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Mental Health and the Uvalde Massacre

close-up photograph of multi-colored brush strokes on canvas

In the wake of the 21 deaths at the school shooting in Uvalde, Texas, the national conversation has once again turned to gun violence. And once again, political figures have saturated the airwaves with an abundance of explanations and solutions. The most prominent, of course, is gun control. However, figures like Texas Governor Greg Abbott and Uvalde Mayor Don McLaughlin have appealed to a different explanation – mental health.

There is reason to doubt Governor Abbott’s sincerity, and he was quickly taken to task for cuts in mental health resources and the deplorable state of the Texas mental health system. Politically, mental health is convenient as it provides a possible solution to problems of gun violence without getting into questions of gun control and gun rights.

However, even if mental health is being deployed as a cynical talking point in this particular context, that doesn’t mean it should not be part of a larger conversation about gun violence.

The causes of events like the Uvalde elementary school shooting are complex, and we can ask how the availability of lethal weaponry intersects with issues of poverty, inequality, racism, gun culture, and yes, mental health, to ultimately lead to violence.

However, folding mental health into the discussion is not without risks. First, it can stigmatize mental illness as something generally connected to violence, and second, it can lead to a very individualistic explanation of gun violence that fails to consider broader social and economic factors.

So, how should we understand the purported link between gun violence and mental health? The Uvalde gunman, Salvador Ramos, did not have a diagnosed mental health condition. Most mass shooters appear not to be classically psychotic – only 8% of mass shooters found to be psychotic in a recent study (although it varies somewhat by study). Although many mass shooters, perhaps unsurprisingly, have a record of being psychologically troubled in some way. The Violence Project, a study of mass shooting not affiliated with criminal activity, found generally high levels of suicidality and paranoia. Studies done by the U.S. Secret Service have found around half of mass shooters experienced mental health symptoms prior to attack.

The problem however is that mental health troubles are very common, and that mass shootings are very rare – even in the United States.

Moreover, while mental illness does have some correlation with violence,

the fact remains that the vast majority of people with diagnosed mental illness are not dangerous and violence may often be better explained by associated factors like unemployment or substance abuse.

Focusing on specific diagnosable mental illnesses then does not seem a productive way to address gun violence. The framing Governor Abbott used suggests that anyone who would commit this kind of violence must, necessarily, have a mental health problem. Philosophers and sociologists refer to the process by which something comes to be treated in a framework of health and disease as medicalization, and that is similar to what is happening here – engaging in a mass shooting is being treated as a sign of a medical problem.

However, whether or not something should be treated as a medical problem can be ethically contentious. First because it can subject people to forms of social control, e.g., involuntary hospitalization, and second because it prioritizes a medical explanation, e.g., Ramos’s actions are thought to betray an undiagnosed mental illness. This purportedly medical explanation can then prevent people from considering others causes, such as the availability of guns or the effect of racist ideology like replacement theory.

Medicalization is always a partly social process, but it is responsive to physical and behavioral features. Treating breast cancer or strep throat within the context of our medical system is an easy decision – they have well-known biological causes and are responsive to medical treatment like chemotherapy or antibiotics. There is, however, no parallel response for the tendency to commit mass shootings. We do not know how to diagnose it (prior to the shooting) or how to treat it. Consequently, even a general mental illness framing for mass shooting largely serves as a way to denigrate the behavior as pathological or abnormal, without providing much guidance about what can be done.

Potentially more promising for addressing gun violence are general welfare approaches to health including mental health. The World Health Organization famously defines health as not merely the absence of disease but “a state of complete mental, physical, and social well-being.“ Admittedly, by having such a broad understanding of health, this perspective tends to turn every problem into a health problem.

But it also helps to connect individual problems to societal problems, and individual well-being to societal well-being, making clear the scope of meaningful mental health solutions to gun violence.

This approach would seek the general social and economic conditions such that mass shootings are rare and could include big-ticket items like inequality.

Generally, mental health becomes less of a topic as one leaves the domain of mass shootings and enters the broader world of gun violence. However, there is one more obvious overlap – suicidality. Guns are an incredibly effective means of suicide and they make suicide attempts extremely fatal. As many people who attempt suicide do not then go on to attempt suicide again, the means matter. National attention to mental health could then be a key way to head off the suicide risk caused by high levels of gun ownership.

Governor Abbott’s remarks may be suspect, but the inclusion of mental health in our national conversation about gun control and gun violence is not.

Why the Sunshine Protection Act Is Daylight Robbery

photograph of Los Angeles skyline at dawn

Earlier this month, the U.S. Senate unanimously voted in favor of the Sunshine Protection Act – a bill that would make Daylight Saving Time the new, permanent standard time from November 2023 onwards. Many may rejoice at this news. The process of adjusting our clocks twice a year can be enormously irritating. And it’s also dangerous. This biannual disruption to our circadian rhythms (the natural biological processes that follow a 24-hour cycle) has been linked to all kinds of negative side effects, including workplace injuries, sleep disturbances, stroke, and  heart attacks. This includes a 6% increase in fatal traffic accidents — accounting for about 28 deaths per year.

