 1973.

Some of the most prominent biopsychiatrists admitted that DSM diagnoses are abstractions. Thomas Insel remarked, “[W]e actually believe [diagnoses] are real. But there’s no reality. These are just constructs. There’s no reality to schizophrenia or depression . . . [W]e might have to stop using terms like depression and schizophrenia, because they are getting in our way, confusing things.” The psychiatrist and Columbia University professor Michael First has said people “take diagnosis too seriously . . . It is a convenient language for communication, and nothing more.” Others have referred to DSM diagnoses as placeholders. Steven Hyman, another former NIMH director, called DSM diagnoses “fictive [categories].” Allen Frances has said that a psychiatric diagnosis is a fiction sold to the public as fact.

With biopsychiatry’s failures on display, the time was right to finally (finally) move to the recovery model called for a decade earlier. In 2018, SAMHSA pledged recovery services and support to those with mental illnesses. Finally.

Yet mental health clinicians, the American Psychiatric Association, and the World Health Organization still haven’t adopted the recovery model. They continue to press upon us the biomedical model that says all we can do is cope, not hope.

When it comes to adopting the recovery model, the 2020s feel like they’re already slipping away. They aren’t, of course, but they’re the decade to finally fulfill a promise psychiatry actually has the ability to keep.

We know the biomedical model doesn’t work. Biopsychiatrists spent billions trying to show the supposed biogenic origins of mental illness. In doing so, psychiatry failed to care for patients by establishing better (some would say humane) treatments and systems based on rehabilitation and (yes) recovery. As Thomas Insel put it in his book Healing: Our Path from Mental Illness to Mental Health,

“I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”

This has led some to fault Insel, but I admire him for talking about this publicly and trying to rectify the situation in his current work in biotech. How many professionals—particularly doctors, researchers, and other clinicians—admit when they’re wrong?

Recovery has slowly made its way into academia: John Strauss and Larry Davidson at Yale (Davidson ran the Program for Recovery and Community Health for twenty-five years); William Anthony at Boston University; and John Gilmore at the University of North Carolina School of Medicine. Although the Yale program and others help secure some funding and lend recovery research an air of prestige, that funding is a fraction of what’s poured into yet more studies trying to prove the biological origins of DSM diagnoses.

Pharma still has its tentacles in psychiatry. Even if we were to purge all academic psychiatrists and patient advocacy groups of their conflicts of interest, pharma influences clinicians, those in the most direct contact with patients.

But we are moving in the right direction. In 2021, SAMHSA opened its Office of Recovery to enforce its commitment to giving every American the chance to heal from mental illness and psychiatric conditions. It named September National Mental Health Recovery Month to declare publicly that there is hope.

The biomedical/maintenance model alone isn’t working. As the New York Times reported in 2021, rates of mental distress and suicide have risen: “[T]he science did little to improve the lives of the millions of people living with persistent mental distress. Almost every measure of our collective mental health — rates of suicide, anxiety, depression, addiction deaths, psychiatric prescription use — went the wrong direction, even as access to services expanded greatly.” We are, by many counts, in the midst of a mental health crisis.

So why aren’t we publicizing recovery to the public, patients, and their families? Why isn’t recovery mentioned in more research studies and during every clinical appointment in which mental health is discussed and in at least some media coverage?

Part of the problem is that there are many definitions of recovery, and medicine prefers single answers. Officially, there are two types of mental health recovery: clinical and personal. Clinical recovery is rooted in the biomedical and maintenance model. It’s aimed at the reduction of symptoms. It says we’re basically all the same. Symptoms in one person are the same as symptoms in another. It’s determined by a physician. The expert defines the course of treatment and, often without telling the patient, decides if and when the patient has healed.

In personal recovery, we determine if we’ve healed. We set the standard. We create lives that signal our recovery—whatever that looks like.

Currently, research on recovery is term-dependent and narrow in focus. Recovery rates depend on whether clinical recovery (the complete absence of symptoms, many of which are part of the human experience, like depression) or personal recovery (hard-to-quantify properties like hope, optimism, empowerment, confidence, work satisfaction, finding meaning in life, having a safe living environment, and feeling part of one’s community) is the benchmark. Much of the research on recovery focuses on serious mental illness, particularly psychosis/schizophrenia, because those suffering are most in need, often have little access to services, and are typically thought of as “hopeless” cases whose conditions will continue to degenerate and bring early death.

More and more clinicians—those who believe recovery from mental illness is possible—now consider personal recovery a clinical outcome. We can recover and play an equal role in determining our treatment. Only then will we save lives and give people the futures they deserve.

Thank you for reading!

Buy Pathological

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.” Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not.

If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

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Of course, there is no recipe for mental health—not if we think of mental health as a blissful or even generally neutral state.

I know because, having fully recovered from twenty-five years of serious mental illness, I still experience depression and anxiety and panic and all (or most) of the negative emotions.

Today, my body aches. It’s the kind of bone-ache that comes with depression, along with hollowness and irritability.

Bracing against it makes it worse.

Speaking to it doesn’t make it disappear, but it lessens and, of course, makes me feel less alone. Sarah, I say to myself, you’ve got this. Nothing has gone wrong. You’re okay.

And it “works,” meaning, it normalizes it.

Let me explain how I went from being chronically suicidal for five years to this.

Five years ago, I read ’s Chatter: The Voice in Our Heads, Why It Matters, and How to Harness It, which should be required reading for all humans everywhere, and discovered this skill’s name: self-talk. It’s what it sounds like: positive statements we intentionally say to ourselves, often amidst a sea of irrational, negative, unintentional thoughts.

But positive self-talk isn’t toxic positivity—because negative self-talk is automatic and will outwit toxic positivity every time. Our internal narrator is onto us before the words I’m enough or I live in abundance can form in our minds. It’s a coping strategy to deal with tension, stress, and mental and emotional pain.

It can act like an inner enemy. As the former Nightline anchor turned bestselling author and award-winning podcaster put it: “The voice inside my head is an asshole.” Mine has always been a really mean fifth-grade girl whose bullying knows no bounds.

Supposedly, most negative self-talk stems from a single, universal fear: not being good enough. But I think it’s more about our brains just trying to keep us alive and being terribly misguided. Our inner monologue is evolutionarily designed to keep us alive, not make us happy. It just wants us to conserve energy, seek pleasure, and avoid pain.

The machinations of our inner bully are something of a mystery. The subvocalization results from a phonological loop in the brain, including the inner ear. The research psychologist Russell Hurlburt, who has been studying auditory inner experiences since the 1970s, found that not everyone has an inner voice; some people think purely in images. Of those who do experience internal speech, many don’t know what it’s saying. Most people perceive their inner voice as sounding like their own.

For two decades, sports psychology has been studying positive self-talk and its effect on athletes’ performance. Positive self-talk is in the second or third person: You’re okay or Sarah is okay. Researchers found that the key to self-talk is the use of the second person: You’ve got this. Focus. Using your own name can also help: Sarah, focus. The second-person voice (you’ve got this) is like having a personal therapist on call.

It isn’t just for athletes. A 2020 study showed that those who used positive self-talk had less anxiety and OCD symptoms during the pandemic. Students who participated in a 2019 study experienced less performance anxiety if they recited affirming statements before a performance.

Reducing my negative self-talk and creating positive self-talk slowly became the core of my recovery. No more vicious critic (I suck), only coach (you can do this). I invented a supportive voice (you) I’d never heard before, one that became essential to my recovery and staying well.

Another thought-management skill that virtually or literally saves my life after being chronically suicidal for five years comes from brain-dumping on a piece of paper.

Of course, writing is one of the most powerful “wellness strategies” I find. First, it’s just about distancing myself from my thoughts by writing them down and throwing them away.

A study found that people who wrote down their thoughts and threw away the piece of paper cast off the thoughts themselves. Those who wrote down their thoughts and carried them around had the opposite effect. Essentially, we “tag [our] thoughts—as trash or as worthy of protection.” Mindfulness and seeing our thoughts as clouds drifting by aren’t enough; we have to actually write them down, crumple the paper, and discard the thoughts that might otherwise stay with us, influencing our decisions and actions or inaction.

The writing-health connection started to be explored in the 1970s and 1980s and is most often associated with the psychologist James Pennebaker. He wanted to see how keeping a traumatic secret rather than writing about it affected both physical and mental health.

More recently, studies looking at the effects of writing across diverse populations have shown its effects. Writing about your difficulties can result in better grades, fewer missed days of work, and a better chance of getting a job after being laid off. For some, it means improved immune and hormonal dysfunction, less stress, and fewer physician visits. A 2011 study published in Science found that writing down worries before an exam alleviated anxiety and improved performance. A 2006 study showed that writing down thoughts can stop you from brooding and ease depression.

That only gets me so far. I’m a hard case. I’d tried other therapeutic techniques that rely on writing to regulate thoughts and emotions, but Cognitive Behavioral Therapy (CBT) and the myriad other modalities given to me in various hospitalization programs (DBT, ACT) never worked.

I found a life coach named Brooke Castillo who came up with a modality called The Model. Some people see it as the same as CBT—seeing that our thoughts create our feelings, which create our actions, which create our results—but it’s not. It sees our thoughts through an evolutionary lens.

For example, I sit at my desk, take a pad of paper and a pen, and do it. I write down my thoughts in a list. They’re random, occasionally mean, and uniformly negative—full of self-pity and self-hatred: This is awful, I’m going to get sick again, I’m so stupid, I hate this, I’m in trouble, I’m not doing this right, and on and on to the bottom of the page. When I go back through the list with evolutionary psychiatry in mind, I see most of them differently. This is awful, I’m going to get sick again, I’m in trouble, and I’m not doing this right are alarms sent by a brain—my brain—on the lookout for danger.

Thoughts aren’t evil. They aren’t from some dark place, as Sigmund Freud wanted us to believe. My fifth-grade bully is actually trying to help, not beat me up. Thoughts are the brain’s overly vigilant way of trying to keep us alive in an environment where such extreme vigilance typically isn’t required. They’re just my primitive instincts gone awry.

Within a week, every morning, I was writing down my thoughts and doing The Model. Soon, I was doing it at breakfast, lunch, and dinner.

Then I try gratitude.

I’d forced and faked gratitude before—on Thanksgiving, in yoga classes, upon receiving gifts—but it felt disingenuous, even a little deceitful. Gratitude can have a punitive ring to it: You better be grateful. Or too rosy. Or manipulative—I’m doing this to get that.

And the science doesn’t back it up. Although some authors claim that the research on gratitude points to its positive effects, the science of gratitude is still a nascent field. Even the University of California-Berkeley’s Greater Good Science Center, the country’s gratitude hub, readily admits that gratitude studies haven’t, for the most part, been replicable, meaning they’re more theory than proof.

Part of the problem is that researchers can’t agree on what gratitude is. Robert Emmons, professor of psychology at the University of California-Davis and reigning authority on gratitude, wrote, “Gratitude has been conceptualized as an emotion, a virtue, a moral sentiment, a motive, a coping response, a skill, and an attitude. It is all of these and more.” Gratitude depends on the person experiencing it and the context, but Emmons and his colleague Michael McCullough define it as “recognizing that one has obtained a positive outcome” and “recognizing that there is an external source for this positive outcome.” The source is often thought of as a benefactor, but it doesn’t have to be a person; often, it’s God, the universe, fate, etc.

Checklists and scales try to measure gratitude. The Greater Good Science Center’s Gratitude Adjective Checklist asks people to gauge how much they’ve felt the emotion of gratitude on a scale of one to five. The Transpersonal Gratitude Scale measures the more ethereal aspects of gratitude, like being grateful just for being alive. There are others, but the most telling is the Gratitude Questionnaire-6:

Write a number beside each statement to indicate how much you agree with it.

• 1 = strongly disagree

• 2 = disagree

• 3 = slightly disagree

• 4 = neutral

• 5 = slightly agree

• 6 = agree

• 7 = strongly agree

1. I have so much in life to be thankful for.

2. If I had to list everything that I felt grateful for, it would be a very long list.

3. When I look at the world, I don’t see much to be grateful for.

4. I am grateful to a wide variety of people.

5. As I get older, I find myself more able to appreciate the people, events, and situations that have been part of my life history.

6. Long amounts of time can go by before I feel grateful to something or someone.

Does anyone really get a perfect score? Are they grateful in all the right ways and never disgruntled? It’s not that the statements determining positive levels of gratitude require Mother-Teresa thankfulness. But there’s something inhuman about someone who’s 100 percent grateful. (Even she wrote about how she wasn’t grateful all the time.)

Gratitude emerges in different ways. You can have a grateful disposition, which means your baseline is one of gratitude. You can be in a grateful mood, which is more transient. Experiencing the emotion of gratitude is typically short-lived and in response to an event.

Evolutionarily speaking, gratitude is a mercenary act, something we and animals do to get something. A parrot gives one of his seeds to his brother parrot, so his brother will do the same later. If you send that thank-you note, your aunt will send money on your next birthday, too.

Still, I did the whole gratitude-journal thing. I lay in bed, put my pen to the page, and waited for gratitude to flood through me. Images of gratitude websites and pithy social media posts flashed through my mind.

All I had to do was write three things I was grateful for. What was wrong with me? Why couldn’t I simmer with thanks?

My eyelids started to droop. I fell in and out of sleep.

Tony Robbins (and I’m sure a million other people) have said that it’s impossible to be angry, anxious, sad, etc. and grateful at the same time.

Lamely but genuinely, I scribbled walking, fresh air, Dad, and turned out the light.

Thank you for reading!

Buy Pathological

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.” Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not. If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

For those on the go, I read this to you here ↑

I’d been living in a tiny studio apartment that looked out onto a brick wall. Now that I’d advanced far enough along in my recovery to be able to advocate for and do things for myself, I determined to move. The apartments were either too expensive or dilapidated; there was no in-between.

One apartment seemed promising though the photos were all taken at night, making the rooms seem small and a little dismal, which might be why it was available. A friend of the owner showed me the apartment.

It was late dusk. The moment we entered, I was home.

It was palatial in comparison to my brick-wall studio: 720 square feet. The open floor plan made me want to run through it. (I didn’t.) The kitchen had all new appliances. They gleamed. There was a dishwasher—something I’d never had. The rest of the main room had space for a small kitchen table and chairs, a sofa, and my desk. The bedroom area was sectioned off.

Then I saw it: the balcony. I walked toward it. It was brittlely cold out, so I didn’t open the sliding glass door. In the distance was the skyline in full view. No brick wall. The city lights flickered and danced—mostly because I wasn’t wearing my glasses but still, they danced.

The other best part: It was quiet. Not a sound from the surrounding apartments like in my studio. No bass thumping through floorboards.

I made an appointment to see it again the next day.

Most of my family came with me. The agent showed us in. I followed my mother, stepmother, and father around the apartment, trying to gauge their expressions.

The four of us stood at the sliding glass door. The winter sky was flawlessly blue. The skyline stood strong. I could see the lake—pewter blue and still—the same lake I once thought of drowning myself in.

My stepmother said it first: “This was a great place.” My father nodded. My mother smiled.

My illness had taken a toll on them. It led to periods of caretaking and strain, tension and distance. Having them there was almost as important as having found a place to live.

My mother helped me move in. For five years, I lived with her in her apartment. We turned the room she used as a study/office/den into a makeshift bedroom. One year became two, then three, then four. Five years of her as my caretaker—dealing with my moods and anxieties and compulsions and depressions, going to the emergency room with me, being on suicide watch. Too much to ask, especially of someone without the emotional support family members and caregivers needed and deserved.

She unpacked the dishes and took them out of the newspaper. I shelved books and set up my computer.

After an hour, she surveyed the main room and said, “You look like you’re in good shape. I don’t think you needed me anymore.”

She meant that afternoon, but the words—in all their meaning—made my stomach do a little flip with what must have been excitement or pride. It was true. I didn’t need her the way I once did.

We walked to the door and hugged. For the first time, we hugged each other equally.

My new couch was against the wall, just where it should be. In the bedroom, my bed was made. My desk was set up for me to write tomorrow morning.

At dawn, I woke and rushed to the balcony and stood at the sliding glass door. Fog had rolled in off the lake. I was high enough up—the twenty-sixth floor—so that I was above it. There was only blue sky and fog below.

I got my phone and took a picture.

Every morning for the next year I’d do the same, photographing pink sunrises; white, puffy cumulus clouds; orange sunsets; heavy clouds of pewter grey and the faintest blue—it didn’t matter. I photographed them all. One late afternoon, I captured a whole rainbow, end to end.

The history of how we’ve treated and housed those with mental illnesses is inexcusable, particularly the nineteenth-century asylum system.

Although the word asylum may bring to mind images of half-clothed, raving “lunatics” chained to walls, it means sanctuary.

Select early asylums were true to the actual meaning of the word. They functioned as retreats. As Yale researcher Larry Davidson and his colleagues have shown, they boasted astounding recovery rates.

