Alternate Lives: Critical Junctures in Psychiatric Illness

Photo by Vladislav Babienko on Unsplash

In her 2022 book, Strangers to Ourselves: Unsettled Minds and the Stories that Make Us, the writer Rachel Aviv considers the pitfalls of psychiatric diagnosis, drawing on her own experience as a young child. When Aviv was six, for reasons still unclear to her, Aviv stopped eating and developed various phobias around food. Weight loss led to a swift diagnosis of anorexia- in the absence of any evidence of distorted body image, or even awareness of the cultural meaning of thinness- and hospitalization with a cohort of older anorexic girls.

The longer Rachel was there, the more “behaviors” became familiar to her, like compulsive exercising to shed calories. Aviv left the hospital, and recovered from whatever was ailing her, but she remains fascinated with just how easy it would have been to shift tracks and end up chronically ill, like Hava, an older girl she admired.

“This sense of narrow escape has made me attentive to the windows in an early phase of an illness, when a condition is consuming and disabling but has not yet remade a person’s identity and social world. Mental illnesses are often seen as chronic and intractable forces that take over our lives, but I wonder how much the stories we tell about them, especially in the beginning, can change their course. People can feel freed by these stories, but can also get stuck in them.”

Although I have issues with her case study methodology (hindsight, but not psychiatric practice, being 20/20), I think there is one thing Aviv gets exactly right. Psychiatry is spinning its wheels debating the validity of diagnoses and endlessly parsing treatment algorithms. The real question is not whether problems like anorexia or depression exist, but whether at critical points in a person’s trajectory there might be real alternatives to psychiatric diagnosis and treatment, which, as Aviv points out, often incur a risk of more pathology.

Does chronic illness require chronic treatment? Or does exposure to treatment create chronically ill patients? And crucially, if there are certain key junctures when chronic illness might be averted, how do we identify them?

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I first heard of anorexia at boarding school. A girl in my dorm had developed it and had left school. In the basement of that dorm, I later watched a made-for-tv movie in which a waif-like teen collapses in the street due to hunger and is hospitalized. I was lonely, and unhappy, and I think it appealed to me for suffering to be no longer just internal but to made visible.

Like Aviv, I never thought I was fat. I was terribly aware, in fact, of how thin I became in the course of the illness. I remember cinching in a belt and draping a shirt over it to hide the scant waistline. Much of my practice had to do with asceticism, not achieving some sort of physical ideal. When I was hospitalized at age 18, they gave me a test about body image. Shapes of women- thin, normal, obese- were projected on a screen, and I was asked which resembled my body. I knew that anorexics usually thought they were fat, but I did not. I chose the thinnest one.

What, then, is an illness? Is anyone who is motivated to lose weight an anorexic? Can one be driven by forces not adequately characterized by a list of criteria, and perhaps not even comprehensible to the sufferer or those around her? Aviv’s doctors offered the usual formulations about her parents’ marital conflict and internalized stress.

Depression is the third most common cause of disability and is expected to be the leading cause by 2030. Such a statistic begs the question of whether what we call depression is really a catch-all for psychic dis-ease in Western society, much as low back pain is the communal hallmark of a sedentary lifestyle. About half of people who present at the primary care doctor’s office with depression will get better by twelve months without treatment- a figure not dissimilar from the percentage who would improve on an anti-depressant. Yet both Psychiatry and the public would be aghast at the prospect of not treating someone who was identified as depressed. I wonder whether we need to be.

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I met Alys Culhane at a memoir workshop in Montpelier, Vermont, in the late 1990s. Alys, a compact, cheerful, sun-weathered woman with a lazy eye, had ridden her bicycle from her home in New Hampshire and, unlike the rest of us, was camping on the lawn of the college to save money.

We’d submitted work beforehand, and Alys’ essay was the only one I could stand; it was called “Boat Poor,” and described wryly how she and her partner Pete had sold all their furniture to subsidize their obsession with kayaking. One of the kayaks was now doing double duty as their coffee table.

I gave Alys and her bicycle a ride home, and we kept in touch for years. I’d sometimes go visit her and Pete; we’d kayak or cross-country ski and then read each other’s work. But at home, in my apartment in Arlington, MA, I was isolated and depressed. I could not get out of the hole I’d climbed into in med school; I spent nights crying and often thinking about suicide.

Since I had by this time “failed’ many meds, and had had a bad response to ECT, my psychopharmacologist gravely told me there were few options left. One possibility was deep brain stimulation, which involves the implantation of an electrode to stimulate parts of the brain. So far it was indicated only in OCD and possibly Parkinson’s Disease; I called the couple of programs I’d heard about and been told the waiting lists for experimental treatment of depression were a year or longer.

Alys and Pete eventually moved back to Alaska, where’d they’d met, and soon after, Alys invited me to visit. I sat in my therapist’s office and tearfully told him that I wasn’t up to it, that I really didn’t want to do this anymore- this, as usual, meaning living. I remember being extremely depressed and filled with dread on the flight there.

I woke up on the floor in the Anchorage airport; my friends, running late, were leaning over me, bundled up in layers. It was early November and already bitterly cold.

They took me home, and over a meal of eggs with potatoes and vegetables Alys revealed the real reason she’d invited me. A good friend’s daughter in Fairbanks had been hospitalized for some sort of psychotic episode. The father was caring for her son, his grandchild, and he was very distressed; he had told Alys he had no idea what was going on, that he was getting no information from the hospital. I apparently was the consult service, flown in from the East coast.