While often blamed on farmers, daylight saving time was actually first introduced in the U.S. during World War I as an energy saving measure. Farmers, it turns out are vehemently opposed to the practice — which creates a huge interference with their standard routines. Given all of this, it might seem obvious why the Sunshine Protection Act received unanimous support in the Senate. But it turns out that there’s more to this issue than meets the eye.

For one, it isn’t simply a case of scrapping the biannual time transition. Most people are in favor of this — which might explain why the bill has received such widespread support. The more important part of this process is deciding which time we will permanently transition to. And here, we have two options. First, there is Standard or ‘Solar’ Time — that is, the time the U.S. currently uses from November through March. This time is based on the movement of the sun, and pins midday to the moment at which the sun is at its highest point in the sky (hence the term “high noon”). The alternative is Daylight Saving Time (DST) — that is, the time currently used from March through to November. This time sees our clocks offset from solar time by one hour, so that the sun is instead at its highest point at one o’clock in the afternoon.

It might seem like an arbitrary choice — and you might think that so long as we get rid of that meddlesome biannual adjustment, nothing else really matters. But this couldn’t be further from the truth.

It turns out that DST harms us in numerous ways. For one, it’s a public health risk. We sleep less long and less well, with Americans losing an average of 19 minutes sleep per night during DST. This may not sound like much, but this society-wide DST-induced sleep-loss has been connected to significant increases in the risk of heart disease, stroke, diabetes, cancer, high blood pressure, obesity, metabolic disorders, personality disorders, unintentional midday sleep, caffeine abuse, alcohol abuse, depression, and suicidality. That’s probably why we see things like a 24% uptick in heart attacks immediately after we change to DST each year. And this isn’t merely a result of the time transition, since the move back to Solar Time in November sees a corresponding reduction in heart attacks by around 10-21%.

DST is also bad for business. Workplace injuries among laborers typically increase 5.7% under DST, and result in 67.6% more days of lost work. Office productivity plummets by 20% for an average annual loss of $434 million nationwide. Perhaps worst of all, permanent DST would see most of us start school and work before sunrise for around a third of the year.

Unfortunately, the sole motivation behind the initial move to daylight saving — that is, the conservation of energy — no longer applies. This is largely down to the ways our lives have changed since World War I. DST now causes us to use more power — mostly in the form of morning heat and evening air conditioning. This subsequently leads to an increase in home energy costs, pollution, and climate change.

What’s interesting is that the U.S. already trialed the implementation of permanent DST back in 1974. Initially, 79% of the population were in favor of the change (no doubt fueled by relief that they would no longer have to adjust their clocks twice a year). But this support dropped to only 42% after just one winter — a winter in which eight children lost their lives walking to school on dark winter mornings in the space of just one month in Florida. The experiment ended shortly thereafter.

Given all of this, it’s deeply concerning that, while eradicating the biannual time transition, the Sunlight Protection Act is attempting to implement DST — not Solar Time — as the new standard time. But when we dig a little deeper, the choice isn’t all that surprising. There’s a lot of money to be made in DST. As previously noted, DST sees power and fuel consumption skyrocket — lining the pockets of the companies who provide those amenities. The National Association of Convenience Stores has also made no secret of their opinion on the matter, arguing before a Congress subcommittee that DST is “is good for business and commerce across the United States.” Other huge benefactors from a permanent transition to DST will be golf courses, with the National Golf Foundation admitting that the extra evening light will allow course operators to “accommodate more golfers/greens fee revenue.”

Ultimately, what might seem like an innocuous issue — whether to set our clocks according to the sun — is actually a matter of tremendous moral importance. While the shift to permanent DST might financially benefit certain businesses, it will come at a huge cost to society and the economy at large — robbing ordinary citizens of sleep, health, and money. Eradicating the biannual time transition in favor of permanent Solar Time would instead provide the best outcomes for the well-being of U.S. citizens — even if it means buying a few less slushies and rounds of golf.

Hotline Ping: Chatbots as Medical Counselors?

photograph of stethoscope wrapped around phone

In early 2021, the Trevor Project — a mental health crisis hotline for LGBTQIA+ youths — made headlines with its decision to utilize an AI chatbot as a method for training counselors to deal with real crises from real people. They named the chatbot “Riley.” The utility of such a tool is obvious: if successful, new recruits could be trained at all times of day or night, trained en masse, and trained to deal with a diverse array of problems and emergencies. Additionally, training workers on a chatbot greatly minimizes the risk of something going wrong if someone experiencing a severe mental health emergency got connected with a brand-new counselor. If a new trainee makes a mistake in counseling Riley, there is no actual human at risk. Trevor Project counselors can learn by making mistakes with an algorithm rather than a vulnerable teenager.