Between 1813 and 1843, retreats reported recovery rates between 70 and 90 percent for those patients who’d been admitted within the first year of experiencing a psychiatric crisis. (Let that sink in.) Overall, the recovery rate was between 45 and 65 percent. (Though some scholars contend that these percentages are too high, in the 1950s, Davidson cites studies that have confirmed these numbers.) In 1881, one public asylum, Massachusetts’ Worcester Asylum for the Insane, surveyed over a thousand patients who’d been discharged and found that 58 percent had not experienced mental illness again.

Several asylum superintendents—later called alienists and then psychiatrists—claimed that under the right conditions, the insane could recover their sanity. (Mental illnesses fell into two categories: insanity and idiocy though the terms were often used interchangeably.) This was a bold claim. Patients typically included the most severe cases of mental illness, alcoholics, the elderly suffering from senility, and syphilitics. Enthusiasts like mental health advocate Dorothea Dix, politician Horace Mann, and the heads of the Ohio State Asylum and the McLean Asylum in Boston insisted that mental illness was entirely curable through moral and humane treatment.

The “cure” for mental illness had everything to do with where the patients were housed.

The architect, physician, and mental-health advocate Thomas Story Kirkbride designed asylums that offered patients fresh air, beauty, privacy, and comfort. The center structures of his buildings proudly faced out, and the wings let in fresh air and natural light. They housed museums, libraries, and workshops. Patients had their own rooms, which had twelve-foot ceilings. They sometimes tended the lush grounds themselves.

Mental hospitals, Kirkbride said, should impress the patients and inspire faith in the psychiatric profession.

Retreats offered patients idyllic environments in which to heal. But these retreats were private and very expensive. They housed twenty-five or thirty-five patients and didn’t extend care to the majority of those in need.

By the final decades of the nineteenth century, the number of public asylums increased, as did the number of patients crowded into them. Some, which once housed less than fifty patients, had over two thousand patients. Living conditions were revolting and inhumane.

Hospitalization is still the primary treatment option for those in psychiatric crisis, but the question as to whether people should be removed from their everyday lives to receive care is hotly debated. Davidson and others argue that removing patients from the community—whether to a retreat, an asylum, or an inpatient psych ward—doesn’t help the patient recover. (The question of whether inpatient programs are or are not useful in psychiatric crises and emergencies depends on which activists and scholars you consult.)

He refers to the influential sociologist Erving Goffman, who wrote in 1961 that hospitalizing a patient was akin to saving someone who can’t swim and is drowning in a lake, teaching the person to ride a bicycle, and putting the person back in the lake.

Although the issue of inpatient versus outpatient treatment often concerns those with serious mental illness, recent studies confirm that environment greatly impacts everyone’s mental health. Psychology professor Anthony Mancini discusses the critical role of “the external environment in facilitating the internal conditions of recovery” today. Recovery can’t be brought about by will. He writes, “[I]t must be facilitated by factors external to the person. Unfortunately, these facilitative conditions are typically in scarce supply for people with serious mental illness, in large measure because such illness puts them at risk of being in environments that are suboptimal for healthy functioning.”

The morning after I moved in, I went for a walk, passing the building just north of mine. It was run down. Small windows looked out onto the street, but the windows on either side of the building looked out onto brick walls.

Outside the building stood a group of mostly men, not together, each on their own, all smoking. One muttered to himself. They stared dazedly at the cars passing.

I recognized them, not personally but as people with mental illnesses. Maybe it was a stereotype. Maybe I saw myself in them.

At first, my stomach lurched. I didn’t want to be close to it, didn’t want to be reminded of how I was before my recovery—as if it was contagious.

Then came a shift. Even with healing and a view, I was one of them and always would be. Oddly, my chest swelled with a sense of connection.

The small plaque on the side of the building that read Clayton House confirmed my first impression. A Google search on my phone told me it was a transition home for people with serious mental illness.

When I came back, they were gone. The only difference between them and me was privilege and opportunity: healthcare, eventually finding a good psychiatrist, family support, healthy food, medications with low-side-effect profiles, no co-occurring addictions, and a life filled with purpose in the form of writing and teaching. I had what was needed to heal; they and so many others did not.

How can we expect people to recover from psychiatric disorders—especially those who’ve been struggling for decades—without giving them a safe, supportive environment to do it in?

When it comes to regaining mental health, where we live determines if we heal. The four dimensions of recovery as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA) are health, purpose, community, and home.

Home is the big one. It sits prominently on psychologist Abraham Maslow’s list of basic human needs—home, income, food, safety, and companionship.

Place and recovery: it’s so obvious, yet we’ve done little to create environments for people with mental illness, so they can heal.

As the psychologist and mental health innovator Patricia Deegan, who fully healed from schizophrenia, says, “Stop asking what’s wrong with people with mental disorders and instead ask, ‘How do we create hope-filled, humanized environments in which people can grow and fulfill their human potential?’”

In a meta-analysis of the scientific literature on environment and mental health, researchers analyzed the importance of each aspect of our surroundings.“Hominess” has been found to decrease patients’ physical and emotional pain. Unsurprisingly, views of nature, gardens, and indoor plants can increase positive emotions and lessen negative ones. Natural lighting encourages healing and increases positive thoughts. Ambient chaotic noise, like that found in hospitals, creates stress. A space free of distractions (i.e., phones off, focus time on) contributes to productivity and calmness. Feeling safe and having privacy matter. Color affects mood though the internet is a hotbed of conflicting information on just which colors create which effect.

But the most significant factor is if you have a view. Greenery is best but even being able to see a concrete sidewalk with people on it or a dirt road on which a car might pass is crucial to mental health and healing.

Place.

A view onto something.

A physical view: the physical equivalent of having a future.

Dr. R crossed his leg in a figure-four, bobbed his head. That was that.

Thank you for reading!

Buy Pathological

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.” Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not. If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

My love of sugar is deep.

At the age of seven or eight, I stole money from my mother, silver dollars she received from my grandfather, to buy candy. While the other kids played outside, I snuck away to the corner store and bought a Lik-a-Stix Fun Dip (beware of foods that drop vowels and consonants), a powdered candy you eat by licking a hard candy stick and dipping it in a magical concoction of primarily corn syrup, sugar, artificial flavors, and dyes. Never a good liar, I returned home with my lips and tongue blue from the artificial dyes and was caught in the act.

When I was about six, I received one of those toy baking ovens for Christmas, the ones where you mix the powder and water, and (somehow) a bulb cooks a mini-cake. I’d go in the closet and eat the sugary powder, coughing, trying not to be heard.

In kindergarten, I pocketed extra Flintstone vitamins for the sugar rush, trying to eat them surreptitiously on the reading rug.

When I had anorexia in my teens, my diet consisted of a perfectly measured half cup of Breyers Mint Chocolate Chip ice cream and a baked potato.

Before I started to heal from mental illness in my forties, I ate ice cream every night. A lot of it. I’ve eaten pints of absurdly expensive coconut milk ice cream, almond milk ice cream, soy milk ice cream—with pretend sugars presented as “healthy.” Agave syrup, which it turns out is worse than high fructose corn syrup. Invert sugar. Beet sugar. Brown rice syrup. Stevia. Erythritol. Monk fruit sweetener. Coconut sugar.

All forms of sugar should have been an obvious no for someone experiencing anxiety, distractibility, impulsivity, mania, depression, and panic. I’d been on and ignored enough sugar highs and glycemic lows to know that. If I’d paid attention to what happens after it hit my tastebuds, I’d feel the rush and then my heart beating in my chest.

The links between sugar and mental illness are plentiful. A 2017 study showed a link between sugar intake and depression. A 2015 study demonstrated an association between soft drink consumption and depression. In a 2019 animal study, rats that binged on sugar and then fasted were anxious. (The poor little rats. I’ve spent many nights trying to figure out how researchers knew the rats were anxious.) Sugar has been shown to suppress a hormone that people with schizophrenia may be deficient in.

The branch of medicine called Nutritional Psychiatry exists for a reason. Diet is key to mental health—everyone knows that.

Otherwise, my diet was pretty clean. One of the beneficial byproducts of the years I spent obsessing over my weight and food as someone with anorexia is that I know way too much about nutrition.

Then and today, I followed the Wahls diet, which is basically by color: green foods, orange, purple. And cruciferous. No grains. Dr. Terry Wahls cured herself of multiple sclerosis by eating three massive plates of kale every day and making sure her diet consisted of three cups of green foods, three cups of cruciferous foods, and three cups of color foods before she ate anything else each day.

I could do it because I was—and am—privileged. I lived and live in a city and have access to fresh foods. Dinner doesn’t come from a convenience store. I have time to prepare my food, not traveling and eating in airports or grabbing Chipotle on the go. I don’t have children, so I don’t have to stock chemical-laden, processed foods because fighting with my kid to eat broccoli isn’t worth it, and those foods are designed to be addictive.

So I decided to cut out sugar. Yes, honey too.

One day, I went to the freezer and threw away the two gallons of ice cream that were in there. It was something I—as an addict—had done many times, trying to quit but unable to.

Of course, once the tubs were in the garbage, it all seemed wrong. Did I really need to cut it out? Doing so seemed so extreme, so Puritan.

Other people ate sugar. Then came thoughts of x diet or y celebrity.

Yes, but other people aren’t trying to do what’s supposedly impossible: heal from mental illness.

The addiction part? I considered taking it out of the trash and eating it.

Then came caffeine.

Caffeine consumption, which I did a lot of, should also have been an obvious no.

Caffeine-induced anxiety disorder is a subtype of a diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychiatry’s manual. Caffeine has also been found to trigger manic episodes. And the evidence that it supposedly helps with ADHD symptoms is contradictory, leading many to believe that it makes it worse.

There’s no number of cups of coffee or cans of Red Bull that mark the amount that will trigger its negative effects, but here’s how it works when it goes awry:

• The brain buzzes from the very first sip, which seems like a good thing, but that’s the complex effects of dopamine levels rising in the brain and levels of feel-good neurotransmitter serotonin falling. (Alertness doesn’t bring happiness.)

• Then comes the jitteriness in the hands, the restlessness.

• The heart begins to beat quickly or pound.

• The sweating starts.

• Maybe there’s a ringing in the ears, a sense of dislocation.

• Maybe nausea, chest pain, dizziness.

Giving up caffeine should have been the first recommendation any doctor or mental health physician made, long before any benzodiazepines and other anti-anxiety meds, before mood stabilizers, before antipsychotics and all the other drugs I was on.

I’d been drinking it for years in various forms, mostly coffee and tea (black, green, etc.)—not a lot, one cup in the morning and one in the afternoon but a lot for me. No soda. No Red Bull silliness.

Before any clinician leveled a psychiatric diagnosis and told me (incorrectly) that I had a lifelong, “biological” psychiatric condition due to a “chemical imbalance,” my lifestyle should have been taken into account.

It’s pretty basic. Let’s take all the people diagnosed with anxiety disorders and major depressive disorder and mania and ADHD and have them cut out caffeine and see where we are.

So I decided to cut it out—which I’d tried to do many times and failed (hence the addiction part).

I poured my milky cup of coffee down the sink, threw away the bag of coffee grounds and then my coffee maker.

Then came the thought: Other people get to drink coffee. I’m a writer. Writers drink coffee. Or at least tea. It’s part of the job.

I thought of famous writers and their coffee.

Balzac and his fifty cups of coffee a day. (He woke at 1 AM, so there was time.) He wrote, “As soon as coffee is in your stomach, there is a general commotion. Ideas begin to move…similes arise, the paper is covered. Coffee is your ally and writing ceases to be a struggle”

And Voltaire and his thirty to forty cups.

And Gertrude Stein.

And Capote.

Never mind if I even liked these writers.

Maybe I could be like Jonathan Swift, who drank it once a week and said doing so was essential to his writing.

And I’d read Michael Pollan’s asinine book Caffeine, which basically said the world wouldn’t have been created without it.

*

Of other addictions, I didn’t smoke or drink alcohol or take illicit drugs, which put me at a distinct advantage when it came to recovery.

I quit drinking almost twenty years ago. Unlike with caffeine, it was clear to me even then that if I struggled with depression and regularly drank a depressant (alcohol), it wasn’t going to go well.

Drug use has been found to cause depression, anxiety, and psychosis. Speed (amphetamine) has been linked to a five-fold risk of psychosis. Other drugs that produce drug-induced psychosis include marijuana, psychedelic drugs like LSD, ecstasy, and MDMA. Ketamine is also known as the street drug Special K. Cocaine produces symptoms of psychiatric disorders, even in those who don’t suffer from mental illness, including agitation, paranoia, hallucinations, delusions, violence, as well as suicidal and homicidal thinking.

Knowing how hard it’s been to recover from mental illness, I’m not sure how anyone heals from co-occurring disorders (mental illness and substance use disorders).

A few years ago—post recovery—I enrolled in a one-hundred-ten-hour training in substance abuse recovery counseling.

I listened to people who quit heroin and crack and healed from mental illness, a few while living on the streets. A young woman—maybe twenty—who was a meth addict exuded a ferocity that blew my mind when she spoke of her recovery. They filled me with awe.

*

Not that healing from mental illness was easy.

Sugar was mostly mental, but when I gave up caffeine completely, the panic attacks started. My chest thrummed with an unsettling energy not just after a cup but all the time. My cheeks went numb. The room fell away. I wasn’t really there. I was dying.

Quitting caffeine was a bit like struggling with mental illness.

Knowing it’s a panic attack doesn’t decrease the panic. I’m dying. Eventually, the panic settles after what feels like a very long time.

I started negotiating with the term “quitting caffeine,” attempting to outwit the milligrams of caffeine in each substance. Coffee was out, but tea was okay. Then black tea was out, but green tea was okay. Then green tea was out, but hot cocoa is okay.

At one of my appointments with my psychiatrist Dr. R, we sat opposite each other.

I told him I was trying to quit drinking caffeine.

He bobbed his head the way he always did. “Good idea.”

My stomach sank with disappointment. I wanted him to say, Ah, don’t worry about that. A little caffeine is okay.

But he was an excellent psychiatrist—the first to tell me that diagnoses are meaningless labels meant for physicians to use, not patients to identify with, and to present recovery to me as an option.

He hadn’t volunteered that I should quit caffeine, but during that session, he agreed that no amount of caffeine is “okay.”

It still seemed unfair, like everyone else had it easy.

That was the discouraging part about mental health recovery. There was so much to give up to get well.

But there were also so much data showing people recovered and that I could too.

Though many mistakenly believe that depression is biological, chronic, and lifelong, at least a century-and-a-half of studies have shown otherwise, citing recovery rates from 49 to 76 percent.

In a meta-analysis, Samuel Guze and Eli Robins at Washington University Medical School, who actually inspired the biomedical model, found that 50 percent of people hospitalized for depression had no recurrence and only one in ten people were chronically ill.

In the 1960s and 1970s, before the Prozac-biomedical-model era, the official line from the National Institute of Mental Health (NIMH) was that depression tended to resolve itself.

One NIMH official wrote, “Depression is, on the whole, one of the psychiatric conditions with the best prognosis for eventual recovery with or without treatment. Most depressions are self-limited.”

One NIMH study saw 73 percent of patients with schizophrenia discharged after just one year and remaining in the community three years after discharge.

Another study found that 85 percent of patients discharged within five years successfully lived in the community more than six years later.

An additional study determined that of nearly half of the patients discharged in 1950, more than half never relapsed over the next four years. Overall, these studies indicated that during this pre-pharma era, only 20 percent of patients with schizophrenia needed to be continuously hospitalized.

Dr. R crossed his leg in a figure-four, bobbed his head. That was that.

Thank you for reading!

Buy Pathological

You can buy my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.”

Pathological traces how we’ve come to believe that ordinary emotions are mental disorders.

If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

At a tennis center on Chicago’s southside, my sister and I wait for my nephew’s game to start. Courts of teenage boys face each other in singles and doubles matches. The whack of tennis balls hitting racquets echoes through the space. It smells of sweat and dirty socks.

My sister has found me a chair, so I don’t have to put weight on my broken foot. When she invited me, she was clear: “You need to get out of your apartment, even if just for a little bit.”

It’s not going well—all the healing I’m trying to do. I keep walking on my broken foot. And then there’s the whole recovering-from-twenty-five-years-of-serious-mental-illness thing.

My new psychiatrist, Dr. R, recently spoke to me about recovery. In all the years I was in the mental health system, not one clinician mention getting well; the best I could do was “manage” my symptoms. My diagnosis was biological and lifelong—inside me, never to be resolved.

Which would have been fine if it were true. Turns out no psychiatric diagnosis is purely biological or necessarily a life sentence.

Three-quarters into the qualifying match, my nephew’s losing. The other player is good. If his first serve hits the net or goes out, he lobs his second, which throws off my nephew’s rhythm.

This tournament will affect my nephew’s ranking and determine whether he qualifies for the state championship at the end of the season.

My nephew is best described as solid—emotionally, physically, mentally. He loses, is disappointed, and gets over it. Within hours, he’s cracking jokes and smiling. Not that things don’t get to him; they just don’t absorb him.

It’s pretty clear he’s going to lose. He uses his shirt collar to wipe the sweat from his forehead and under his glasses and mutters in frustration.

Then he regains focus.

Everything comes together: his serve, his backhand, his agility. He plays loose and light as if he’s never had a moment’s frustration or doubt the whole game.