The next day, we climbed into Alys’ truck, with her dog riding shotgun, unsafely cradling the gear shift. I had not realized just how far Fairbanks was from Anchorage.

The landscape was remote, untouched and breathtaking; we drove for hours at a time without seeing a gas station or other evidence of human existence. The mountains – the Chugach and Talkeetna ranges- set up a perimeter of gleaming ice, forbidding and unreal. The rivers were so pristine it was as though they’d been created that day. I had a sense of being in a wild and alien place, almost a new planet, that required constant alertness and respect. I felt jolted awake.

After sitting with Alys’ friend, Bill, who described the events leading up to the hospitalization, I headed over to Fairbanks Memorial Hospital. A release of information was arranged, and I had 100 pages’ worth of medical records printed out.

Alys and I stayed with other friends of hers in an inn they had built by hand. There were wide planked floors and narrow wooden spiral staircases. We hung out in the kitchen, and they regaled me with stories of the Alaskan winter. “It gets so that you can see the cold roll in, hit the wall and roll back out again,” someone cracked. The record low was -40 degrees Fahrenheit. They told me that, when it got like that, they would go around and check on each other. Everyone was so open and friendly that I felt immediately accepted.

There was no real sleuthing involved; the young woman likely had schizophrenia, there had been signs earlier. I was able to explain to Bill what the implications were and what the doctors were doing. Eventually I spoke with one of his daughter’s psychiatrists by phone, and we discussed further treatment options.

“Do you want a job?” he asked. He seemed to be relatively serious.

I flew home in much different spirits than when I’d left- although the gloom descended pretty quickly upon my return. Back to my insular life, seeing patients, seeing my therapist. And back to my paltry treatment options.

I made a list at one point which today amuses me, but which at the time felt deadly serious. It was a pro/con list comparing three options: Deep Brain Stimulation, Suicide or Moving to Alaska. I think I presented this list to my therapist and my psychopharmacologist.

It now astonishes me that no one pointed out that this was a ridiculous juxtaposition- of course I should have moved to Alaska. If you can avoid messing with your brain, or destroying it, by making a change in your social or life situation, that is the obvious choice. Moreover, the fact that it felt like a change in my environment would help – actually, had recently helped- seems to me to indicate that, even at that late stage, my depression was not immutable. Perhaps, in fact, it was never inevitable.

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In Ted Chiang’s dystopian short story, “Anxiety is the Dizziness of Freedom,” a device has been created that allows the user to contact a version of themselves which has followed another path at a critical juncture in time. This parallel self- or “paraself”- might have married someone instead of breaking up with them, might have taken a different job, committed or not committed an act of violence. As one might imagine, it proves fairly addictive to have the capacity to see how your life might have turned out, had you made a different decision.

I don’t have such a device, so I don’t know if I would have been happy, or free of depression, had I moved to Alaska. I have Raynaud’s Syndrome; my fingers turn numb in 50-degree weather, so by now I might well have lost all my digits. But moving seemed to offer me a constellation of things I’d lacked: meaningful work along with a community and a connection to the outdoors- things the author Johann Hari, in his book Lost Connections, states are far more helpful for depression than medications or therapy.

Aviv writes specifically about opportunities to diverge in the early phases of illness, before that illness has “remade a person’s identity and social world.” It can be hard to differentiate the constriction of one’s life that comes with illness from that incurred by being a patient. I found at a certain point that my life in therapy, my relationships with providers, felt more palpable and intimate than did my life outside- a sure sign something was wrong. On the other hand, I was pretty depressed by the time I got to treatment in Boston.

I wonder about this thing we call refractory depression, or even depression at all. If someone doesn’t “respond” to traditional therapies, perhaps the problem is not to be found in the DSM, nor the solution to be found at the pharmacy, or even in therapy, but “out there.” I had for years conceptualized my problem as depression, rather than a problem of living, a pattern of introspection and self-scrutiny which was not serving me well. I felt like my mind was sick, but really I was just, as Aviv writes, stuck.

I think Aviv is right; those shifts are easier to make in the beginning, before the quicksand of pathology grips us inexorably. Year after year, a scaffolding of insults is laid over the initial kernel of illness, trapping us brick by brick. I couldn’t move to Alaska because by that time my life felt rather fixed- those treatment relationships were so essential, I was afraid of being unmoored. I think I also downplayed the transformation I‘d experienced, because it seemed to mean I’d never really been depressed. When illness has cost you so much, it becomes dangerous and discrediting to simply abandon it. In her diary, Hava wrote, “I’m not completely convinced I want to be rescued.”

I question the role of psychiatry and psychotherapy in finding these moments of plasticity in someone’s life. My revelation in Alaska, where I was inundated with the feeling of being helpful, mattering, being liked, was so profound because it was spontaneous. No one could have planned or prescribed that experience, no hospital could have simulated it- it just had to happen.

What we can do as clinicians is to recognize the importance of these moments, and remain curious about the possibilities for healing the world might provide. Even chronically ill Hava, whose story is picked up by Aviv in the last chapter of the book, briefly finds an avenue towards better health when she falls in love. We know little about what causes illness and still less about the myriad, unique paths people may follow to recovery, if given the latitude and permission- perhaps even encouragement- to do so.