Unsurprisingly, this technology soon expanded beyond the scope of training counselors. In October of 2021, the project reported that chatbots were also used to screen youths (who contact the hotline via text) to determine their level of risk. Those predicted to be most at-risk, according to the algorithm, are put in a “priority queue” to reach counselors more quickly. Additionally, the Trevor Project is not the only medical/counseling organization utilizing high-tech chatbots with human-like conversational abilities. Australian clinics that specialize in genetic counseling have recently begun using a chatbot named “Edna” to talk with patients and help them make decisions about whether or not to get certain genetic screenings. The U.K.-based Recovery Research Center is currently implementing a chatbot to help doctors stay up-to-date on the conditions of patients who struggle with chronic pain.

On initial reading, the idea of using AI to help people through a mental or physical crisis might make the average person feel uncomfortable. While we may, under dire circumstances, feel okay about divulging our deepest fears and traumas to an empathetic and understanding human, the idea of typing out all of this information to be processed by an algorithm smacks of a chilly technological dystopia where humans are scanned and passed along like mere bins of data. Of course, a more measured take shows the noble intentions behind the use of the chatbots. Chatbots can help train more counselors, provide more people with the assistance they need, and identify those people who need to reach human counselors as quickly as possible.

On the other hand, big data algorithms have become notorious for the biases and false predictive tendencies hidden beneath a layer of false objectivity. Algorithms themselves are no more useful than the data we put into it. Chatbots in Australian mental health crisis hotlines were trained by analyzing “more than 100 suicide notes” to gain information about words and phrases that signal hopelessness or despair. But 100 is a fairly small amount. On average, there are more than 130 suicides every day in the United States alone. Further, only 25-30% of people who commit suicide leave a note at all. Those who do leave a note may be having a very different kind of mental health crisis than those who leave no note, meaning that these chatbots would be trained to only recognize clues present in (at best) about a quarter of successful suicides. Further, we might worry that stigma surrounding mental health care in certain communities could disadvantage teens that already have a hard time accessing these resources. The chatbot may not have enough information to recognize a severe mental health crisis in someone who does not know the relevant words to describe their experience, or who is being reserved out of a sense of shame.

Of course, there is no guarantee that a human correspondent would be any better at avoiding bias, short-sightedness, and limited information than an algorithm would be. There is, perhaps, good reason to think that a human would be much worse, on average. Human minds can process far less information, at a far slower pace, than algorithms, and our reasoning is often imperfect and driven by emotions. It is easy to imagine the argument being made that, yes, chatbots aren’t perfect, but they are much more reliable than a human correspondent would be.

Still, it seems doubtful that young people would, in the midst of a mental health crisis, take comfort in the idea of typing their problems to an algorithm rather than communicating them to a human being. The facts are that most consumers strongly prefer talking with humans over chatbots, even when the chatbots are more efficient. There is something cold about the idea of making teens — some in life-or-death situations — make it through a chatbot screening before being connected with someone. Even if the process is extremely short, it can still be jarring. How many of us avoid calling certain numbers just to avoid having to interact with a machine?

Yet, perhaps a sufficiently life-like chatbot would neutralize these concerns, and make those who call or text in to the hotline feel just as comfortable as if they were communicating with a person. Research has long shown that humans are able to form emotional connections with AI extremely quickly, even if the AI is fairly rudimentary. And more seem to be getting comfortable with the idea of talking about their mental health struggles with a robot. Is this an inevitable result of technology becoming more and more a ubiquitous part of our lives? Is it a consequence of the difficulty of connecting with real humans in our era of solitude and fast-paced living? Or, maybe, are the robots simply becoming more life-like? Whatever the case may be, we should be diligent that these chatbots rely on algorithms that help overcome deep human biases, rather than further ingrain them.

Of Pajamas and Self-Care

photograph of masked businessmen in tie and pajamas working at laptop at home

If you’re like me, then you’ve been spending a lot of time working from home as of late. This has its benefits – e.g., no need to commute into work, snacks are abundant, my cat is here – and its detriments – e.g., I spend hours and hours sitting in the same place and looking at the same computer monitor, day-in, day-out. One additional benefit comes in the form of what you wear: without having to be around coworkers you’re pretty much free to wear whatever you want (except on days with Zoom calls, of course). A popular pandemic choice has been pajamas: comfortable and easy to just throw on, you can sit in comfort as you watch the barriers between your work life and non-work life slowly dissolve away into nothingness.

While pajamas and/or sweatpants have become the de facto lockdown uniform, numerous news outlets have recently reported some worrying news: a recent study showed that wearing your pajamas all day while you work correlates with reports of declining mental health. “Academics who are tempted to remain in pajamas during the work day should think again” says Insider Higher Ed, warning that “those who stay in bedroom attire are twice as likely to report a worsened state of mental health.” While the study in question did not show any effect of pajama-wearing on one’s productivity, other outlets have warned that all-day pajama wearing could be part of a larger set of behaviors that would result in such a decline, urging those who work from home to “create a routine and structure that you force yourself to stick to” (a routine that involves, presumably, changing into something other than pajamas).

Let’s say that one has some minimal obligations to one’s own well-being; in other words, you have a duty to take care of yourself, and part of that duty will involve your mental health. If it is, in fact, the case that pajama-wearing correlates with decreased mental health, then it would seem that one should throw on some less comfortable, at least during the workday.