During match point (in my nephew’s favor), they volley for what seems like a very long time.

Then: he wins. I want to leap to my feet with joy but can’t.

Before leaving the arena, my sister and I stop to talk to his coach—an older, chubby, balding man. He gushes with enthusiasm over my nephew’s win. “Amazing. He crushed it.” The coach holds up his phone. “This is what we listened to in the van on the way down here. And it did it.”

Onscreen is a YouTube video—black and white—of a guy wearing headphones speaking into a mic. His head is shaved. His face is acutely square, his jaw severe. He has the neck of a serious weightlifter.

My nephew’s coach says, “Jocko Willink. He’s why your nephew won today.”

I get home, google, and learn that “Jocko,” as he’s known, is a phenom. A retired Navy Seal who served in Iraq, he’s published books on leadership and runs a company that serves as a pseudo-military training ground for businessmen who want to lead as if they’ve once been Navy Seals even though haven’t. Jocko’s passion is Jiu-Jitsu. His YouTube motivational speeches and interviews get millions of views. His podcast has tens of millions of downloads.

If he helped my nephew, maybe Jocko can help me.

Within a week, I’m deep into the world of Jocko. I dip in at first, catching clips of his motivational speeches on YouTube. Soon,

I’m listening to the full one-to-two-hour podcasts.

My fascination morphs into infatuation and then fixation.

Most of his guests are soldiers or leaders who’ve experienced hardships I couldn’t begin to fathom. Jocko’s three-hour interview with Congressional Medal of Honor recipient Ron Shurer, a staff sergeant who served as a medic in Afghanistan and then in the secret service and was also battling cancer, holds me rapt.

On another episode, Jocko interviews a vet who’s a quadruple amputee who runs a center for other quadruple amputees and their families.

Another interview is with a vet who’s a double amputee and runs multiple marathons each year to raise money for a nonprofit.

When Jocko addresses us, his devoted listeners, he’s all grit. He says life is war. We need discipline and to take responsibility for our actions. In his gravelly voice, he tells us to “crush it”—“it” being any project or task. He urges us to “get after it.”

We have to be ultra-aggressive, ultra-confident, and uber-in-control.

Jocko is problematic in many ways. He refers to women as “girls,” talks way too much about Jiu-Jitsu, and often comes off as melodramatic. At the end of his show, he sells Jocko-sponsored-and-made merchandise like T-shirts and krill-oil supplements and (for reasons I can’t begin to grasp) soap.

It’s bro-culture in the extreme, but in a way, it works. Telling myself to attack, push, pursue gives me the courage to stop obsessing over my broken foot, my broken brain, my brokenness.

When one of his listeners emails to say that he’s considering suicide, Jocko says that suicide is never an option because when you’re on your last bullet, you shoot the enemy, not yourself—the enemy being something along the lines of whatever difficulties you’re facing.

Sitting in my apartment with my broken foot elevated, unable to walk (my long, long walks were the one thing helping me in my mental health recovery), he becomes an abrasive balm.

He seems to have what I want: the power to heal.

*

According to mental health professionals and patient advocacy groups, Jocko’s toughen-up approach is ill-advised when it comes to mental health recovery.

The patient advocacy group Mental Health America (MHA) warns that “tough love” can backfire. Pushing through is the equivalent of walking in the boot, putting weight on a broken bone.

Self-love, self-compassion, and vulnerability are the preferred methods of mental health care.

I learned a lot about this triad in my first partial hospitalization program (PHP). In the PHP, we’d sit in a circle in a frigidly air-conditioned therapy room and learn “skills” to deal with our respective issues or mental illnesses.

The staff recommended books by self-help gurus, psychologists, and researchers.

The favorites—and I mean favorites—were self-compassion icon Dr. Kristin Neff and vulnerability guru Brené Brown.

Neff defines self-compassion as “being warm and understanding toward ourselves.” Self-love has lots and lots of definitions, most of which have to do with “an appreciation of one’s own worth.”

Brown’s version of vulnerability entails embracing uncertainty, allowing weakness, and revealing our inner thoughts and emotions to others.

But herein lies the crux of the vulnerability paradox: It says that those who visibly embrace their weaknesses are strong whereas those who don’t are weak because we don’t expose our weaknesses.

And it seemed easy for Neff and Brown, two privileged women who’d never experienced a mental health crisis (let alone too many to count), to tell us to embrace what American culture deems weakness and make ourselves vulnerable.

As far as I was concerned, I’d been weak and vulnerable enough.

*

My nephew’s tennis season continues and he’s on a winning streak. I get texts from my sister telling me how he’s won this match and that match.

When a black wave of depression comes over me, I harden against it. No, I say. Not happening.

When anxiety seizes me, sending sweaty, sickening rushes of panic through my body, I do the same. No. Not happening.

Sometimes it works; sometimes it doesn’t. But I say it every time until it works more often. When darkness envelopes me, I don’t stop to show myself compassion. I don’t “turn towards it.” When I feel afraid, I don’t “lean into it;” I steel myself and move on.

Healing is in my control. I’m going to do it despite the hum in my chest and surges of energy and the dark pit in my stomach and my pounding heart and my numb lips and cheeks and the sense that I’m not really there.

*

I’m in my apartment grading essays when a text comes in from my sister. It’s a photo of my nephew. He’s outside, a tennis court in the background. His green T-shirt is soaked with sweat. In his hands is a trophy. He’s won the conference title.

I don’t know what he thought or said to himself to win all those games. All I know is that every day, he was on the court, playing.

I hobble to the kitchen and fill my espresso maker with water and coffee grounds, seal it, and turn on the stove. My ankle aches. Teaching the day before, I stood too long at the podium, wanting to give the presentation standing up, the way I would have before I broke my ankle.

Later, I’ll realize that I was already tough—long before Jocko; I’d just lost sight of it.

People with mental illness are some of the strongest people on earth.

You have to be fierce to be in that struggle—regardless of whether one heals.

*

Around the room are weights, massage tables, a stationary bike, a treadmill, and yoga mats. Resistance bands hang from the wall. In the corner sits an enormous, inflated exercise ball.

Colleen, the physical therapist I’ve been assigned is very nice and very pregnant. She’s also very fit. She’s a runner and still runs long distances in her eighth month.

It’s my third time seeing her. I take off the boot and lie on the massage table on my back. I had visions of physical therapy being restful and relaxing, but it’s tedious and painful. Colleen is more taskmaster than therapist.

She stands next to the table and commands me to point my toes fifteen times. Restoring range of motion is the first step of physical therapy for a broken foot. Next will come strength and balance.

“Flex—then rotate left and then right,” she says.

Dr. Patel said I could be out of the boot as soon as my next appointment, so I do as I’m told.

An elderly man lies on the massage table next to mine. Liver spots dot his balding head and hands. A physical therapist moves his body, which is so thin it looks as if his bones might break.

Pain shoots through my ankle as I let my toes return to neutral. I wince.

“You don’t have to push so hard,” Colleen says.

The physical therapist gently rotates the man’s arm. The man’s face is passive, accepting.

When I’m finished, Colleen hands me the exercise band and tells me to do the same exercises using it as resistance. With her arm resting on her belly, she walks away.

I loop the band under my foot and, holding it, point my toes and return to neutral. Point and return. Point and return. My ankle is stronger. It has to be.

Colleen comes over and asks how I’m doing. She doesn’t know how important healing is right now.

I tighten my grip on the band, rotate my ankle left, and return to neutral. “I can do another set.”

Her brow furrows. “You don’t have to.”

*

Dr. Patel gently places his fingers on my still intensely bruised ankle. Behind him is a medical resident. The resident looks at the x-ray of my ankle with a skeptical look on his face, as if to say, I wonder how that’s going to heal.

“It doesn’t hurt,” I say for the second time during the visit, even though it isn’t true.

He and the resident exchange glances.

I want to heal. “It feels better.”

With a sigh, he turns to the computer monitor and starts typing. “Do you know what happens when you break a bone?” He clicks the keys. “The bone bleeds. Your bones contain blood vessels, and when the bone breaks, they clot and pool around the broken ends. That clotted blood has to become solid bone.”

The gravity of what he’s saying, the tone of just slow down, let yourself heal doesn’t register. “How close are we to being out of the boot?”

He continues typing, eyes on the monitor. “We’re only in phase two.”

I ask how many phases there are.

“Three, basically. You’ve been through the inflammatory phase, fracture hematoma formation. The blood clots have done their job. Your ankle is now in the repaired phase.”

I like that it’s called the repaired stage, not repairing or potentially repairing. It’s repaired. Healing is inevitable—a done deal—so unlike the way the many mental health clinicians I saw spoke of the psychiatric diagnoses they gave me over twenty-five years.

He points to the X-ray on the computer monitor. The resident looks over his shoulder.

I ask if I can get the short boot, the quaint one that looks more like a shoe than a Storm Trooper boot.

They turn to me, their expressions an almost audible no. “This is the deep healing phase. Fibrous tissue and cartilage have to form a soft callus at the ends of the broken bone. They’ll join, and the hard bone will replace the soft tissue. This is serious.”

“And then we’re done?” What they don’t understand is that I’m also trying to heal from mental illness. My new psychiatrist has said it’s possible—even for me, whom other doctors had condemned to lifelong suffering—and although I doubted him at first, I want it desperately. It’s taking too long too.

“We’ll see,” he says, standing. “Stay in that boot.”

*

Clifford Beers has become one of my heroes—in a way.

Beers’s memoir A Mind that Found Itself is a harrowing account of his breakdown in 1900, his suicide attempt (he jumped from a second-story window, feet first), and hospitalizations in one asylum after another.

The conditions Beers met with in the asylums made him worse. He was put in straitjackets, physically abused, emotionally berated, and isolated in a padded cell, among other injustices. While at the Connecticut State Hospital at Middletown, he vowed to get well and write a memoir campaigning for reform so no other patient would experience the horror he did.

His descent into hypochondria and depression and panic and paranoia and finally mutism make my experiences of mental illness pale in comparison.

A Mind that Found Itself doesn’t tell only of madness, as so many mental-illness memoirs do; it describes how he healed:

“I have already described the peculiar sensation which assailed me when, in June, 1900, I lost my reason. At that time my brain felt as though pricked by a million needles at white heat. On this August 30th, 1902, shortly after largely regaining my reason, I had another most distinct sensation in the brain. It started under my brow and gradually spread until the entire surface was affected. The throes of a dying Reason had been torture. The sensations felt as my dead Reason was reborn were delightful. It seemed as though the refreshing breath of some kind Goddess of Wisdom were being gently blown against the surface of my brain. It was a sensation not unlike that produced by a menthol pencil rubbed ever so gently over a fevered brow. So delicate, so crisp and exhilarating was it that words fail me in my attempt to describe it. Few, if any, experiences can be more delightful.”

I know that sensation in the brain now. I can’t relate to “a menthol pencil rubbed ever so gently over a fevered brow,” but I’ve felt the delicacy, crispness, exhilaration, and delight of becoming well—fully well.

For twenty-eight years, Beers worked tirelessly to eradicate the inhumane treatment patients suffered and improve attitudes toward those with mental illness.

He joined forces with the eminent psychiatrist Adolph Meyer and the philosopher William James. Together, they founded the National Committee for Mental Hygiene, which researched the causes of mental disorders, trained medical students, and helped pass legal reforms on behalf of patients. The mental hygiene movement sought to move away from strictly biological explanations of mental illness and examine the patient’s history, community, and environment as potential causes and cures. The National Committee for Mental Hygiene later became the patient advocacy group Mental Health America (MHA).

The mental hygiene movement had a serious dark side. It later focused on eugenics. Citing the supposed permanence and heritability of mental illness, the movement sought to prevent people with mental illness from procreating by sterilizing them. This, too, lent to the mistaken idea that mental illness is hopeless and lifelong.

Beers’s life didn’t end happily. In 1939, he succumbed to depression and nervous exhaustion. He eventually committed himself to Providence, Rhode Island’s Butler Hospital, a psychiatric institution, where he died four years later.

Maybe he didn’t fully recover, but I will, and I’ll help change the mental health system.

*

Dr. Patel stands smiling before me, flanked by a resident—this one as boyishly young as the others. The office seems larger than it did before, less medical, more pleasant.

We’re in phase three: the remodeled phase. Solid bone will continue to grow, and blood circulation around where the break occurred will eventually improve.

He turns to the computer monitor and clicks the mouse. Onscreen is the x-ray of my ankle. The bones don’t look as if they’ve joined correctly. Dr. Patel explains that they’re supposed to be uneven.

“How long will it take to heal completely?” I hop off the examination table.

“It depends. It can take six months or longer.”

“How much longer?”

“To be fully cured, it can take years.” He types something. The words logging out appear onscreen. “It’s a slow process. It’s actually the majority of the healing time.”

“How many years?”

“You won’t need to come back in, but you’ll continue physical therapy.” The screen goes dark. “Gradual weight-bearing exercises are encouraged.”

I stride down the hallway on my out, carrying the boot. It’s a sunny early-summer day, not too hot. In the first trash can I see, I toss the boot.

Along the lakefront path, I walk and walk. There’s pain, but I ignore it. The fresh air seems fresher, the lake bluer, the sky brighter.

By the time I get back to my apartment, I’m limping. The room is dark. Out the window, my sliver of sky is starting to cloud over.

*

“You shouldn’t have done that,” Colleen says at our next appointment.

Holding onto the exercise band looped around my foot, I point my toes.

“Now rotate right,” Colleen says. “You have to think long-term and not push it.”

She wouldn’t understand that I think only about living as someone already healed.

“You aren’t out of the woods yet,” she says, echoing Dr. Patel. “The remodeled phase takes time.”

I rotate my ankle once, twice, counting, taking my time to reach fifteen.

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Thank you for reading! You can buy my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.”

Pathological traces how we’ve come to believe that ordinary emotions are mental disorders.

If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

Buy Pathological

The fall happens fast. One moment, I’m walking down the stairs at the gym; the next, I’m moving through space.

I land to the sound of bone snapping.

Within minutes, a flurry of personal trainers is around me, helping me limp over to a weight bench and prop up my leg. The irony is rich that I’ve injured myself walking down the stairs, not doing some bionic box jump or high-speed treadmill run, which I don’t do anyway.

“I think you broke it,” one says, biceps bulging beneath his t-shirt.

“Definitely,” the other says, his face aglow with health.

Soon, my ankle is Gothically swollen. I call an Uber. They help me to the door and navigate the slush outside and ease me into the car.

At Immediate Care, my ankle is x-rayed. The attending physician tells me my distal fibula is fractured. She puts the X-ray against the lightbox. It’s unmistakable: a piece of bone broken off in the blackness as if floating in space.

There’s no question the bone is broken. The diagnosis isn’t in doubt. We can see precisely that it’s the fibula, not the tibia.

In this, it’s so unlike the six mental health diagnoses I received over the past twenty-five years. No X-rays for those. No blood tests. Just doctors’ best guesses at how to define my bouts of depression, anxiety, confusion, exhaustion, obsessions, hyperactivity, compulsions, insomnia, panic, and suicidality (not all at once).

“The fibula isn’t a weight-bearing bone,” she says. “It supports and stabilizes. It keeps us steady. To heal, you need to immobilize your ankle.”

No doctor or mental health professional who leveled a psychiatric diagnosis ever mentioned healing.

Then it strikes me (slowly, dully) that I won’t be able to walk. “For how long?” I hear the panic in my voice. I’m already trying to heal from serious mental illness, and I’ve stopped taking Klonopin—just quit cold turkey, which is a terrible, terrible idea, as Dr. R will later inform me. The only relief from the constant hum in my chest is walking miles and miles—no matter how cold or snowy it is—as far as it takes.

“The orthopedic surgeon will give you a precise estimate for how long you’ll need to wear the boot,” she says, clearly not understanding the tragedy that’s just occurred.

“A week or so?” Even to me, what I’ve just asked sounds absurd.

“Um,” she draws out the word, “I’m going to guess it’s going to take longer than that.”

A nurse comes in with a huge, heavy, black orthopedic boot.

The physician’s tone is firm. “Don’t go walking around in it. When I say immobile, I mean immobile.”

“But I’ll be able to walk?” I ask as if she didn’t just say Don’t go walking around in it.

“The boot is support. A broken bone needs to remain stable. Otherwise, it won’t join or regrow properly. People try to push it, but that will just delay healing.”

I ask if I can walk a bit, just here and there, just—

“You can—if you don’t ever want to heal or walk again.” She opens the door to leave. “And keep it elevated even when you sleep. Maybe even sleep in the boot.”

*

People like to compare mental illnesses to physical illnesses. Type 2 diabetes is a favorite comparison. But the metaphor implies that psychiatric diagnoses like major depressive disorder and anxiety disorders and eating disorders and obsessive-compulsive disorder and attention deficit hyperactivity disorder are necessarily lifelong, which we know they aren’t.

One of the most valuable illness metaphors comes from Dr. Thomas Insel, a neuroscientist, psychiatrist, and the former director of the National Institute of Mental Health (NIMH).

When I interviewed him years after I broke my foot, he likened mental illness to breaking a bone. As with a broken bone, we can heal from every type of psychiatric diagnosis, even schizophrenia, which is often treated like a death sentence. Healing is a long, complex process, he explained. When the bone first breaks, it bleeds. Then it becomes inflamed. Only then does it begin to repair. Finally, it starts to heal, which can take months or years, sometimes as long as a decade. What’s most remarkable is that after a bone heals, the point of the break becomes the strongest part. It’s as if we become stronger for having broken it.

Some people with mental illness take issue with the broken-bone comparison because they think it’s simplistic and dismissive. But breaking a bone is a big deal, and Tom Insel isn’t saying that everyone will heal from mental illness, only some.

It’s not a perfect metaphor in other respects. We don’t, of course, have the equivalent of an X-ray to show that someone actually has the psychiatric diagnosis they’re given. Approximate diagnoses and treatments are all we’ve got. It’s a lot to ask of psychiatrists: Heal me even though you don’t what exactly is wrong or have the remedy or cure. Plus, the bone is only the strongest part for a short time. After recovery, we don’t reach some sort of blissed-out state of high-functioning happiness.

As with mental health recovery, recovery from a broken bone will actually look different for each person. Some will heal relatively perfectly. They’ll run marathons and ultra-marathons, forgetting they ever broke a bone unless reminded. For others, the bone won’t quite set right, resulting in chronic pain or a limp for which they need continuous care.

Ultimately, no metaphor suffices. Mental illness is unlike any other experience or condition. It’s brutal and excruciating and can be fatal. But as with a broken bone, it can also result in full recovery.

The diabetes comparison might actually be the best after all. There’s early evidence that type 1 diabetes, once said to be lifelong (no exceptions), is, in fact, curable. In a recent study, one participant’s daily insulin use decreased by 91 percent, and—this is the miraculous part—his body started producing insulin on its own. It’s early yet and the study used a very small sample, but it seems that a once-incurable disease is curable after all.

*

Sleeping in the boot borders on Medieval. It’s like a very mild version of being on the rack. The boot weighs down my leg, stretching the ligaments no matter what position I sleep in.

For the next few nights, insomnia becomes my closest companion. Each morning, in front of my computer, drinking coffee, the ice I put on my ankle numbs the pain but brings with it an icy burn.

I’ve been feeling the blackness, the unsteadiness, the sodden pit in my stomach, the hum in my chest again. They’d lessened, which I’d seen as proof that I was, in fact, healing from mental illness.

The hum in my chest intensifies. The refrigerator drones. My thoughts race on repeat: I’ll never heal. My foot will never heal. My mind will never heal. My brain will never heal. My brain is broken.

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Within a week, hobbling in the boot has become familiar but no less tedious. I’m able to click along at a fairly good pace. This, of course, goes against the very point of the boot. The boot is meant to immobilize so my broken foot can heal.

I enter the waiting room of the osteopath I was assigned in Immediate Care. After checking in, I sit amidst the other patients. Some are in casts, others in braces, and others in splints. Some show no sign of having been injured.

According to Dr. Patel’s profile on the hospital website, he’s certified by the American Osteopathic Board of Orthopedic Surgery. Foot and ankle fractures are his specialties. He has eight hundred and twenty-three ratings which average 4.8 stars.

I never thought to find reviews of any of the psychiatrists I saw. One psychiatrist is connected to this same hospital. I look him up. His profile shows he’s certified by the American Board of Psychiatry and Neurology. His profile has no star ratings.

Another of my psychiatrist’s profiles is tied only to the private practice he’s associated with. It links to his CV, which is replete with licensures, certifications, trainings, honors, and awards. No star ratings there either.

My current psychiatrist, Dr. R, is also affiliated with this hospital. His profile doesn’t even have his photo. No bio, just where he got his Ph.D. and M.D. His profile lists his publications, the titles of which are so scientifically specific they’re like gobbledygook: DNA/RNA-binding protein, chick aggrecan, ubiquitin-mediated degradation. If I’d gone by his profile, would I have chosen him? Probably not, but he’s the best I’ve seen.

The nurse calls my name. I limp assertively behind her. She walks slowly to accommodate me. I want to tell her I’m fine. I’m healing. We can go faster.

She shows me to the examination room. Eventually, Dr. Patel comes in with a resident in tow. The resident looks so young he could be fresh out of college. Dr. Patel is handsome, confident but not arrogant, caring but brusque. The clock on our appointment time is clearly ticking. He clicks the keyboard, and soon the X-ray of my broken ankle is on screen. The two of them consult.

Dr. Patel helps me out of the boot, touches various spots, and asks me if it hurts. It does, but I don’t want to say so. I want out of the boot. I want to be healed.

“You don’t need surgery,” Dr. Patel says. “Six more weeks and we’ll see how you’re doing.”

Panic rises in my chest. “Six weeks in the boot?”

Dr. Patel explains his reasoning at length. I’ve torn ligaments too, and those take longer to heal. I look to the resident as if for help, but he just smiles.

Dr. Patel says I can get a second opinion. He says this easily and without malice.

A second opinion? In a couple of months, I’ll read advice from Dr. Allen Frances, one of the most powerful figures in psychiatry. In his book Saving Normal, he’ll stress the importance of getting a second opinion whenever you see a psychiatrist. I’d never thought of it. No one recommended that I do. This is, of course, a luxury, especially in our overcrowded mental health system, but I wish I had thought that way.

I shake my head. I trust Dr. Patel. It’s a feeling.

“You’ll be out of that boot soon enough,” he says.

As I hobble to the elevator, my foot seems to hurt more than it did when I came in. Six weeks. But it will heal. Dr. Patel said as much. You’ll be out of that boot soon enough. He’ll track my progress as my ankle goes from broken to healed.

*

What if one of my psychiatrists or therapists had spoken to me that way? You could be out of this depressive episode soon enough. You’re experiencing an intense bout of anxiety, but it is possible to heal. People have healed from bipolar disorder—not that it’s easy. ADHD can be resolved. Anorexia isn’t necessarily lifelong. No promises. Lots of could’s and can be’s and necessarily’s. Conditionals, but also possibilities.

During the twenty-five years I was in the mental health system, not one clinician gave me the recovery statistics of the diagnoses I received or explained the stages of recovery.

One recovery model, taken from the Transtheoretical Model of the Stages of Change, traces recovery as a nonlinear process in which a person moves from seeing themselves as a diagnosis whose life is limited to someone believing, committing to, and taking action to create the life they want. (Some people dislike this model because it’s so focused on taking action, which is both Puritan and capitalist, but there are other models.)

This model has five stages:

• Stage 1—Impact of illness: the person is defined by stigma and the symptoms they experience and sees themselves as the diagnosis, which may or may not be helpful

• Stage 2—Life is limited: the person glimpses but doesn’t think change is possible because they can’t imagine an identity outside of their diagnosis

• Stage 3—Change is possible: the person has hope, yet still isn’t willing to take the risk

• Stage 4—Committed to change: the person starts to take steps toward recovery

• Stage 5—Action taken: the person no longer sees life as limited and trusts in themselves

These stages aren’t prescriptive; each person determines what each stage will entail and what the end goal will be.

But recovery wasn’t mentioned on WebMD. Or on the National Alliance for Mental Illness (NAMI) website. (NAMI wouldn’t have a webpage dedicated to it until 2021—though it’s excellent.) No media outlet—not The New York Times or the Washington Post—covered it. BP Hope, the bipolar magazine I depended on, said that bipolar disorder was physiological like heart disease and “can be managed but never goes away.”

Soon, I’ll learn that most of the time I spent in the mental health system, the U.S. government had embraced the recovery model over the biomedical model, which emphasizes that mental illness is biological and can only be managed.

Beginning in 1999, the government had called upon the psychiatric community to make the recovery model the core of our mental health system.

Recovery as a concept had gained traction with the passage of the 1990 Americans with Disabilities Act, which recognized serious mental illnesses as disabilities. Surgeon General David Satcher’s 1999 report on mental health was the first official policy to include the term recovery: “All services…should be consumer-oriented and focused on promoting recovery.… [T]he goal of services must not be limited to symptom reduction but should strive for restoration of a meaningful and productive life.”

News that a full recovery from mental illness was possible seemed to take hold with politicians at the turn of the twenty-first century. The President’s New Freedom Commission on Mental Health in 2003 called for a “profound change” on the federal level that would shift the focus of treatment toward recovery and protect the rights of adults with serious mental illness.

Its Executive Summary led with these words: “We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured…” It promised a transformation “not at the margins of a system, but at its very core.”

*

The restaurant is crowded. Every table and every seat at the counter is full. My father and I stare down at the laminated menus. We’re at a four-top, so I can prop my foot on the extra chair. Condensation beads down our water glasses, forming rings on the table.

My broken foot and being in the boot are hampering my determination to recover from mental illness. I’ve lost the ability to go for the long walks that used to help calm and soothe me and make me feel like I was making strides toward recovering my mental health.

Even now, a hum pulses in my chest. The pit in my stomach is so heavy and black that it’s my whole being. The clank of plates being put in bus bins sounds as if it’s inside my head. The table next to us is too close. The two couples drink mimosas. Their voices are too loud though I can’t make out what they’re saying.

The server arrives, and we order. Out the window, the sunlight faintly lights the street. She brings my coffee, which I pour milk into and sip. The pulsing in my chest intensifies. I keep sipping.

Eventually, our food arrives. The skillet the server places in front of my father still sizzles. The omelet she puts in front of me is the size of my forearm. My father puts hot sauce on his eggs. I pick at my omelet.

He says, “I’m really sorry this happened to you, hon.” He means my ankle.

No one knows I’m trying to recover from mental illness. It’s being done in secret to prevent anyone from discouraging me. I tell him I’m going to get better, referring to my mental illness.

“Of course you are,” he says. “Just wear that boot.”

To be continued next week…

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Thank you for reading! You can buy my journalistic memoir Pathological: The True Story of Six Misdiagnoses (HarperCollins), a USA Today bestseller that traces how we’ve come to believe that ordinary emotions are mental disorders. If you’ve already read it, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

I like to imagine the Hospital Bicître in Paris in 1793.

The above sepia-toned photograph comes to mind: the cobblestone path leading to the arched entrance, the stone buildings stretching past the gates.

A century earlier, it looked more like a rural prison, which it was—in part.

It was part prison, part housing shelter, part mental asylum. Most patients were afflicted by dementia, syphilis, or paralysis.

In most asylums, “lunatics” were typically divided into aggressive and non-aggressive. They were physically abused and not given clothing. The first line of treatment involved chaining them to walls.

But that’s not what I think when I picture the Hospital Bicître because patients there were freed thanks to two men: Philippe Pinel, a physician, and Jean-Baptiste Pussin, governor of the hospital.

Pinel is credited with having liberated mental patients, for which he’s now often referred to as “the father of modern psychiatry,” but he learned from Pussin. As governor, Pussin found that patients fared better when (surprise!) they weren’t chained to walls.

Maybe I shouldn’t think so highly of Pinel and Pussin. Patients were still put in straight jackets and isolated.

But the two men revolutionized how people with mental illnesses were viewed.

Since the Middle Ages, the insane had been seen as degenerate, demonic, bestial, and alien. Pinel and Pussin changed that. They thought of them simply as people suffering from mental and emotional distress.

People with mental illnesses were seen ordinary human beings, albeit more sensitive to the world than others (qualities we sometimes value in artists and other “creatives,” as they’re now called), with rights like anyone else. Pinel and Pussin pushed for holistic care and developed traîtement moral (not to be confused with moral treatment, which came later in the U.S. and England). Traîtement moral had nothing to do with morality (right and wrong, good and bad); it asserted that those with mental illnesses (surprise!) shouldn’t be abused and should receive psychological care.

It worked. The hospital boasted a cure rate of 90 percent if—and this was a big if—patients were not treated at another hospital first.

Why?

Because Pinel and Pussin knew that physical abuse and the emotional toll of being denied your human rights and told you’re beyond help compounds mental illness and leads to further deterioration.

We worsen not because we have a mental illness but in response to how we’re treated.

Psychiatrists today don’t like the word cure, but curing mental illness isn’t the same as boasting of a cure. Cure comes from the Latin curare, meaning “to take care of someone.”

It wasn’t until the Middle Ages that cure was even associated with medicine and used as a noun to mean a remedy.

There’s no single cure for mental illness—no pill or magic bullet. The definition of the verb to cure is “to restore to health, soundness, or normality.” Those categories (health, soundness, or whatever we think of as “normality”) are abstractions determined by each person and culture.

Traîtement moral was rooted in the belief that patients could not only be cured but cured so entirely that they could return to the hospital and be employed to help others heal—an early example of what’s now called peer support.

Pinel even hired ex-patients to work at the hospital. Pussin—get this—had once been a patient at the hospital before he became governor (albeit for tuberculosis, not mental illness).1

In the scientific literature, Pinel introduced three pivotal truths that we still have trouble accepting some two hundred years later. Professor of Psychiatry at Yale Larry Davidson and his colleagues outline them in their excellent history of people healing from mental illness over the past two centuries, The Roots of the Recovery Movement in Psychiatry:

1. anyone can develop a mental illness;

2. mental illness occurs in response to external events (it’s not solely biological); and

3. it’s not all-encompassing, i.e., even in an acute phase, it merely influences a person’s perceptions, judgments, ideas, and reasoning (it’s not the whole person).

Think about it.

1. We still believe that only certain people suffer (read: the weak, the biologically flawed, etc.).

2. The chemical imbalance myth (yes, it’s a myth) and the biomedical model of mental illness continue to reign supreme.

3. Some people adopt diagnoses as identities as if having depression or anxiety or ADHD or schizophrenia infuses every part of them and their lives instead of being just one aspect of it.

Traîtement moral showed that mental illnesses can be episodic and aren’t necessarily chronic, something many clinicians still don’t either know or simply don’t encourage. Healing depends on restoring hopefulness to patients, yet from the most stigmatizing to the least, diagnoses are believed to be forever. “Symptoms” like depression and irritability and distractibility and anxiety and obsessions and compulsions, which are part of the human condition, supposedly represent a catastrophic brokenness in the brain. The American Psychiatric Association (APA) frames major depressive disorder, anxiety disorders, ADHD, OCD, bipolar disorder, and other diagnoses as “common” and likens them to heart disease or diabetes, implying they’re inevitably chronic, which they aren’t.

How can we heal if clinicians don’t encourage us to do so?

It turns out that very little encouragement is needed to create conditions for healing—not just in mental health but in all areas of health.

A 2018 study conducted by Stanford psychology Professor Alia Crum and her colleagues showed that a few comforting words from a physician speed healing. In the study, participants who were told that their allergic reaction would start to diminish and their symptoms would go away experienced relief and less itchiness than those participants to whom the doctor didn’t speak. Reassurance from a clinician induces the placebo effect, in which a person’s mindset influences recovery outcomes. A lack of support can produce a “nocebo” effect, in which a negative outlook leads to deterioration.

All we need is a word: possible. It’s possible to heal and create the life that’s best for us. Just maybe that’s the truth.

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What would our mental health system be like if everyone knew that recovery from all psychiatric disorders is possible? What if we were taught the history of mental health recovery? What if they understood that in the 1980s, just when it seemed that the contemporary Recovery Movement would transform psychiatric practice forever, gearing treatment toward wellness, not a lifetime of illness, it both blossomed and met with near-movement-dissolving obstacles?

By that point, the Recovery Movement had its own national conference. It had gained more respect, leading to invitations to be involved in political events, psychiatric conferences, and lobbying efforts. It received more media attention, including two of the movement's leaders’ appearances on The Oprah Winfrey Show.

But it was also determined to remain outside the establishment. The movement wasn’t, as one of its leaders Chamberlin explained, anti-psychiatry. “Anti-psychiatry” is a theoretical debate waged by intellectuals. The movement believed in self-help, the premise that patients could determine their treatment and lives.

As the Recovery Movement gained momentum, different factions arose, each with its own goals and approaches. Ironically, the splintering within the Recovery Movement occurred because more people wanted to join in the fight for better treatment for people with mental illnesses.

Family members seeking secure services for their loved ones started their own movement. They eventually founded what would become the National Alliance for Mental Illness (NAMI), one of the most powerful mental health advocacy groups in the country.

Families didn’t fall in line with the goals and outlook of the Psychiatric Survivors Movement. While families questioned aspects of the mental health system but pleaded for more—or in some cases, any—resources, psychiatric survivors doubted that hospitals were beneficial at all, even in a crisis.

Like Pinel and Pussin, they knew that the longer patients remained in inpatient care, the more likely it was they would become “chronic” cases.

Psychiatric survivors did want to work with the government and other bureaucratic entities and believed psychiatry could be reformed. Patients, who they referred to as consumers to destabilize the power dynamic, needed transition programs that would assist them in moving from inpatient care to living and working in the community again.

Terminology was also a sticking point. Families adopted the term consumer when referring to patients. Survivors and ex-inmates like Chamberlin rejected the label. Although families said that consumer suggests having influence over the mental health system and inverts the typical power imbalance, Chamberlin reminded them that she’s a consumer when shopping for a refrigerator, not when being involuntarily committed.