Still, one might not be convinced. While pajama wearing may correlate with decreased mental health, one might think that it is surely any number of the many additional variables – such as being isolated, not being able to see or interact with one’s friends and family face-to-face, not being able to do many of the activities one did in the pre-pandemic world, etc. – that are causing this reported decrease in mental health. If anything, one might think, wearing pajamas all day can be something that can make you feel just a little bit better.

Hence we see another side to the pajama issue: instead of providing warnings about mental health and establishing routines, some businesses have begun to cater to the work-from-home lifestyle by offering a range of “home loungewear.” “As working from home becomes the new normal, many are finding that changing out of pajamas can be quite a daunting task,” says Celia Fernandez at Insider. Rather than advising that we find something else to wear, she instead suggests that we lean into it, helpfully providing some “perfect loungewear options that feel like pajamas without looking like them.” If wearing pajamas helps you feel better, then you might as well exercise this little bit of self-care with style.

We are thus being presented with conflicting messages: on the one hand, wearing pajamas all day may be indicative of having fallen into a rut, and thus it seems that one ought to make changing into non-pajamas part of one’s daily routine. On the other hand, working from home all the time takes a mental toll, and so you should do whatever little things you can to make this time a little less terrible. And if wearing pajamas all day will help with that, so be it.

This conflicting advice represents the difficulty in balancing what might seem to be competing duties one has towards self-care: on the one hand, it seems that we have short-term duties to ourselves to allow us to best cope with the problems that we are dealing with here and now; on the other hand, it seems that we also have long-term duties to future selves, to make sure that we are able to cultivate habits that allow us to be happy and healthy in the long run. While we may always face this conflict to a certain extent, pandemic-times have brought some of the conflicts to the front and center, feeling both that one should do everything one can to get “back to normal,” while also feeling like one needs to just get through another day.

While there’s no solution to this problem that can be applied universally, it is worth considering what is more pressing on an individual basis. For instance, if things are feeling particularly tough on any given day and wearing some stylish pajamas will make a significant difference in how you’re feeling, then by all means go for it. If, however, you find that staying in your pajamas all day does not so much bring you comfort as it just feels like a normal part of pandemic living, then you might consider thinking about working towards improving your long-term well-being instead.

Second-Victim Phenomenon

close-up photograph of physician's face with mask and headlamp

In 2000, Albert W Wu introduced the term second-victim phenomenon to describe the emotional distress that physicians have when they make a medical error that results in harm for a patient. Since then, the term has been cited over 400 times in The Web of Science, and PubMed has over 100 titles with “second victim” in the title or abstract. The purpose of the term, as described by Wu, was to bring attention to the need of emotional support for doctors who are involved in a medical error. Since then, however, it has been debated whether that phrase is appropriate terminology given the severity of the implications.

Doctors and nurses experience an emotional rollercoaster everyday with high pressure jobs and people’s lives at hand. Mistakes in the field can have lethal, legal, and emotionally- distressing effects for the provider as well as the patients and families involved. Doctors have been under an increasing amount of pressure recently as well with the increasing amount of productivity requirements and increased required documentation. The nature of the job with the additional pressures leads to an increase of physician burnout.

Hospitals analyze mistakes made by physicians in a few different ways. They have Morbidity and Mortality conferences, critical incident debriefs, and even peer review systems. Hospitals aim to find the root cause of the problem. They want to identify any safety nets that were missed and find ways that mistakes can be prevented. However, these initiatives typically lack to touch on the emotional distress that the physician can feel after the accident.

One way that hospitals have attempted to incorporate a mental health support system for these cases is called Schwartz rounds, named after a healthcare attorney who died of lung cancer that was touched by simple acts of kindness he had in his last days of care. During a Schwartz round, a doctor talks about the care of patients in the hope of increased compassion and collaboration between physicians and patients. Dr. Elaine Cox, the Chief Medical Officer of Riley Children’s Health says, “The overwhelmingly positive response to such rounds underscores the desire for connection and support that all of our clinicians are thirsting to find. This type of intervention, and others that accomplish the same end, may be the most pressing need to support those who work in health care.” Unfortunately, there are very few resources that exist to further these initiatives.

There are dangers in not addressing the emotional traumas that professionals are left with after a medical mistake. Physicians can react in ways that are detrimental as a way to protect themselves. They respond to their own mistakes with anger, projection of blame, or by acting defensively and/or blaming the patient or other members of the healthcare team. Long-term ramifications for the emotional distress experienced by physicians can lead to burn out, substance abuse, or even suicide. On average, 400-700 physicians take their own lives per year. “Second victim” terminology was designed to draw attention to these serious consequences of medical mistakes that are so often overlooked.