Members of the Psychiatric Survivors Movement, particularly those who’d experienced horrific abuse while hospitalized and had since fully recovered, didn’t believe those without experience of mental illness could or should set goals and assume leadership roles. According to a 1990 article by Chamberlin, published in the Journal of Mind and Behavior, groups that let in mental health professionals and non-patients pivoted away from the movement’s militant liberation stance and adopted a reform-from-within approach, which went against their goals.

Politically and economically, the 1980s promised to deepen the mental health crisis. The strides made under the Carter administration during the 1970s didn’t last. The administration’s Mental Health Systems Act hadn’t answered all the issues like lack of access to services, neglect of those from marginalized groups, the shortage of clinicians, and the burden on families, but it attempted to establish the community mental health centers the country so desperately needed.

President Reagan had only been in office only seven months before repealing most of it. Although the Patients’ Bill of Rights remained, it remanded funding of mental health services to individual states. That meant the country didn’t have a unified national mental health system. We still don’t have one.

Reagan also “cleaned up” the disability benefits (SSDI) program to get rid of the “freeloaders,” making it difficult for those with mental illnesses to stay on disability. It isn’t possible to conjure up mania or depression to prove to a disability claims reviewer that you’re disabled enough to warrant assistance.

Reagan’s attitude toward people with mental illnesses receiving disability services added to a growing list of stigmas. Those in the Recovery Movement used the terms mentalism and sane chauvinism to describe the public’s negative assumptions: that we’re incompetent, violent, irrational, hopeless, and, now, trying to game the system.

Despite Reagan’s evisceration of mental health funding and support, recovery and the idea that those with lived experience of mental illness had much to contribute to the mental health system started to gain traction, the Recovery Movement experienced an important but not well-publicized windfall in 1987.

The same year I was admitted to my first intensive outpatient program and my psychologist told my mother and me that I’d never recover and would likely die as a result of complications from anorexia, Courtenay Harding published the landmark Vermont longitudinal study of people with schizophrenia.

Harding was a registered nurse studying research psychology at the University of Vermont. She was tasked with following up with patients who’d been diagnosed with schizophrenia in the 1950s. A long-term psychiatric study of its kind had never been done. Schizophrenia was thought of as chronic or deteriorating at best and hopeless and incapacitating at worst. But Harding found that one-half to two-thirds had “achieved considerable improvement or recovered.”

If that was true of schizophrenia, what of other supposed chronic, hopeless disorders? Harding would later point out the grave effect of calling any mental illness deteriorating or chronic or lifelong. She writes: “These perceptions about schizophrenia have pervaded and guided clinical judgments, treatment programming, policy formulation, and decisions about priority for funding.”

We don’t recover without being given the means to do so, yet some of us, as Harding showed, somehow manage it anyway. There’s no reason it has to be this way nearly half a century later. As Harding wrote, “These perceptions have also stripped hopes of recovery from patients and their families.”

We need to start teaching young people about the recovery movement—from Pinel and Pussin to Chamberlin and beyond—showing them that along with the multiple diagnoses they may receive, recovery is possible.

Thank you for reading! You can buy my journalistic memoir Pathological: The True Story of Six Misdiagnoses (HarperCollins), a USA Today bestseller that traces how we’ve come to believe that ordinary emotions are mental disorders. If you’ve already read it, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.

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My idea about what it meant to recover from serious mental illness got tangled up with the American obsession with being very, very social.

Having friends can be wholesome and fortifying, but not when it’s seen as evidence that we’re worthy. The misconception is that if we have lots and lots of people around, then we’re okay. This line of thinking leads us to regularly attend brunch when we don’t want to, tally the number of people who wish us a happy birthday, take likes and shares on social media seriously, and believe we should have fifty friends instead of the more reasonable (and more common) two or three.

The term introvert is thrown around too easily and defined in different ways, but in the sense that some people are fueled by being alone and enjoying their own company, I suppose it applies to me.

I’ve always been a solitary, albeit a sociable one. I don’t hunger to be around others. Small talk with my neighbors, being with my family, and cat videos on Instagram meet a surprising amount of my need for connection.

Some of us are hardwired for solitude. Researchers theorize that our brains have a social circuitry that strives for homeostasis. When it’s depleted, some people need a lot of interaction to get even a faint dopamine hit; others need little interaction to get the same bump.

Much is made about how important social connection is to our mental well-being, and social support is considered fundamental to mental health recovery. One’s social support network includes someone to do things with, someone who can give emotional support, someone who can validate you and what you might be going through, someone who can do you a favor like driving you to a medical appointment, and someone who has the knowledge to guide you through a problem or help you reach a goal.

But the data is fuzzy when it comes to how much being social helps one heal from mental illness.

Ultimately, in any study on social connection and mental health, there’s no way to tell if socializing spurs recovery or if those who’ve recovered have more social interactions.

Still, I decided that people—“well” people—are social. They go to brunch and parties and don’t feel at all miserable.

I started by going with my family to the theater. To my mother, who’d been my caregiver, almost any musical theater production is a must-see. She raised us on musicals, taking us to see them and playing recordings of Oklahoma! and My Fair Lady and Cats. I knew all the words to “When I Take You Out in My Surry” before I could say the Pledge of Allegiance. My mother saw her share of heady, intellectual theater too, but she preferred “a little song and a little dance,” as she put it, and a happy ending.

But halfway through A Chorus Line, the small theater felt like it was swallowing me. Something is wrong. I have to get out of here. I’m breaking. During the finale, my heart pounded practically in time with each leg lift in the kick line.

I forced myself to go again. At a local production of “Jesus Christ Superstar,” I sat alongside my nephew, niece, sister, brother-in-law, and mother and watched the show. Onstage, the lead actor was in a makeshift jail. He wore only a loincloth and sang of his woes. His voice was redolent, steady, Broadway quality. The rest of the production was less Broadway and more community theater.

I was there but also detached—what psychiatry calls derealization and depersonalization. My thoughts raced about how long the play would last, how long it would take us to get home, etc., etc.

The lead actor with the Broadway voice sang a refrain from an earlier song. The curtain call went on and on. My hands hurt from clapping. I managed to get through standing ovation after standing ovation without breaking down.

While trying to recover, I saw so many plays and musicals. During each one, I had a panic attack or felt like I was disappearing or that the people around me weren’t real.

But it started to happen less and less.

But I never became social—in the traditional sense. Never the well-adjusted woman with lots of friends, following them on social media, a “tribe” with whom to celebrate “Galentine’s Day.”

I’ve been recovered for five years, and I’m nothing like the well-adjusted woman. In fact, my life looks surprisingly similar to how it did when I was sick. It’s quiet. I love to stay home with my cats. Years ago, in writing about the differences between solitude and isolation for Longreads, I described solitude as “a strength…a skill to be mastered.”

A psychiatrist might diagnose me with social anxiety disorder. The difference is that these are all choices I’ve made, ones that further my goals and give me the life I want.

*

Full recovery from mental illness took understanding how my brain works, learning to experience my thoughts, allowing my emotions, and directing my behaviors toward the pursuit of goals. Psychiatric diagnoses supposedly demarcate where our thoughts, emotions, and behaviors become pathological, meaning abnormal and/or a problem.

But what is a thought? Philosophers have a lot to say about thoughts and thinking, but it’s not practical. If we side with the physicalists and believe that the mind is a series of neurophysiological reactions produced by our brains, then thoughts are representations of the real world as discerned by various parts of the brain as communicated by our neurons. Thoughts represent that which we sense (a person’s finger on our upper lip), feel (humiliation), or plan (leave and not look back or stay and convince ourselves it’s fine, really).

For someone whose thoughts seem to be out of control—typically racing and running contrary to each other and to reality—the mind can be a terrible place. It’s ragged and harrowing. Relentless. Fragments of thoughts spin out, colliding into other thought fragments, making us feel cracked and splintering. Other times, thoughts can be unrelenting—fully-formed worries or obsessions—coming in succession again and again and again. Other times, a particularly strong thought—muscly, bullying—can take hold and not let go.

*

Along with our vague understanding of thoughts, theorists can’t agree on how emotions occur. Are emotions responses to a situation? Or do our thoughts create our emotions? Or does it all happen at once? Or does our physical state (hungry, tired, dehydrated, etc.—which emotion theorists call affect or mood) create emotions and determine how we respond to a situation?

On the most basic level, an emotion is a sensation or a series of vibrations in the body: a fluttering heart, sweaty hands, a stomachache, weak knees; a pulsing sensation in your head, a weight on your chest, the tightening of your shoulders and neck, a rush of warmth to your face. The American Psychological Association (APA) describes it as “a complex reaction pattern involving experiential, behavioral, and physiological elements.” Merriam-Webster defines it as “a conscious mental reaction…subjectively experienced as strong feeling…typically accompanied by physiological and behavioral changes in the body.”

Emotions aren’t discrete categories. The bodily sensations we attach to one emotion can apply to another. A churning stomach, shakiness, and a rapid heartbeat could indicate anger but also fear.

Emotions occur for different reasons and produce various effects. Some emotions are passive, others active. We’re consciously aware of some while others seem to pass through us without us being able to process them. Some manifest externally (a smile, crying); others are invisible to those around us. We can spend days, weeks, months, or years experiencing some (depression, anxiety), whereas others pass through us almost instantaneously.

A behavior is obviously something we do.

Except it’s not.

Psychology identifies itself as “the science of behavior,” even though psychologists can’t agree on a definition of behavior. Is it physical movement and verbal effect? Is it a mental experience? Is a behavior influenced by our childhoods, society, biology, or all three? Does it have to be observable or can it be internal?

The big question is if a behavior’s context changes the behavior itself. Does the reason behind the action matter? Is running simply the behavior of lifting one’s feet off the ground a certain degree at a certain pace with a certain momentum? Is a person running to catch a thief the same action as a thief running to escape capture?

What about the emotion fueling the behavior? What about the thoughts driving it?

I was completely unaware of one of the most basic precepts in psychological (and Buddhist) literature: the motivational triad. It says that our thoughts fuel our emotions, which then drive our behaviors. We live in a think-feel-act cycle.

Once I understood this cycle, I developed an awareness of it. No longer did my emotions seem outside my control; they arose because of whatever I was thinking. My behaviors were no longer a mystery to me.

It wasn’t until I understood why we, as humans, think the way we do, that I was able to really heal. Evolutionarily speaking, our brains are designed to keep us alive by avoiding pain, minimizing effort, and, perhaps, seeking pleasure. I viewed racing thoughts and emotions like anxiety and depression and the behaviors that resulted from them as problematic, which made them intense and scary. I’d been trying to control, delete, and fix my thoughts, emotions, and behaviors without understanding why they occurred.

*

My father and I started having lunch together every Sunday. It became the highlight of my week. Not something the well-adjusted woman does—her social outings are voluble or intimate or peppy or all about “connecting.”

We decided to read a book together that changed my life: Randolph Nesse’s Good Reasons for Bad Feelings. Nesse is an evolutionary psychiatrist at the University of Michigan who takes an evolutionary psychiatry view of why our thoughts can be so troubling and distressing.

We used to believe the brain reacted to the world, but the brain is actually a prediction machine. During our waking hours, it sits inside our skulls, in the dark, trying to keep us alive by regulating our physical bodies, evaluating external sensations and situations, and trying to predict what will happen next by drawing on past experiences. Each prediction causes the physical sensations we call emotions which trigger an action that would best serve our bodies.

It’s a thankless job that often results in errors.

This view is fundamental to evolutionary psychiatry and its precursor, evolutionary medicine. Regular medicine is about finding a problem and fixing it; evolutionary medicine is about being curious as to why the health condition might exist in evolutionary terms. Psychiatry seeks to treat what it views as mental disorders; evolutionary psychiatry asks why those “disorders” exist and how, in some cases, they might be evolutionarily beneficial.

Evolutionary psychiatry has its detractors, but it offers a different paradigm for how the brain works. We’re all just trying to survive. The brain is out to maximize the transmission of our genes by keeping us alive—that’s it. It’s not there to make us happy. It’s not there to give us a certain “quality of life.” It’s mercenary. It’s programmed to protect us and conserve energy. We’re designed to fight, flee, and freeze to escape predators and belong to a clan when it benefits us.

In this, our negative and self-defeating thoughts are useful. Thoughts along the lines of this will never work and everything is awful are the brain’s way of warning us of possible danger. That’s its job. No one liked my presentation is the result of the brain looking for what’s wrong. Negativity is our default mode. Unwarranted thoughts like I made a fool of myself at the party and she’s mad at me come from a fear of being expelled from the clan and (evolutionarily speaking) having less access to shelter, protection, and food.

Procrastination is our brain’s way of telling us to conserve energy. I don’t feel like it and I don’t want to are ways to get us on the couch watching TV. I’ll never do it is a call to relax. Slothfulness is human.

All this would be fine, except many people—particularly those who don’t suffer from poverty and are potential victims of violence—live comparatively free of mortal threat. Extreme emotions, responses, and thoughts are natural but no longer useful. We see lions even when we’re just answering emails.

According to Nesse, negative emotions and behaviors serve a purpose, too. Emotions like anxiety and depression and even psychotic thoughts and destructive behaviors like binge eating aren’t pathological; they date back to primitive humankind and, for some reason, haven’t been eliminated by natural selection.

• Anxiety (even edginess) helped primitive humans stay alert and run from lions on the veldt. A panic attack is the result of an all-or-nothing response system; we’re impalas reacting to a noise in the bush, preferring to overreact to a false alarm (a mouse scurrying along) rather than be eaten by a lion.

• Depression might be a reasonable—even evolutionarily beneficial—way of responding to stress. The emotion of depression (a slowing, a weight) could be the body’s response to extended periods of the emotion of anxiety (hypervigilance, rushes of adrenaline).

• Psychosis could be a defense mechanism, a mode of self-protection, or a way of escaping into an alternate reality when the current one becomes too much.

• Binge eating was what we did when we lived on the savannah. If we found a bush of berries, we ate them all because we didn’t know where our next meal would come from.

Evolutionary psychiatry had what I needed: a way to see distressing emotions as normal and not as signs of a mental disorder—or even a problem. It showed me that not wanting to have a million friends or be on social media is an evolutionarily sound choice.

We aren’t designed for this world. It’s unsettling and the noisier it gets, the more demanding it becomes in terms of what and who we’re supposed to be, the sicker we will be.

To support my work, purchase or gift a copy of my USA Today bestselling memoir—and the prequel to Cured—Pathological: The True Story of Six Misdiagnoses.

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When I originally wrote what’s below, my mother was alive.

It’s still hard to believe she’s not somewhere—her apartment, the living facility—and I just need to get from my desk and find her.

In dreams, she’s usually a minor character, a walk-on, and often I yell at her: “You’re supposed to be dead.” She seems not to hear. “What am I supposed to tell people?” She doesn’t answer.

No need to ask Jung what it means. She was the closest person to me, and the dividing line between now/life and then/death has to remain fixed for my grief-addled brain to manage.

They say you shouldn’t rely on one person to meet all your mental and emotional needs. I’m not sure who “they” are, but they’re probably right. It’s doubly true for people with mental illness—or at least it was for me.

I lived with her during the most acute episodes of serious mental illness. I relied on her to be my caretaker, friend, mother, physician, therapist, and medication consultant.

It was too much. My brokenness broke her—a bit. I moved out. I was as much of a mess as you might think. She said she needed time to heal and couldn’t talk to me.

That time may have been more painful than now. When someone disappears from your life but continues to live, it’s almost unbearable.

Maybe it’s just because I was sick that I remember it that way.

I wanted to change what I wrote in light of her death, but the thing about memoir is that it fixes time and experience, fixes in the sense of suspends it. Maybe it fixes, as in repairs, it, too.

My mother opens the front door to her apartment and steps back. We don’t hug—not out of anger. It’s as if we’re not sure how. I take off my coat and hang it in the closet.

Since I moved out of her apartment, where I lived for five years because I was unable to live on my own, sliding into and climbing out of psychiatric crises, she’s needed time to heal.

My bag bumps against my hip as I follow her into the living room. She sits on the blue couch, where we sat so many times, her rubbing my back, trying to calm me. I put my bag on the floor and sit on the white, stiff-backed chair. She’s dressed in slacks and a blazer, her black curly hair set, but her eyes still have that fragile, grey look about them.

This visit is my idea. I suggested I come over and work at the dining room table for the afternoon. The room where I once slept is back to being my mother’s study, but it wouldn’t feel right to be in there again so soon.

She says something about her book club, but I have trouble paying attention. The pit in my stomach expands. I want her to be better. I want everything to hurry up and be okay—me, her, all of this.

I pull my laptop out of my bag. “This is great—working here. Thank you.”

She stands. “I’ll leave you to it.”

I think about revealing to her that I’m recovering from mental illness (bipolar disorder, technically, but I’ve had so many diagnoses, who knows which was the right label to put on my mental and emotional dysfunction) and she doesn’t have to worry anymore. But I don’t know how to explain this or prove it. During the twenty-five years I was in the mental health system yet relying on her for support, no one presented recovery to us as an option. I had this diagnosis or that one and always would and that was that.

After fifteen minutes at the dining room table, trying to grade my students’ midterm essays, my mother walks to the closet and opens the door.

“Are you leaving?” I ask.

“Book club.”

Right. She must have thought I wanted to work here in the apartment, not here with her. I get up and go to the door.

She smiles weakly, shouldering her coat.

I’m heavy with guilt for the stress I caused her. She spent countless nights on suicide watch, which is too much to ask of anyone, countless hours in the emergency room, countless hours trying to help me through psychiatric crises.

When she’s gone, a crushing loneliness weighs on my chest. I think it’s loneliness. Or maybe grief. Or sadness.

Hurriedly, I pack my things, get my coat, count to two hundred to be sure she won’t see me, and lock the door behind me.

At home in my apartment, I fill my espresso maker and light the stove. A pessimist might say the visit was a disaster, confirmation that we’ll never be as close as we once were. An optimist would say it was a step in the right direction.

*

Improving how and where people in psychiatric crises receive care and supporting families and caregivers is one of the tenets of the contemporary Recovery Movement. It’s due in part to what some consider the worst policy change in the history of mental health care in the United States: deinstitutionalization.

By the 1960s, the U.S. government had finally admitted that most psychiatric institutions offered inhumane treatment. The buildings, many a century old, were dilapidated and falling apart. Patients were abused and neglected, left sitting in feces, subjected to ice baths, given lobotomies, forcibly sterilized, put in straitjackets, and overmedicated. Patients had been hospitalized either voluntarily, which meant a total loss of individual rights, or involuntarily, which meant a total loss of individual rights. Some patients went to what they thought were hospitals in the help-you-recover sense of the word and instead of getting help, found themselves in locked wards; put in isolation, sometimes for years; and without any rights or recourse for release.

President John F. Kennedy and others theorized that the way to fix our dismal mental health care system was to close the institutions and establish community centers where people could receive care. Deinstitutionalization would “free” patients. Community centers and new psychotropic medications would fill the role institutions were supposed to have played. Psychiatric facilities were closed; the number of Americans receiving treatment in mental hospitals dropped by 70 percent.

But the promised community mental health centers were never built. Psychotropic drugs couldn’t be the sole source of treatment for any patient. Patients were sent “home” though few had one. In the decades that followed, mental health funding was slashed.

Today, many people with serious mental illness don’t receive any care. They’re forced to live on the streets or in jails. Cook County Jail is one of the three largest mental health facilities in the country, along with the Los Angeles County Jail and Riker’s Island.

Of those with serious mental illness, the fortunate ones—like me—are expected to recover alone or at home, often with the support of family members who have no support themselves.

*

My mother and I start talking on the phone every morning at 9 am. Our connection is tightening—not back to where it was, but we’re getting there. We keep it light and talk about current events, which means right before the call, I read the headlines of the Washington Post on my phone to stay up to date.

I love getting to hear her voice. Every day, she seems better—a bit—and I’m grateful for that.

Our calls are positivity boot camp. She’s asked me not to be so negative, and I’ve been practicing. Not complaining or mindlessly ruminating on what’s wrong is a herculean effort. It’s absurdly difficult, and I’m not even in the throes of a psychiatric crisis.

It’s not like I’m “well.” Anxiety still thrums through my chest and seems to take me over. And there are still times I can’t eat because the pit in my stomach is so sodden and heavy.

But there are signs of healing. My thoughts don’t race anymore. Panic attacks come. Waves of black depression arrive, but they aren’t quite as terrifying.

We visit the Art Institute—one of my mother’s favorite places. Other visitors mull around. Aside from the murmuring voices and scuffling shoes, the marble hall is relatively quiet. A bored security guard stands against the wall, ensuring no one gets too close to the art.

The people around us seem the picture of effortlessness: an older man with someone who might be his son, a young couple arm and arm. They’re fine here—not anxious or upset—in this marble room amidst other humans looking at shapes and colors. I want that. I want that for my mother and me.

We ask so much of our caregivers and forget that when we’re not in crisis, they need time to heal, too.

She and I stand in front of the famous rainy-day pointillism painting I can never remember the name of. It captures a Paris street scene in the nineteenth century. People walk under black umbrellas. The road is cobblestone. In the background are a horse and buggy.

She stares at it appreciatively. I try to see what she must be seeing: the pedestrians, the black umbrellas—people going about their days, protected from the rain.

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Dr. R and I sit in our respective armchairs. Out the window, the clouds hang low. His pants have less of a sheen than usual.

He was the only clinician who was honest with me about my psychiatric diagnosis. My other clinicians leveled the six diagnoses I received (over twenty-five years) with such certainty, telling me or leading me to believe they were biological, caused by a chemical imbalance, and unquestionably lifelong—none of which are true. Dr. R admitted he didn’t know what was wrong with me or which diagnosis to use. Any diagnosis would do as long as it got me the best treatment.

Dr. R is also the one who told me about a patient of his who recovered from schizoaffective disorder. He’s made me want to try to get well, even though I don’t really believe mental health recovery is possible, not for a “hopeless” case like me.

The other problem is that I don’t know what I’m recovering from. He hasn’t revealed the label/diagnosis he’s chosen to categorize the mental illness he doesn’t know I’m trying to recover from, and I don’t want to know.

Over the years, I made each diagnosis my identity. Each was a self-fulfilling prophecy. I identified so strongly with it that I came to embody it. With the depression diagnosis, I saw myself as a depressed person. The anxiety diagnosis made me more anxious. With the ADHD diagnosis came the belief that I was simply someone who was easily distracted and had trouble paying attention. The OCD diagnosis made me pay greater attention to my obsessions and compulsions. As someone with bipolar disorder, I saw even the slightest surge of energy or period of low mood as evidence of my illness. It seems that if I want to heal, it’s best not to do that again.

But I can’t recover from an unnamed illness, so I ask about my diagnosis. I sit up straighter in my armchair, crossing my legs at the ankles.

He says, “I thought it was bipolar disorder, but now I’m thinking—”

I start to lift my hand as if to stop him and tell him I don’t want to know. My eyes tear up. The office feels stuffy. Dr. R’s desk seems cluttered, insofar as his desk could ever be cluttered.

Dr. R jerks his head back in what looks like surprise. “Most people really want to know—”

Just so long as I get treatment, I say. Otherwise, I don’t.

Out the window, the clouds look greyer but also less threatening. I’ve spent so many years seeing myself as this or that diagnosis. If I continue, I’ll never recover.

“It can be helpful,” he says. “Navigating.”

I shake my head.

There’s nothing wrong with psychiatric diagnoses—even if they are little more than constructs, as Former Director of the National Institute of Mental Health (NIMH) Thomas Insel put it—if you use them for, not against yourself. For many people, they’re a relief, an answer, a way to cope.

For some, it’s much more than that. The autism community rallied around that diagnosis and started the neurodiversity movement, which said there’s nothing wrong with them; it’s the neurotypical population that needs to change and appreciate the ways they see and interact with the world.

But many of us see diagnoses as solid, objective realities that are as provable and permanent as physical illnesses that can be shown to exist on an X-ray or brain scan. They can’t.

They come not from laboratories and conclusive research studies but from a book: The Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM started in 1952 with the first edition: the DSM-I. (Each edition is marked by a Roman numeral—DSM-I, DSM-II, etc.—or an Arabic number—DSM-5, DSM-5-TR.) Over the various editions, more and more diagnoses, spectrums, and subtypes were added. Whereas we started with 128 hypothesized disorders in the first edition, we had 541 by the fifth edition. (There’s no agreement on the exact number of diagnoses. Some say over three hundred, others over two hundred. It depends on whether you count subtypes and catch-all categories.)

If you were to open the pages of the current DSM, you’d see a diagnosis listed at the top of the page and, under it, a list of symptoms. If a person has x number of symptoms, that person qualifies for the diagnosis.

For instance, if a person has five of nine symptoms listed under the diagnosis of depression (e.g., sadness, loss of interest, weight loss or weight gain, sleeping more than usual or having insomnia, an inability to concentrate), that person can be presumed to have depression. Alongside the diagnosis would be a diagnostic code (e.g., 296.20-296.36 for depression), which is used for myriad purposes: for reimbursement from insurance companies, to receive disability and educational services, and to settle questions of a person’s competence and/or sanity in a court of law.

In the current edition, personality, lifestyle, and context aren’t taken into account. Someone who’s typically high energy and volatile can still be given a diagnosis of bipolar disorder II.

And if someone experiences distress and even grief after, say, having lost one’s job, it isn’t necessarily considered a reasonable response to the situation; the person can be diagnosed with major depressive disorder. The DSM offers no advice in terms of treatment.

Major depressive disorder requires five of nine symptoms:

1. depressed mood

2. loss of interest/pleasure

3. weight loss or weight gain

4. insomnia or hypersomnia

5. restlessness or lethargy

6. fatigue

7. feeling worthless or excessive/inappropriate guilt

8. decreased concentration

9. thoughts of death or suicide

When asked why a patient needs five of nine symptoms, Robert Spitzer, the bio-psychiatrist and architect of the DSM, said, “It was just consensus. We would ask clinicians and researchers, ‘How many symptoms do you think patients ought to have before you would give them a diagnosis of depression?’ And we came up with the arbitrary number of five…Because four just seemed like not enough. And six seemed like too much.”

That’s the same criteria we use to diagnose major depressive disorder today.

Within each DSM disorder are myriad combinations of symptoms, which means there is no one major depressive disorder or social anxiety disorder or bipolar disorder or ADHD. There are over a thousand combinations of symptoms for major depressive disorder, meaning getting the diagnosis doesn’t actually indicate a particular set of thoughts, feelings, and behaviors.

Diagnoses have been created and the criteria loosened over time so that as many people as possible can receive them. The patient needs only to have experienced five symptoms for just two weeks. The DSM requirement used to be two months until the DSM steering committees and task forces whimsically decided more people needed the diagnosis and shortened it to two weeks.

Psychiatric diagnoses are useful because we use them to get people care, but none is scientifically valid, meaning no test or scan can confirm or show it objectively exists; a diagnosis is based entirely on self-reported symptoms and a clinician’s opinion. (Exceptions include dementia and rare chromosomal disorders—though many clinicians and researchers don’t consider these psychiatric disorders at all.) DSM diagnoses are also largely unreliable, meaning that clinicians can’t agree on the same diagnosis for the same patient even if they see that patient at the same time.

True, physical medicine has some diagnoses that can’t be definitively shown on a test or X-ray—migraines, auto-immune diseases. The problem is that mental health clinicians and GPs don’t always make their patients aware that the diagnoses they’re given are abstractions intended to be used for clinicians to communicate with each other. We’re given diagnoses—often by GPs wearing white coats with stethoscopes around their necks—and are led to believe those diagnoses are conclusive and lifelong.

I understand why we wouldn’t want to expose DSM diagnoses for what they are. They hold sway over hundreds of millions of lives: 46 percent of American adults and 20 percent of American children and adolescents will receive one of its diagnoses in their lifetimes. They’re part of the public imagination, the filter through which we view our mental and emotional lives. Emotions like depression and anxiety are used interchangeably with the diagnoses of anxiety and depression. Our ideas and beliefs about mental disorders—“clinical” depression, anxiety disorders, schizophrenia, etc.—shape how we view ourselves and each other. For some patients and their loved ones, diagnoses offer a kind of certainty, and certainty feels good.

And we want people to get help and/or treatment if they need it. But as the sociologist and historian of psychiatry, Allan Horwitz will later tell me, before the 1970s, most patients didn’t know their diagnoses; they just got help. And many of them—many of them—healed.

Onscreen is the Drop the Diagnosis! conference via Zoom. It’s run by a British organization I’ve never heard of that vows to challenge the culture of psychiatric diagnosis. Two men and two women sit on a stage. I take notes but can barely keep up.

One of the men says, “Treating in terms of diagnoses isn’t working. Rates of mental illness are increasing, as are suicide rates in some cases. We need an alternate system.”

They talk about transdiagnostic approaches to mental health problems. The transdiagnostic approach conceptualizes mental dysfunction along a continuum and targets the processes common to the diagnoses we now use: perception, thought, language, attention, learning, memory, emotion, and sensation. Instead of labeling a patient with major depressive disorder or generalized anxiety disorder or PTSD or anorexia, the focus is on the underlying process present in all these disorders. It acknowledges and embraces the myriad causes that contribute to mental and emotional distress and stresses their complexity and the unique ways they manifest in each person.

Onscreen, the moderator asks a question I miss because I’m too busy taking notes. One of the panelists answers, “Iatrogenic harm.”

I google it, butchering the spelling (itragenic?), but Google Scholar suggests the right word. Iatrogenic harm refers to the damage caused inadvertently in the process of treatment, whether by the careless use of diagnostic labels, misdiagnosis, overdiagnosis, over-medication, withdrawal from medications, abuse, etc. Iatrogenic illness typically refers to the adverse effects caused by physical medical treatments, but it can be applied to the side effects of psychiatric treatment, too.

It will be years before I read the academic psychologist Lucy Foulkes’ excellent book Losing Our Minds: The Challenge of Defining Mental Illness, in which she encapsulates what we actually know about mental illness and distress. She writes that the causes include “a bundle of hundreds of layers of explanation—some biological and some environmental—and those layers all interact with each other.”

The biological layers include our brains and DNA, but that’s a tiny part of it. Primarily, mental illness is the result of myriad factors: our personalities and psychologies, our past experiences, the societies we grew up in, our friends and family. She goes on: “[Y]ou may be better off just accepting that it all played a role: the factors that led to your disorder are as many and varied as we are.” But if a simplistic medical model dictates treatment, we’re lost.

Most importantly, Foulkes writes how mental illness builds based on compound interest—but not the good kind. The longer one suffers from it, the worse it gets. It’s “a suite of interrelated, mutually enhancing symptoms and difficulties that, once established, might even be said to cause itself.”

A woman on the panel recommends that all patients work with their clinicians to establish an exit strategy—a term I’ve never heard—once they’ve received a diagnosis and been prescribed medication. An exit strategy is a plan for when the patient is better, including how to titrate off medication.

When the patient is better? How they’ll titrate off medication?

Ultimately, my recovery will occur in large part because I give myself an exit strategy, which includes “dropping” my psychiatric diagnosis. Learning the flaws in our diagnostic system is forcing me to heal. The truth about psychiatric diagnoses is unsettling. It means there’s no easy answer, but it also means there’s hope.

Years from now, I’ll discover that in the recovery community (yes, there’s a whole community of people who’ve healed from schizophrenia and bipolar disorder and every other psychiatric condition), diagnoses aren’t even discussed. They’re in the past; recovery is the future.

The definition of recovery that will most resonate with me comes from the Depression and Bipolar Support Alliance (DBSA): “Recovery is the process of gaining control over one’s life—and the direction one wants that life to go—on the other side of a psychiatric diagnosis and all the losses usually associated with that diagnosis.” Because losses come with a diagnosis and being denied the right to heal. No matter how a person receives a diagnosis—whether it’s a misdiagnosis or an overdiagnosis or it comes as a shock a limitation or even a relief—to heal, one has to get to “the other side of psychiatric diagnosis.”

After the conference ends, I walk through the park. Along the path, ten teenagers—most lanky and lean—run past me in a line. Three wear sweatshirts with the name of the high school I attended emblazoned on them. The park sits between my apartment building and my old high school—the school where my mental illness began.

The students run the path ahead of me and loop around. The one in the lead wears a long-sleeved, bright yellow t-shirt without my high school’s logo and name. He runs loose and relaxed, his legs kicking up behind him.

The runners loop around and pass me again. The one in yellow is way ahead of the pack.

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What is mental health? I asked myself this question many times during my recovery from serious mental illness. For twenty-five years, doctors had medicalized my mental and emotional pain. Those diagnoses said I was sick, but how would I know when I was well? We don’t talk about mental health recovery. Psychiatry doesn’t have a manual for it. The media doesn’t run segments about it. Journalists rarely write about it.

Like many people, I was trying to recover on my own. At first, I assumed it meant going off medication and leaving therapy. It turns out recovery requires neither.

Then I made another mistake. I confused mental health with meeting societal expectations—specifically, the pressure to be in a romantic relationship, a.k.a. amatonormativity. Heterosexual single women are often perceived as being somehow defective and probably mentally unstable if they aren’t in one. In the dating world, the worst thing a woman can be is “psycho.” The potentially “crazy girlfriend” must be dumped and returned to singledom where she belongs.

It wouldn’t be till much later that I’d learn that recovery looks different for each person, and being “normal” or socially acceptable isn’t part of it.

*

The plan is to spend the weekend at Matt’s farm.

It seems like a good idea. Matt and I have been dating for a few weeks and I’ve known him for years. He’s driven all the way to Chicago to pick me up because I don’t drive.

It’s one of the coldest Januarys on record. Once we’re off the highway, Matt’s truck skids on the ice. Driving painfully slowly through this tiny town in Michigan (“town” is an overstatement; it’s more of a depot), we pass a seemingly vacant church, a closed feed store, and the Freedom Bar & Grill.

We pull into the driveway, and I realize I’m trapped. There’s no way out of here without a car.