However, at the root of medical professional’s job, is the oath of “do no harm.” Some believe that describing doctors as ‘victims’ diminishes the responsibility and accountability of the mistake. Calling physicians ‘victims’ seems to imply that the medical error was a random event, a piece of bad luck, or an unpreventable occurrence. It is reasonable for patients and their families to expect providers to be accountable for their actions. Physicians foremost have an ethical responsibility to tell their patients of an error, especially if the error has caused harm. This is to respect the patient’s autonomy, as they have the right to be told the logistics of their medical care.

Management of patient care is carried out by a combination of institutional systems and the professional actors within it, and healthcare professionals can be agents of harm, even if unintentional. The need for transparency is pressing. Without responsibility and accountability, the effectiveness of patient safety and care is undermined.

Patients represent the central focus of healthcare. While physician health is an important piece, referring to doctors who have committed medical errors as “second victims” obscures the difference between the two in terms of agency. The emotional distress suffered by physicians should be addressed, as it can affect their quality of care with their patients, but we might question whether referring to both patients and providers alike as “victims” is the best way to address the situation.

The Perils of Globalizing Mental Health

Photograph of 1944 poster that says "mental health is your concern"

In an age where self-care is a commonly touted virtue, it’s easy to take for granted what a recent development the gradual de-stigmatization of mental illness is. Celebrities constantly come forward with harrowing stories of struggle and recovery, pop-psychology blogs and websites abound, and every day we see more open and honest discussions about the foundations of and treatment options for mental illness.

Perhaps the globalization of this phenomenon is even more surprising. Mental health has truly become a global concern, with researchers and psychiatrists from a diverse array of cultural backgrounds contributing to our understanding of mental illness. Counseling is now considered an essential part of post-disaster relief packages, trauma being an assumed result of natural disasters. In the wake of the earthquake and tsunami that devastated Indonesia in October of 2018, for one recent example, clinical psychiatrists and trained volunteers were deployed by the World Health Organization to administer psychological first aid. These changes seem to signify the end of stigma, indicating more effective approaches to treating nebulous and painful conditions that afflict people around the world.

But despite the growing global concern over mental illness, the West still acts as a dominant force in the discourse around mental health. The DSM, or the Diagnostic and Statistical Manual of Mental Disorders, a handbook of symptoms and treatment options for mental illnesses compiled by the American Psychiatric Association, is considered the gold standard for diagnosing mental illness around the globe.

We rarely stop to ask whether or not applying American understandings of mental health can have a detrimental effect on the way mental illness is treated in non-Western cultures. Our culture has come to consider conditions like depression and schizophrenia solely through a biomedical lens, as illnesses entirely dependent on a complex set of neurological misfirings rather than cultural causes.

But in his book Crazy Like Us: The Globalization of the American Psyche, Ethan Watters examines the ways in which the biomedical approach taken by Western psychiatry can have a negative effect on those suffering from mental illnesses in places with different understandings of what it means to have a unified sense of self. He argues that importing Western cures for mental illness, which are deeply rooted in our own cultural mores, to other nations is unethical.

Watters distinguishes between the pathoplastic and pathogenic causes of mental illness. Mental illnesses don’t function in the same way that diseases like cancer do, where the  expression of the disease is completely independent of cultural context. There are two ways that mental illness can express itself; the pathoplastic causes, which are individualized and culturally-specific, and pathogenic causes, the underlying psychological imbalances.

The difference between pathoplasticity and pathogenicity is explored by novelist Esmé Weijun Wang in her collection of essays The Collected Schizophrenias. She sees a vital distinction between “explanations”, the “spiritual narratives” that color pain and illness with cosmic significance, and “causes”, the neurological reasons for mental illness that are uniform for humans across the board. In other words, the pathoplastic causes of a disease, the explanations can have meaning for the afflicted, whether these explanations are rooted in culturally-specific expressions of pain or find outlets in things like religion.

Most researchers dismiss the pathoplastic causes as irrelevant, but Watters posits that “culture and social setting play a more complicated role in the disease than simply influencing the content of the delusion.” In Western society, we push the narrative that mental illness is biomedical, an illness as removed from cultural influences as cancer, but research suggests that the biomedical approach, taken solely on its own, can be harmful and even heighten stigma against mental illness.

Despite our growing interest in helping the mentally ill, stigma against mental illness in the West has actually been increasing since the 1950’s. According to a 1996 study,

Among adults who associated mental illness with psychosis, the odds of describing a person with mental illness as violent in 1996 were 2.3 times the odds of describing a person with mental illness as violent in 1950 […] Perceptions of dangerousness were associated with causal attributions of mental illness. Causal attributions of genetics or chemical imbalance increased the odds of perceiving a person with schizophrenia as dangerous to themselves and others.