His house is one story and has the feel of a storage unit. The kitchen and living room are one open space. Then there’s a bedroom, Matt’s study, and a bathroom.

There’s no heat. Well, there’s heat but only from the wood stove in Matt’s living room. He likes to keep his house cool, he says, to save money. And he likes the wood stove, likes the challenge of heating the entire house with it.

I put on my down coat.

He watches a football game on TV. I’ve never owned a TV. The sound of the commercials is like nails on a chalkboard to me.

I try to write. I’m working on a novel—a thriller—that’s not particularly thrilling. I get nowhere, so I read workshop submissions from the Introduction to Creative Writing class I’m teaching.

How will I make it through the night and then a day and then another night? Why am I there? I’m sick. I’m a sick person.

Or maybe this just genuinely sucks.

*

We make dinner. He chops peppers. Whack! Whack! Whack! We eat.

Afterward, we sit on the couch. Twenty, maybe fifty flies come from somewhere and buzz around the light.

Matt gets a fly swatter, stands on the couch, and starts at them: swat, swat, swat.

“This happens at night,” he says. Swat! Swat!

“In the winter?” I ask.

He shrugs.

Then it’s as if the night is inside me. My depression isn’t like other people’s—or at least not the way I hear people talk about it or the way it’s portrayed on TV. It doesn’t cause me to stay in bed all day. It’s jagged and sharp. Black, yes, and heavy but charged with irritability and unsettledness.

Pressure builds in my chest. I’m there, but I’m not there. I’m going to die out here. There’s a rushing energy behind my ribcage.

*

Part of the problem is that I never considered what recovered/mentally healthy means to me. I should have thought about the terms mental health, mental wellness, and mental well-being, so I understood what I was aiming for.

The WHO states that mental health is “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”

Realize our potential, cope with stress, be productive, and be good citizens? Really? That seems like a very high bar to set.

Other definitions aren’t as stringent. Mental health can refer to our overall mental, emotional, social, and behavioral well-being.

Merriam-Webster’s definition is often seen as problematic: “the condition of being sound mentally and emotionally that is characterized by the absence of mental illness.” The WHO and others have taken pains to refute this description, stating that mental health isn’t just the absence of a mental disorder or a disability. I can be bipolar and have good mental health, i.e., manage my illness.

Then there’s mental wellness, which is basically mental health meets capitalism. Mental wellness is an industry with an economy that brings in $121 billion each year. It associates our mental stability with our ability to create value and revenue for a company. Its week-long mental health breaks are meant to combat burnout, which, in turn, increases profits. The term appears on job postings and corporate websites to signal on-the-job perks and “health-focused workplace environments.” It indicates medical benefits, time off, and life insurance. It can mean luxury: corporate massages, in-office meditation breaks, and catered gourmet meals. It’s epitomized by Googleplex, a corporate campus flush with tennis and volleyball courts, organic gardens, and “nap pods.”

Mental well-being has complex layers of meaning and a long history. Although it can be traced back to ancient Greece, it didn’t fully emerge until the post-WWII era. The 1940s saw the ratification of the National Mental Health Act and the creation of the National Institute of Mental Health (NIMH). Mental well-being—particularly hedonic well-being, i.e., how we find meaning, has been a subject of research by psychologists and sociologists ever since. Simply put, well-being is quality of life. It can be divided into two subtypes: objective well-being (how we’re judged by others) and subjective well-being (how we judge ourselves).

*

The flies continue to buzz as Matt turns out the lights. We go to bed. I manage to sleep but wake impossibly early. It’s still dark. Something isn’t right—not in my mind but in my body.

Pain lingers in my lower abdomen. Any woman who’s had a urinary tract infection will tell you the feeling is unmistakable.

I wake Matt and tell him I need to go home.

He gets out of bed—naked—and hugs me. I feel him—his warmth. Has he been this welcoming the whole time?

He’s not a “shitty guy,” just someone with preferences and a singular way of interacting with the world. There’s a woman out there who likes rural environments and doesn’t mind flies.

*

The two-hour drive back to Chicago is excruciating. A look of concern occupies Matt’s face. He drops me off. I go to Immediate Care and get antibiotics.

They make everything better. A simple remedy.

A week later, I walk my usual route through the park. Same path every day: from my apartment past the Benjamin Franklin monument, around the pond, along the lagoon to a tree I ritualistically loop, and then back again.

The zoo sits just west of me. It’s free, but I never go through it. Not on my usual route. No deviating from the path.

Recovery is different for each person. It doesn’t have uniform requirements. William Anthony, who founded Boston University’s Center for Psychiatric Rehabilitation, put it this way: “Recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”

I grew up blocks from here. Each morning, my babysitter, a Polish woman named Sophie, who was firm but kind, took me to the zoo. She’d sit on a bench and talk to the mothers and other babysitters while the other children and I watched the seals bob and glide in the water and galumph along the rocks.

Even to me, a child, the zoo was both exciting and not quite right. The animals’ cages were obviously too small; their “habitats” were dilapidated, made of tile and rope instead of dirt and trees. It’s a little better now—slightly larger areas for the animals, more natural-habitat-like.

On the left is a pond and beyond it, the flamingo atrium. On the right is the reptile house.

I stop outside the Lion House. In one of the outdoor cages is a tree that reaches almost to the very top. It takes a moment for me to spot the snow leopard. He’s stunning and regal. His plush fur is white and beige, dotted with black circles. His huge paws hang over the edge.

His expression should be pained, but it’s strangely serene.

According to the information plaque, his name is Taza. It also says snow leopards are solitary creatures who only come together to breed. Otherwise, they live happily on their own. They can’t roar, but they’re one of the few big cats that purr.

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Sunlight breaks through the clouds and comes in Dr. R’s office window. On the street below, rain soaks the pavement. The two together seem wrong: sun, rain.

I face him and take in his encouraging smile. His white shirt is perfectly crisp. I try to smile too, then glance back at the sunlight and the wet pavement. Without looking at him, I say, “I don’t want to change my meds—ever,” hearing the tremor in my voice. I’m still wrecked—shaky, cold-sweaty, brain-zapping—from having tried to go off my medications.

This is my second mistake in moving toward recovery from mental illness. Before that, I’d linked recovery to “normalcy” believing I shouldn’t be in therapy. It seemed obvious: “normal” people don’t need therapy or take psychotropic drugs; recovered people shouldn’t either.

If I’d had the guidance of Dr. R or someone who’d recovered, they’d have told me how wrong I was. Some people have been on medication for so long that their bodies are dependent. Withdrawal had already brought me to the brink of ending my life twice; this time, it brought me close enough to vow never to try to go off my meds again.

Changing my medications—going off one to try another, upping the dosage of this one, lowering the milligrams of that one—has only complicated my mental health struggles. When new drugs and dosages are changed and changed again, it’s impossible to know what helps and what harms, how much is the drugs and how much is the result of mental illness. I now have a baseline where the side effects are minimal. Having the drugs in my system is my normal. And it doesn’t mean I’m sick.

Dr. R nods. “Okay. Any reason you don’t want to ever change your meds, ever again?” He says this slowly.

I tell him my baseline theory. Whatever painful emotions, troubling thoughts, and unwanted behaviors come, I won’t answer them with medication changes.

Dr. R nods, Got it. Not a problem. “Ultimately, it’s your treatment.”

I look out the window onto Michigan Avenue at the cars streaming through the stoplight. It’s hard to make that decision and have him agree. Until then, I did as my doctors told me to do. Should I really be the one to determine what’s best for me?

*

Had I known about the principle of shared-decision making in psychiatric treatment, I may not have hesitated. For two decades, studies have shown that treatment tailored to patient preferences is associated with

• greater engagement in treatment,

• an improved therapeutic relationship,

• increased patient satisfaction, and

• improved outcomes of care.

That doesn’t mean a clinician isn’t involved, just that treatment is aimed at recovery, not maintenance as it is now, i.e., we’re given the chance to do more than just “manage” our symptoms. And treatment isn’t determined by the clinician and accepted by the patient. The clinician may make suggestions, but the patient is in charge.

I know how that may sound. I can imagine how it would have sounded to my mother during my worst times. How could I—chronically suicidal and unable to live independently—really determine my own treatment?

Maybe I couldn’t have been in charge while in crisis. Someone in a psychotic or manic or suicidal or depressive episode may not have the inner resources to do that.

Self-determined treatment takes that into account. It involves deciding what we want when we’re in remission, i.e., stable, or even before we ever walk into a mental health professional’s or GP’s office. A mental health advance directive.

It might come in the form of the shared decision-making card developed by Maria O’Connell and Janis Tondora, both professors of psychiatry and researchers in the Program for Recovery and Community Help at Yale School of Medicine.

On the shared-decision making card, patients mark the three most important things they want from their clinician and treatment, e.g., obtain medication that works for me, ask who I want to be involved in my care, respect my time, be informed of all options for treatment, receive an accurate diagnosis, not be rushed.

O’Connell and Tondora stress how important this could be for someone in crisis. And think how it could serve young people—or any of us—in preparation for when we have to articulate our mental health needs.

A card like this—or a document—can only help our clinicians. We ask so much of them. They can’t be everything and all to us. They can’t know what we need if we don’t tell them. To get the best treatment, we have to create our own care.

*

Shared-decision making likely wouldn’t exist as a principle if not for the Recovery Movement. Unfortunately, the day I sat in Dr. R’s office, I’d never heard of the movement. During my twenty-five years in the mental health system, no one mentioned it. I was in and out of hospitalization programs, in and out of psychiatrists’ and therapists’ and GPs’ offices, and it never came up. I’d learned about Sigmund Freud and cognitive behavioral therapy and second-generation anti-psychotics and a lot of misinformation about the supposed chemical imbalance theory of mental illness (which would turn out to be and always have been totally false) but nothing about the legions of people and groups in the Recovery Movement who have been trying to tell us that we can, in fact, recover from mental illness, even serious mental illness, and psychiatric disorders if we receive the right treatment.

The right treatment depends on self-directed care. Since the 1970s, the Recovery Movement has focused on patients’ rights. By then, the government policy to close psychiatric institutions and replace them with community mental health centers had failed. Only a third of the promised mental health clinics had been built, inpatient beds were scant, and funds meant for community services ended up mired in bureaucracy or wasted on maintaining the remaining dilapidated institutions.

During this period, a group of strong-willed ex-patients set out to abolish the mental health system, liberate patients who’d been abused and mistreated in psychiatric institutions, and create a new system of care. The movement’s core members took their cues from the civil rights movement, including Black Power and gay pride, coining the term insane pride. Various groups organized the movement, including the Insane Liberation Front based in Portland, Oregon (1970); the Mental Patient’s Liberation Front in Boston (1971); the Mental Patient Liberation Project in New York City (1971); and the Network Against Psychiatric Assault in San Francisco (1972).

The movement went by various names: the Mental Patient Liberation Movement, the Psychiatric Survivor’s Movement, and the Ex-Patients Movement. In most cases, non-patients weren’t allowed. Often, membership was limited to patients who’d been hospitalized; those who’d received outpatient care didn’t qualify. Mental health professionals were occasionally granted a tangential connection to some groups.

At first, they sought to overturn psychiatry, not improve the current system. To them, psychiatry was a capitalist industrial complex. Reform wasn’t possible, only abolition. The slogan “Nothing about us without us” sent the message that mainstream psychiatry’s days were numbered.

The movement’s leaders focused on fighting for the rights of “psychiatric prisoners” based on their own experiences. Howie Geld—a.k.a., Howie the Harp, a nickname given in honor of his love for the harmonica, which he learned to play while institutionalized after a suicide attempt as a teenager—ran the Mental Patients’ Liberation Party and eventually founded the Community Access mental health center in New York City. Leonard Roy Frank, a one-time graduate of the Wharton School of Business who was hospitalized for paranoid schizophrenia and subjected to thirty-five rounds of ECT treatments and thirty-five psychosurgeries, was one of the primary writers on the staff of Madness Network News, the movement’s media outlet, which published the views of ex-inmates and psychiatric survivors. Other pivotal activists included Sally Zinman, Dan and Su Budd, Tom Wittick, Dorothy Weiner, Tanya Temkin, and Rae Unzicker.

Judi Chamberlin, a self-described “crusader,” was the movement’s most visible spokesperson. When she was in her twenties, she sought treatment for postpartum depression. After her first office visit, a psychiatrist quickly prescribed her two potent antipsychotics: Thorazine and Stelazine. She didn’t improve. The psychiatrist said she should be hospitalized. Over six months in 1966, she went in and out of six New York hospitals. She went into treatment a housewife suffering from depression and came out a patient diagnosed with “chronic schizophrenia with homicidal and suicidal tendencies.”

With the help of a psychologist and finding purpose in the Women’s Liberation Movement, she recovered and joined the cause for patients’ rights.

Her 1978 book On Our Own: Patient-Controlled Alternatives to the Mental Health System called for a system in which people with mental illnesses weren’t “passive recipients of institutional ‘care’” and instead were encouraged “to see the strong and positive aspects of themselves as they, in turn, help others.” As Dan Fisher—a protégé of Chamberlin’s and a clinical psychiatrist who healed from schizophrenia and has been working in the Recovery Movement since its inception—told me, if the Diagnostic and Statistical Manual (DSM) is psychiatry’s “bible,” On Our Own was and is the Recovery Movement’s “bible.”

The Recovery Movement made history-making strides throughout the 1970s. Privately funded community centers run by those with lived experience of mental illness started across the country: Horizon House in Philadelphia, Fellowship House in Miami, The Green Door in Washington, D.C., and Thresholds in Chicago. These centers managed to keep their doors open without proper funding or government support, so determined were they to give people the ways and means to heal.

Fifty years ago, those in the Recovery Movement knew that healing occurs when patients are treated as human beings, play a role in their treatment, are given the opportunity to recover, and aren’t assumed to be suffering from chronic conditions. As Phyllis Vine points out in Fighting for Recovery: An Activists' History of Mental Health Reform, the term chronically mentally ill riled those in the movement.

Chronic typically means persistent but is often understood to mean lifelong. As Stephanie Bernell and Steven Howard, researchers in public health, show, there is no uniform definition of chronic, not even within the Department of Health and Human Services. Some say it’s any condition lasting longer than three months, some longer than a year, some “of long duration,” and some simply an illness that “cannot be cured.”

The general idea behind the term is that our conditions are hopeless. They aren’t. Not when we dictate our own care. Those in the Recovery Movement knew this, as do so many today.

I straighten my skirt and enter the café. Matt’s already there, waiting. He sits at the counter, a full cup of hot chocolate in front of him. The cafe isn’t crowded. He stands and hugs me, pressing his body against mine. Definitely not a friendly hug. I think people call this lust. How long has it been—a decade?—since anyone hugged me like this?

At the counter, I order a cappuccino, which the barista starts to make with glacial slowness.

This is the third mistake I make in my recovery from mental illness. The first: believing that I couldn’t continue in therapy because (supposedly, to my misguided brain) mentally healthy people aren’t in therapy. The second: thinking I needed to be off my meds. Neither, it turns out is true.

This time, my logic goes something like this: If I can be in a romantic relationship it will mean I’ve recovered from serious mental illness. Isn’t that the sign of mental wellness—being in a happy, stable romantic relationship? Don’t you need to be mentally healthy to cohabitate and compromise and commit? Certainly someone with a fragile mind, someone who’s been chronically suicidal and hasn’t been able to live independently and has instead been living with her mother would be considered too disabled to even think of partnering with another human.

I turn back to Matt, who’s looking at me with such longing, my face flushes and I turn away. We met on a dating app years ago. We won’t talk for six months or a year and then get together, always with that underlying sexual tension. Nothing’s ever happened.

The barista finishes frothing the milk for my coffee and expertly fluffs it into the cup. I pay and sit on the stool next to Matt. He tells me about the house he’s building on his farm.

To say we have nothing in common is an understatement. He was once a trader who retired at forty-five and now farms soybeans in Michigan. He also sails on racing teams. His hobbies include being outdoors and hunting, which he says he does responsibly though I’ve never been able to understand how killing animals for sport is responsible.

I’ve spent the past twenty-five years reading, writing, and teaching others how to read and write while battling mental illness. Most of my energy has gone toward managing manic nights of pacing the streets of Brooklyn, the compulsive need to eat only one color of food, racing thoughts that tell me I’m dying, and depressions so thick I’ve had to duck into Chicago alleys and cry. I’ve tried to make sense of my thoughts and feelings, those ineffable parts of us, via diagnoses and initialisms (GAD, OCD, MDD, ADHD, BP, etc.).

“I’m ready now,” Matt says, smiling sheepishly, and I wonder what he’s ready for. “I’m ready to settle down.” He’s almost fifty, balding but attractively so, and has never been in a long-term relationship. “Well, not marry, but…” He gives me a look: I would have sex with you right now. After a beat: “I’ve missed you.”

This seems unlikely, given we’ve collectively spent maybe fifteen hours together, but my stomach flutters. It’s a dull flutter because I’ve taken a healthy dose of Klonopin to be here. It has me feeling open, not so much at ease but easy. And it feels good to be wanted.

He knows about my illness—though not the depths of it. The last time we saw each other, sitting in this same café, I blurted out my current diagnosis—reckless, wanting to see what would happen. Would he say, oh in a tone that makes the word sound more like ick, and lean back in his chair, establishing a little more space between us? No, he was unfazed, practically oblivious. His uncle, he said, was bipolar too. He loved his uncle.

“I think we should…try,” he says. “Long distance.”

He leans over, and we kiss. The thought I can do this meets another—This is all wrong.

*

I don’t know it then, but much of the reason I equate being in a relationship with normalcy (which I then equate with health) comes from America’s couple-obsessed culture. Our marriage/relationship fascination has not just one name but two: amatonormativity and matrimania (my favorite). The cultural conversation insists that being married is something to strive for (at least for women), and studies show that most Americans want to be in a serious relationship and cohabitate—for better or worse, till death do them part.

One of the most potent cultural myths is that having a partner makes a person happy, healthy, and fulfilled. It doesn’t. Married people aren’t any happier. (The studies that said married people are happier were found to be flawed.) A single person is just as likely to be healthy as someone legally bound to another person is. For some time, it was assumed that married people were more likely to survive cancer because they were married; it turns out it’s because doctors are biased against single people. Doctors presume we don’t have the social support to survive more aggressive treatments and therefore aren’t as likely to recommend them.

A third of Americans are single by choice. Half of all singletons (a stupid name) don’t even pine for coupledom. Ninety million Americans exist dating-app-free and get to live in a home where the household tasks are done exactly how they like them.

I never asked myself if coupledom was really essential to a happy, fulfilling, healthy life. I just assumed it was. And in my attempt at mental health recovery, thinking that way made me go very far astray.

*

Michigan Avenue is crowded with shoppers. Christmas music comes from speakers mounted to one of the streetlights. I’m nearly at the hotel where I’ll meet Matt.

We text daily—me more than him, me much more than him—and have decided to spend the night together. His farm is an hour-and-a-half drive away and I don’t drive. My apartment just didn’t feel right.

He meets me in the hotel lobby, which buzzes with tourist energy. We hug that same hug. It might be romantic except my heart hurts, and I believe I’m dying. I should know it’s a panic attack surging through my chest and mind, but a panic attack only causes panic because it pretends to be something else.

Luckily, a Klonopin has started to settle me in a soupy way. It’s like being there but not there.

At a sushi restaurant, we have California rolls and awkward conversation. Then we go back to the hotel. After we have sex, the Klonopin and the heavy curtains make the room seem like it’s not there either. I don’t sleep. He does—heavily. Another Klonopin. A little sleep.

Morning comes, and all I want is to escape. Be alone. Walk in the cold. Gingerly, I dress. He doesn’t stir. In the elevator, I text him to say I had to go and thank him for such a wonderful evening. I xx and oo, wondering if that’s too many x’s or too many o’s.

By the afternoon, he still hasn’t texted. My mood swings. Walking, I feel heavy and brittle at the same time. I text. No response. I text again. Soon, the need to hear from him takes hold of my mind like a vice and tightens.

I text again. My mind goes on repeat, texting and checking again and again for the red notification bubble that says everything’s okay, I’m okay, he’s there and we’re together and I’m recovering.

I’ve become the dreaded “desperate” woman. In a romantic relationship, it’s the worst thing you can be. Magazines, websites, and morning talk shows devote whole articles and posts and segments to instructing women on how not to appear desperate. According to Brian Alexander, a writer who’s covered sex and relationships for NBC and Glamour and elsewhere (so m deprived women.” (Who knew they had such extra-sensory gifts?) The desperate woman gives off “telltale signs.” She shows too much affection, dresses scantily, comes on too strong, and buys too many gifts. And, of course, she texts too much.

But I’m way past the point of “seeming” desperate and besides, I’ve felt real desperation. Those nights sitting on the edge of my bed with the pill bottle in my hand. That day walking by the lake trying to figure out how I might avoid having my body wash up on shore.

The despair I feel now is mild and mostly about control. I need him to do what I want—play a role and prove I’m mentally healthy or at least mentally okay. Later, much later, I’ll learn that only I can do this.

To support my work, buy my journalistic memoir Pathological (HarperCollins), a USA Today Bestseller that traces how we’ve come to believe that ordinary emotions are mental disorders. If you’ve already read it, thank you! You can gift a copy to a friend, your local library, or your favorite independent bookstore.

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I don’t need therapy.

That’s my first mistake.

Stopping group therapy seems to make sense. If someone is mentally healthy, she isn’t in a group program that’s part of the partial hospitalization program she was once in. Having been in a hospitalization program means something was terribly, irrevocably wrong with me.

It’s embarrassing to recall how, on Thanksgiving, at ten in the morning, the other patients and I sat in the facility’s test kitchen making mini apple pies. We weren’t allowed near the ovens. Or the knives. The assumption wasn’t necessarily that we were potentially dangerous, but the program couldn’t open itself to lawsuits. Still, not being allowed near knives and an oven at forty-six was humiliating.

There’s no reason it should have been. The program was a lifeline. Having been in an acute psychiatric crisis (which usually means someone has ended up suicidal, psychotic, volatile, or manic), I needed its stability and routine.

We watched as one counselor cut a cored, peeled apple in half, then quarters, then eighths. His knife skills were poor, and I worried he’d cut himself.

The other counselor, a no-nonsense woman with red hair that reached her waist, walked over to help him. She nimbly took an apple from the bowl and brought the knife down on them with a whack!

A third counselor handed out mini disposable pie pans. She placed one in front of each of us, almost rhythmically in sync with the whacks! coming from the cutting board area.

The petiteness of the pies was infantilizing. Or maybe the fact that it was mid-morning and way too early for pie.

Of course, the point isn’t the pie. It wasn’t about making a delicious dessert to savor. The pie represented a manageable goal people like us could be proud of—something within our grasp to achieve, albeit without access to sharp objects.

I did as I was told but with an attitude. Reluctantly, I put the sugar- and butter-coated apple slices in the tin and covered them with strips of dough.

If there’d been talk of healing in the program, if I’d thought making a lilliputian pie was going to lead me closer to recovery, I would have gladly done it. Instead, we were given “skills” (CBT, DBT, ACT, mindfulness, etc., etc.) and invited to cry and vent in group therapy and individual therapy sessions and required to express ourselves in art therapy in what felt like a vacuum. Goals beyond the management of our symptoms weren’t for us to contemplate.

So I think getting away from that—far away—is the answer.

*

My sister lifts the orchid off her countertop and places it in the sink. My niece and nephew are at school, and my brother-in-law is at work. The house somehow still feels full of people. It’s a home belonging to a family, a clan all their own.

I’ve told her I want to stop going to group therapy, which I’ve been attending weekly.

Carefully, my sister turns on the tap—just a bit—giving the orchid precisely the right amount of water. “Are you sure you’ll be okay without it?”

My sister is thin and strong. I think of her as wearing glasses, which she did for much of our childhood and throughout her teens, but she had laser surgery decades ago, and her vision has been twenty-twenty ever since. She’s let her dark hair gray and is one of those women who looks even more beautiful—and formidable—for doing so.

Before I can answer, she says, “Maybe right now isn’t the best time.” She places the orchid on a paper towel to let the excess water seep from the soil. It will be perfectly hydrated and won’t succumb to root rot. “Just wait a while. Maybe until you’re—” The paper towel is already soaked with excess water. She switches it out with a dry one. “Until you’re sure.”

“I might try it,” I say. “See how it goes.”

If I’d googled the words mental health recovery, I would have discovered that recovery and therapy—or any other kind of treatment—aren’t mutually exclusive. Healing doesn’t necessarily mean leaving the mental health system.

*

At my next appointment, Dr. R’s pants shimmer in the sunlight from the window. I sip the lukewarm cappuccino I bought on the way to his office.

“How’s it going?” he asks, bobbing his head affirmatively.

The withdrawal effects haven’t improved. I want to ask him about the Google executive he mentioned, the one who healed completely, and find out if she’s the exception. Did she go to therapy? How did she heal?

But I don’t want to ask him because what if he says the Google executive is, in fact, a unicorn? What if Google-executive types have some other-worldly power to heal, something I don’t have? Like many people, I still don’t believe mental health recovery happens.

Dr. R leans back in his chair.

I tell him I’ve stopped going to group.

His eyebrows raise, but he continues to nod affirmatively. “Why?”

I shrug and say I just don’t need to go to group anymore.

Really, it’s because there’s no guide to recovery. He’s all I have, and I’m not using him or group or a therapist as a resource. I should. Of course, I should.

I pick up my cup of coffee and pause before bringing it to my lips. “I wanted to ask you about—”

He nods, encouragingly.

I shake my head. “Nothing.”

“You sure?” he asks.

I nod, uncertain, still believing I have to go this alone.

At our next appointment, Dr. R’s office looks even tidier than usual. Spare. Clear. His pants have their usual luster.

I look out the window at Michigan Avenue at the pedestrians and tell him I want off all my meds.

His brow furrows with concern or confusion. I can’t tell which.

It’s logical—or so I think. To recover from twenty-five years of serious mental illness, I can’t take psychotropic medications. People with mental illnesses take meds, ergo, if I want to heal, I can’t.

This is the second mistake I make in my recovery. The first was believing that I shouldn’t be in therapy, which I’m not anymore.

This time, the idea is that being psycho-pharmacologically pure signifies recovery. Never mind that few medications have been studied long-term and most lead to dependency. Regardless of how recovered someone might become, they may have to remain on their meds to maintain a state of homeostasis. Never mind that the last time I tried to go off the SSRI, the withdrawal effects were so severe—involuntary muscle twitching, paranoia, nightmares, crying spells, brain shivers that made me feel like a waterfall of needles were cascading down the back of my head, brain shudders that felt like my mind was trembling, and brain zaps that made me feel like I was being electrocuted—I wanted to end my life.

“It’s not worth it,” Dr. R says. “Those medications aren’t hurting you. Low-side-effect profiles.”

I insist.

He uncrosses his leg and breathes deeply. “Okay, we can try with the lamotrigine, but why?”

I don’t share with him my plan to heal; I’m still too scared he’ll tell me it’s not possible. Here, I’m missing out on the collaboration of care that might have helped my recovery.

“We’ll go down twenty-five milligrams,” he says. “Start there.”

Out the window on the street below, the pedestrians again seem like toy figures. Their outlines are stark. The buildings’ too.

*

Psychiatric medications have harmed and helped many people and may help many as they work toward recovery. Demonizing psychotropic drugs and shaming those of us who take them doesn’t serve anyone. Like many businesses, Big Pharma is mercenary, sometimes criminal, but we have to separate the CEOs from the researchers and others who truly want to help people. And sometimes, their efforts save lives.

Most psychiatrists and researchers agree that medications are best used to relieve acute distress. Often, clinicians either don’t know about this or haven’t told patients this. In tandem, they present a diagnosis as chronic and/or lifelong and don’t offer patients an exit strategy for tapering off medications. The result is that patients are kept on drugs for five or ten or twenty or thirty years instead of three months. Our bodies become dependent on the drug, and withdrawal attempts throw us into psychiatric crises, which we see as evidence that we haven’t recovered and start taking the medications again.

Dependence on psychotropic medications and their adverse side effects—not to mention how little we know about how they work and their dangers—complicate the very idea of mental illness and what causes it. The journalist Robert Whitaker offers compelling evidence that the rise in mental illness is correlated with the wide prescribing of psychotropic medications for long-term use. Studies show that long-term recovery rates have been higher for nonmedicated patients diagnosed with depression, bipolar disorder, and schizophrenia.

Forced medication is sometimes necessary but can also rob patients of their autonomy, worsen their conditions, and even lead to death. The psychotropic drug industry is a multi-billion-dollar machine, the aim of which has been profit, not public service. Side effects are listed, but clinicians aren’t required to discuss the risks with patients, thereby not procuring true informed consent. Taking medications long-term can mean having to remain on them indefinitely despite sometimes life-threatening side effects (e.g., antipsychotics that cause weight gain, diabetes, etc.).

In recovery, psychotropic drugs are just one small part of what Patricia Deegan calls Personal Medicine. Deegan was diagnosed with schizophrenia, healed, and became a psychologist, innovator, and professor at Dartmouth College School of Medicine. As she healed from schizophrenia, Deegan developed her own personal medicine: “Medications were just one tool in an entire set of recovery tools I slowly pulled together for myself. I built my recovery toolkit over time, intuitively, and without even having heard the word ‘recovery.’”

Personal Medicine is a strategy built on individual needs: “Personal medicine reminds us that there are many ways to change our body’s biochemistry and that, within the task of recovery, pill medicine must complement and support Personal Medicine, or the things that give one’s life purpose and meaning.”

If I’d known of Deegan and Personal Medicine, I wouldn’t have felt shame for taking medication or risked going through withdrawal again. But I have no awareness of the recovery community and no guidance.

*

A few mornings later, still in my pajamas, I pace my apartment. Voices come from the hallway. My neighbors are leaving for work. An hour ago, it came on fast: the heaviness, the sodden pit in my stomach, the jitteriness. I’m weighed down and revved up.

I dress and put on my coat and running shoes. Riding the elevator takes a long time. The lobby of my building is empty of people. Outside, it’s damp, the sidewalks wet with rain.

In the park, where I walk every day almost without fail, I wait to feel better. Moving will lighten me, steady me.

I circle the pond. A family of turtles sits on a rock. They’re placid, pure, unbothered—together.

It happens to be Thursday—the day when my group therapy session is held. The group I’ve rejected. I have to wait hours, but that evening, I ride one of Chicago’s Divvy bikes to the partial hospitalization program downtown and wait for group to start.

The others arrive. I know them by their diagnoses, not their names: PTSD and her emotional support dog; borderline personality disorder and depression; anxiety disorder, ADHD, and PTSD; depression, obsessive-compulsive disorder, and PTSD. I want to know their names, who they really are, and if they’ve ever thought of healing, but it’s not something anyone talks about in group.

The woman with bipolar I enters and sits across from me. Her short brown hair is functional, her deep voice commanding. In group, she was my ideal of what it means to accept your illness. I’ve envied how high functioning she is—a tenured professor with a life partner and an adopted son. Her stories of manic episodes (nights without sleep, maniacally working on spreadsheets for her job) and depressive lows (able to get out of bed and teach but with disassociation and hopelessness and anhedonia so extreme she finds it hard to hold a conversation, even with her wife) have held me rapt.

The counselor with waist-length hair comes in late. She wears black jeans and a black shirt. Her face shows no emotion. It never does. She reads the group rules, including how we should respect other people’s views and be punctual.

“And, of course,” she says, “give others space—”

The woman with bipolar I interrupts. She talks and talks, her words moving quickly, almost blurring into each other.

The Klonopin I’ve taken must make her seem like this. The scrappy emotional support dog breathes unevenly. The other women in the group seem to be listening. The counselor turns the pages of her notepad.

The woman with bipolar I says she’s been sleeping on the couch again. Actually, she hasn’t been sleeping. Her partner is angry at her. They both knew a manic episode was coming on. She laughs. We knew. We knew. We knew. We knew.

At some point, she stops talking. We all sit without speaking. Finally, the woman with the emotional support dog says she’s brave for coming to group.

The woman with bipolar I tugs at the collar of her shirt and says, “I guess I shouldn’t have stopped taking my medication.”

Maybe I shouldn’t have either.

*

The next day, I stand behind a podium teaching my Introduction to Literature course. We discuss Amy Tan’s essay “Mother Tongue.” Tan tells of the discrimination her mother has faced since immigrating to the U.S. because she speaks what Tan calls “broken English”—a mix of English and Chinese.

I start to sweat. My insomnia has been at a pitch. Last night, I paced and paced. My inner motor has been on high. There seems to be a constant hum in my ears.

A student raises his hand and shares that he’s a child of first-generation immigrants and has had the same experience with his parents.

My cheeks go numb.

Another student raises her hand.

Her words are indiscernible.

Ten minutes left of class. Sweat soaks my bra, my camisole, and my shirt, and is starting to go through my blazer. Luckily, my blazer is black, so maybe the students can’t tell.

The student is still speaking. I want to hear what she’s saying. I nod. I need out of this room.

After white-knuckling it through class, I hurry back to my office. Before the door is even closed, I pull my phone out of my bag and begin scrolling to find Dr. R’s number.

I leave a message. My shirt and bra are so wet I have to peel them off. I hang them on the bookcase to dry. Waiting for him to return my call, I sit shirtless, feeling my heart pound.

When he returns my call, I tell him about the withdrawal. I’m half-naked and don’t care.

He reassures me—genuinely—that it’s okay. He tells me to go back up on the SSRI to my usual dose.

We end the call. My next class starts in five minutes. I put on my wet bra and shirt and use the blazer to cover up what’s happened.

Thank you for reading.

You can purchase the national bestselling memoir Pathological: The True Story of Six Misdiagnoses (HarperCollins), the prequel to Cured, here. Both a memoir and a work of investigative journalism, it explores the ways we pathologize human experiences and ask, Is a psychiatric diagnosis a lifeline or a self-fulfilling prophecy?

Buy or gift Pathological now