While “perceptions of dangerousness appear to have stabilized” between different illnesses from 1996 and 2006, with “no significant differences […] in the public’s perceptions of dangerousness of adults with schizophrenia or depression,” the perception of dangerousness hasn’t faded from mental illness as a whole. The biomedical perspective on mental illness, the study suggests, has insidiously increased stigmatization by casting the mentally ill as inherently dangerous, helpless prisoners of their own minds. Watters suggests that the Western approach, while offering valuable insights on the underlying causes of disease, can be dehumanizing for the afflicted. It reflects a very Western sense of the body as divorced from culture, a neutral space only affected by genetic predispositions. Watters argues that what we’re actually importing to other cultures is not Western psychiatry but the Western idea of the self, our conception of what it means to be a functioning member of society. In our culture, we tend to have a strongly internal locus of control, meaning most Americans view themselves as completely in control of their lives, whereas other cultures have a more external locus. Our approach towards mental illness reflects this; those with mental illness are often viewed as lacking the willpower to overcome their condition. Despite the biomedical approach most Westerners subscribe to, which should firmly place the cause of mental illness outside of the afflicted, these beliefs persist.

This issue is part of an important ongoing conversation about the impact of globalization and Western hegemony. In the next century, we’ll see more natural disasters caused by climate change, which will inflict trauma on large populations of those already disenfranchised by poverty and disease. More trauma means more counseling and medication, specifically Western counseling.

Diagnoses can stick, sometimes doing more harm than good. Esmé Weijun Wang remarks that in Western society, “it is easy to forget that psychiatric diagnoses are human constructs, and not handed down from an all-knowing God on stone tablets; to ‘have schizophrenia’ is to fit an assemblage of symptoms, which are listed in a purple book [the DSM] made by humans,” and therefore not infallible. While therapy is undoubtedly useful for many, we should be cautious before applying it as a universal cure-all, and encourage rather than discourage global diversity in the field of mental health.

Why Blaming Ariana Grande for Mac Miller’s Death is Unethical

"Ariana Grande" by Emma is liscensed under CC BY 2.0 (via Flickr).

Substance Abuse and Mental Health Administration (SAMHSA) hotline: 1-800-662-HELP (4357)

On Friday, September 7, well-loved rapper and talented musician Mac Miller died of a drug overdose, according TMZ. The tragic loss of the 26-year-old musician was a painful shock to many, including singer and Miller’s ex-girlfriend, Ariana Grande. Grande, who is usually active on social media, has been understandably silent, posting only one image on her Instagram. Continue reading “Why Blaming Ariana Grande for Mac Miller’s Death is Unethical”

“Unbearable Suffering” and Mental Illness

Photograph of a single bed with a curtain and chair

Trigger warning: suicide attempts, multiple mental illness mentions

List of international suicide hotlines: http://ibpf.org/resource/list-international-suicide-hotlines

Aurelia Brouwers’ Instagram bio is terse and pointed: “BPD, depression, PTSD, anxiety etc. Creative. Writer. Gets euthanasia Januari [sic] 26. Fights till then for this subject.”

Brouwers was a twenty-nine year old Dutch woman who suffered from multiple mental disorders. She received her first diagnoses of depression and Borderline Personality Disorder at the age of twelve. As she recounts: “Other diagnoses followed – attachment disorder, chronic depression, I’m chronically suicidal, I have anxiety, psychoses, and I hear voices.” After an estimated twenty failed suicide attempts, Brouwers thought she found the solution to her suffering via euthanasia or physician-assisted suicide (EAS). EAS has been legal in the Netherlands since 2002, but Brouwers faced obstruction as her request was refused by multiple doctors. She finally turned to The Hague’s End of Life clinic, which approved her request and set a date for January 26 of this year. Scenes from Brouwers’ last fortnight of life were recorded by RTL Nieuws journalist Sander Paulus, who noted the young woman’s ongoing mental distress as well as the conviction with which Brouwers anticipated her euthanasia date. Footage featured by the BBC shows Brouwers collectedly making plans for her cremation ceremony with a funeral consultant. On January 26, surrounded by loved ones and two doctors, Brouwers consumed a liquid poison and “went to sleep.”

Brouwers’ case stoked vigorous debate in the Netherlands and elsewhere regarding the intent of euthanasia legislation. Her youth is one point of contention. Another factor is the nature of her affliction. In the discourses following Brouwers’ life, we see evidence of an assumed distinction between physical and psychiatric disorders. Journalist Harriet Sherwood went so far as to note in the tagline for her Guardian article that ”there was nothing wrong with her [Brouwers] physically.”

While psychiatric disorders are still primarily diagnosed via mental and behavioral markers, it is not strictly correct to assume that mental health disorders lack physical foundations. Often, the ways in which we speak of mental disorders reveal our imperfect knowledge of the biological elements (as differentiated from the more traditionally observed psychosocial components) of mental disease. This relative ignorance exists in part because researching biomarkers for psychiatric disease is a complex undertaking. What is known is that mental illnesses can often be life-long conditions that require ongoing treatment, treatment that appears to have been provided in Aurelia Brouwers’ situation.

The 2002 Dutch act exempting physicians from prosecution in specific EAS cases requires ”due care” by the attending doctor. This includes ascertaining unbearable suffering on the part of the patient without hope of improvement. The Netherlands is joined in this relatively open model by other European nations, including Belgium, Luxembourg, and Switzerland. Several American states, the Australian state of Victoria, and Canada also allow EAS, but in much more restricted circumstances mirroring the “Oregon model,” which stipulates a terminal illness with established life expectancy.

Arguments in favor of euthanasia often rest on the basis of respect for individual autonomy and on compassionate grounds. Here, for the sake of simplicity, I assume ethical assent to these grounds in support of voluntary euthanasia or physician-assisted suicide which is at the informed, long-standing behest of the patient. This is the only form of active euthanasia currently legal anywhere (whereas what some call ”passive” euthanasia or the withdrawal of futile treatment is considered to be normal medical practice). These moral justifications – autonomy and compassion – are taken as reasonable in states in which EAS is legalized. In the Netherlands, however, where EAS has been legal for sixteen years, Brouwers was initially refused by several doctors, and garnered national attention. Why?

Brouwers’ example seems to challenge notions of what constitutes “unbearable suffering,” impossibility of improvement, and “terminal” conditions. Popular conceptions of mental illness present it as something that one can “overcome” through patience or willpower, although the same perceptions do not apply to a broken bone or a cancer diagnosis. Dutch psychiatrist Dr. Frank Koerselman, speaking to the BBC, notes that Borderline Personality Disorder, from which Brouwers suffered, is known to decline in severity after the age of 40. But BPD was only one of Brouwers’ multiple diagnoses, which taken together, caused her immense suffering. Along these lines, some argue that her mental disease was itself terminal, as does Kit Vanmechelen in the BBC article. Brouwers had already engaged in numerous, though incomplete, suicide attempts.

What happens, though, when we allow EAS for psychiatric suffering as well as physical suffering (the more traditionally accepted justification)? As a society, our understanding of mental suffering does not seem to be as advanced as that of physical suffering (only recently was it discovered that emotional pain activates neural correlates similar to physical pain).

Many believe that it is a mistake to open this door. Dr. Koerselman opposes EAS for psychiatric disorders, in part because he posits it is not possible to distinguish a rationalized decision to die from a symptom of mental disease itself. On the other hand, a recent study of Belgian mental health nurses’ attitudes toward euthanasia for unbearable mental suffering found a widely positive response. Nurses were the subjects for this study because of their closeness to patients’ lives and frequent role as intermediate and advocate between patients and doctors.

Ethics is about individual cases, as well as the general principles that they reveal or elicit along the way. The case of Aurelia Brouwers is undeniably a tragic one, although Brouwers herself appeared to find some peace in her capacity to make an informed choice, supported by medical care. But what her life surely reveals is that we need to invest more in exploring the genesis and maintenance of mental disorders within our societies. One in four people world-wide will suffer from some form of mental illness. We need to invest more in understanding the biological bases of mental illness, as well as the social structures that are implicated in psychiatric disorders’ psycho-social components.  In the words of Brouwers, “I think it’s really important to do this documentary [of Brouwers’ life] to show people that mental suffering can be so awful that death, in the end, is the lesser of two evils.” As a society, we need to do better by those who experience mental pain.


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The 21st-Century Valedictorian and the Battle for First Place

An image of high school graduates during a commencement ceremony.

According to 16-year-old Ryan Walters of North Carolina, abolishing the title of valedictorian in high schools only serves to “recogniz[e] mediocrity, not greatness.” Ryan was interviewed for a Wall Street Journal article about ridding schools of valedictorian titles, and he provides a voice of disapproval and disappointment. After working toward the glorious title of valedictorian for many years of his life, Ryan’s dream is over, as his high school has decided to do away with recognizing the top performer in each graduating class. This harsh critique by the Heritage High School junior may have some validity, but it can also be refuted.

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Is it Fair to Blame President Trump’s Behavior on Mental Illness?

A dark photo of Donald Trump clapping.

On October 25, former Oklahoma Senator Tom Coburn (a Republican) said that President Trump has “a personality disorder.”  He was not the first to posit that President Trump has some form of mental illness. The press has been engaging with such speculation since the start of his campaign, though there has been a decided increase of late. On October 26, New York Times columnist David Brooks reported that some Republican senators thought Trump is “suffering from early Alzheimer’s.” In an article titled “Some Republicans are starting to more openly question Trump’s Mental health,” Business Insider reports that “One psychiatric professor at Yale said about half a dozen lawmakers had contacted her over the past several months.”

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Mental Health, Information Literacy and the Slenderman Stabbing Case

A sidewalk chalk drawing of Slenderman.

On May 31, 2014, two 12-year-old girls lured a friend, also 12, into the woods with the promise of a game of hide-and-seek.  Once there, one of the girls pinned their friend down, while the other stabbed her 19 times with a long-bladed kitchen knife, causing serious injuries to major organs and arteries.  The young perpetrators then fled the scene, leaving their young friend to die of her injuries.  Miraculously, the victim survived.  She was able to crawl to a road where a cyclist found her and went for help.  

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Diagnosis from a Distance: The Ethics of the Goldwater Rule

The September/October 1964 issue of Fact magazine was dedicated to the then Republican nominee for president, Barry Goldwater, and his fitness for office. One of the founders of Fact, Ralph Ginzburg, had sent out a survey to over 12,000 psychiatrists asking a single question: “Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” Only about 2,400 responses were received, and about half of the responses indicated that Goldwater was not psychologically fit to be president. The headline of that issue of Fact read: “1,189 Psychiatrists Say Goldwater is Psychologically Unfit to be President!”

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Classical Music and the Cost of Perfection

Growing up, I always knew I wanted to be a singer. I was that child who always told her friends and family that she was going to be on American Idol when she turned sixteen, but was actually talent-less, which usually fostered an encouraging pat on the back and an “oh, that’s nice, dear,” from amused adults. Thanks to several outstanding music educators, I fortunately grew into my voice in high school, and decided I wanted to pursue a career in opera.

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To Whose Benefit is Aversion Therapy?

It is doubtful that any individual ever grows up expecting to have a child with any type of physical or mental disability. No one plans their life thinking that one day they will have to care for a person with special needs. Parenting is a challenge as it is, but learning to parent a child with disabilities is infinitely more difficult because of this lack of preparedness.

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The 21st Century Cures Act and Prioritizing Diseases

The 21st Century Cures Act represents the kind of bipartisan diligence and compromise from a bygone era. Passed with overwhelming consensus by the House on November 30th 392-27, this mammoth health spending bill has brought two parties together that have been polarized during the recent presidential campaign. This over 1,000-page bill combines the efforts of millions in lobbying spending, Republican values of deregulation and Democratic values of expanding health care spending and including individual patient advocacy in drug testing regimen. Who are the winners and losers of the 21st Century Cures Act, and are the controversial aspects of this monumental legislation?

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Depicting Mental Health on Halloween

In a recent post published by the Prindle Post, staff writer Carrie Robinson discussed the ethics behind displaying mental health in Knott’s Berry Farm attraction FearVR 5150, which “sparked concerns about the stigma surrounding mental health.” 5150 corresponds to a California police code that denotes interactions with individuals with mental illnesses. Essentially, the ride took individuals through various scenes displaying their version of what a haunted mental health hospital would entail. This inherently portrays highly polarized and stereotypical views of mental health issues that negatively depicts those who suffer from them.

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Rap Culture’s Effect on Mental Health

Recently, rapper Scott Mescudi, also known by his alter-ego Kid Cudi, checked into a rehabilitation clinic. Upon entering rehabilitation services, Mescudi published a Facebook post detailing the internal struggle he has been going through after delaying the release of his anticipated album Passion, Pain, and Slayin’ Demons. Mescudi’s brave and open look into his personal life has facilitated many conversations surrounding the feminization of mental health and its correlation with race. His openness has allowed us to ask key questions on how we should talk about mental illnesses and how our daily actions can have detrimental effects on the ones around us.

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Mental Health Stigma at Knott’s Berry Farm

 

Knott’s Berry Farm’s Halloween theme park, Scary Farm, has recently closed its Buena Park, California attraction, Fear VR, in response to criticism. The ride was originally called Fear VR 5150,  the number corresponding to a California police code regarding involuntary detainment of individuals with mental disorders. The 5150 was dropped from the name before the ride’s opening in response to concerned mental health advocates in an attempt to create further distance between the supposed mental health connection. However, the original connection to code 5150 leads some to speculate that Knott’s Berry Farm did in fact intend a relationship between the ride and mental health, at least at first.

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Has Your Newsfeed Hurt Your Mental Health?

Within the past few years, it has become even easier to put up videos on social media instantaneously. So many of those that go viral depict something violent, such as the many horrible instances of police brutality that have made the news this year alone. Though often shocking, disturbing, and tragic, these videos do serve as evidence in cases of violence, and sharing them on Facebook can help spread awareness against the crimes committed in them.

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From the Cuckoo’s Nest to the Jailbird: What’s Happening to the Mentally Ill in America?

The history of mental illness is riddled with what are now horror stories: mental illnesses “treated” by bleeding patients with leeches, dousing them with hot or cold water, or simply putting them to death. From the 1600s to the 1800s in Europe and in the newly established United States, it was common for mentally ill people to be locked away in asylums, sometimes chained to the walls in what were essentially dungeons. Movements in the 1800s by activists like Philippe Pinel in France and Dorothea Dix in the northeastern states of the US helped to change these dungeons into what better resembled hospitals, with more comfortable housing and medical doctors.

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A Student Perspective on Trigger Warnings

I first encountered the classroom trigger warning in the fall semester of my junior year. The course in question covered humanitarian intervention, a particularly dark topic amongst any number of dismal subjects in political science. As a result, soon after talking through the syllabus, our professor made special mention of the topics at hand. The classes to come, we were told, would cover a number of heavy topics: genocide, ethnic cleansing, wartime rape and other forms of systematic violence. Reading about such material on a daily basis, the professor warned, could be emotionally upsetting. Drawing attention to this fact wasn’t an effort to silence the topics or distract from their discomfort. In communicating their emotional gravity, our professor was simply trying to prepare us, encouraging us to keep tabs on our mental well-being as we proceeded through each difficult discussion.

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