Mental(izing) Health
Newsletter, #35
No mental health professional is successful in all cases. But when we fail, how scrupulous are we about understanding what went wrong (especially in private practice)? Why don’t we have more developed practices for assessing mixed success and failure? Patients can be unresponsive to treatment; some patients might even have a desire or a motive or both to defeat their therapists’ effort to help. And, of course, therapists can be awkward and misguided with some people, despite being terrific with others. We fail because the system works to undermine the treatment that would be most appropriate for the patient. We fail simply by virtue of being out of reach for many people. We also fail because of our own biases, disavowed and unacknowledged. Treatment is not widely available for minoritized people, and insensitivity to issues around race, ethnicity, and culture have alienated many patients who have sought our help.[i] Multicultural competence is only meaningful against the recognition that there is a history and ongoing consequences for all therapists to reckon with and strive to overcome.
In this month’s newsletter, I want to write about an extraordinary recent book, Strangers to Ourselves: Unsettled Minds and the Stories that Make Us, by Rachel Aviv, a New Yorker journalist.[ii] I shall focus narrowly on one of the six cases that she writes about and will not be reviewing the book in toto.[iii] However, I cannot resist recommending the book, as it presents the work that we do as mental health professionals from the perspective of patients in a way that we need to hear in the era of evidence-based treatment. The book is fierce in its embrace of complexity: in each of the cases, we are asked to consider both how diagnosis illuminates and diminishes the person, and to ponder how our efforts to make sense of mental illness cannot escape both the radically idiosyncrasy of each individual and the shared suffering that no human escapes.
The case of Naomi is about an African American woman who commits a horrible act: in a combined suicidal and homicidal gesture, she jumps from a bridge in St. Paul on July 4 at the Taste of Minnesota Fair with her twin children, one of whom survives and the other of whom dies. She is saved in a remarkable act of altruism by a man whom she later befriends, when he contacts her in prison. Naomi is tried for second degree murder but agrees to a plea bargain (where she would serve 14 years in jail and 4 years on supervised release), and then emerges to reclaim her life. We cannot begin to make sense of who Naomi is without hearing more about her early life history.
Raised in one of 28 concrete buildings in one of the largest and most notorious housing projects on the south side of Chicago, the Robert Taylor Homes, Naomi’s prospects were not bright. She was a sensitive kid and was fortunate to have an older sister who guides her in a way that her mother is unable to do. It is moving to hear how her older sister would read to Naomi, encouraging her to imagine different worlds and to escape mentally from her immediate circumstances. Naomi’s mother drank and did drugs; she moved to Milwaukee to escape an abusive boyfriend (to whom she later returns). We hear about her mother’s history of being barely literate and having grown up in foster care. The intergenerational transmission of trauma, while not named by Aviv, emerges as a key theme in the narrative.
Naomi loved to read and spent up to 8 hours a day in the library while living in Milwaukee. The family moves back to Chicago temporarily; her mother then moves on to St. Paul, and Naomi follows her after having a child. Things improve for them because of the social support they receive. Naomi graduates from high school, takes college classes and works as a teacher’s assistant. She also joins the Vibin’ Collective, a group of activist poets and singers whose work highlighted “poverty, police brutality, and the failure to educate black children” (p. 122). Nevertheless, Naomi began to experience depression, undergirded by a sense of dread about her child’s future. She ended up slitting her wrist in a suicidal gesture. Naomi was hospitalized, but released with a prescription for Zoloft, which she decided not to take, so she would be able to confront the social world she inhabited.
Eventually, Naomi developed a relationship with a musician and gave birth to the twins. She struggles to care for her children, and her family intervened and tried to help her out. Naomi became preoccupied with the belief that she could cure racism, and after she exhibited bizarre behavior a month after giving birth, her mother calls 911 and she was hospitalized again. She was diagnosed as bipolar and put on anti-psychotic medication (Zyprexa). Soon after, she was hospitalized again, this time diagnosed with “psychosis not otherwise specified.” While Aviv observes that there was no recognition of her psychosis as post-partum, she does not specifically entertain whether Naomi endangered herself and her twins under this shadow. In an on-line interview, Naomi refers to being diagnosed with post-partum psychosis (along with bipolar and schizoaffective disorder.[iv]
Another hospitalization occurred after Naomi was found wandering in the night with her children in tow. She was diagnosed as bipolar, relapsing and cycling, and with “no insight into her disease.” Four months before the suicidal and homicidal act, Naomi returned to the ER, and the psychiatrist documented her stated wish “to convert people into not being racist and accepting her people” (p. 146). Aviv supplements Naomi’s saga with attention to history and to ideas that pertain to the experience of minoritized people, especially with the mental health system. For example, she cites the following from the work of bell hooks: “Many black folks worry that speaking of our traumas using the language of mental illness…will lead to biased interpretation and to the pathologizing of black experience in ways that might support and sustain our continued subordination” (quoted from p. 130). Aviv mentions the Lafargue clinic, a psychoanalytic mental health clinic in Harlem, founded by the writer Richard Wright, that closed after not being able to find city or state funding.[v] The work of Helena Hansen, a psychiatrist at UCLA, seems especially significant, as she stresses that her patients find it therapeutic and empowering “when she acknowledges the social structures that have contributed to their state of mind” (p. 145).[vi]
In Naomi’s trial, she opted for an insanity plea, which was rejected on the basis of her coherent views about race. How ironic, and how symbolic that her enlightenment about diversity, equity and inclusion ended up being used against her. Of course, Naomi’s responsibility for the death of her son is disturbing, and it is apparent that she struggled with states of mind that were paranoid, grandiose, and irrational. With advice of her attorney, she agreed to the plea bargain, and began to serve her sentence.
Naomi’s experience in jail spanned highs and lows. She was forced to take medication (Geodon, an anti-psychotic, and Depakote, a mood stabilizer) but did well on them, telling a nurse that “The person here today would never have harmed her children” (p. 147). She spent a lot of time in the library and is then offered the desirable job of working there by the librarian who becomes a strong supporter. Naomi formulated a plan to write a memoir. She had an encounter with a young, white psychologist that seems to go well. She attended groups. It is noteworthy, without a doubt, that Naomi was able to develop positive relationships under such difficult circumstances. However, things begin to go worse after her medication (Geodon) was stopped because of its expense, and subsequently Naomi choose to go off her other medication (Tegretol). She decompensated, and she ddi so severely after being put in solitary confinement for 60 days.
Sixteen years after her crime, Naomi was released from prison. One of her daughters came to live with her. Life for a former convict was tough: Naomi was rejected to work as a peer specialist; she takes a job at a dollar store and was offered a promotion only to be denied because of her history. She told Aviv the following about her state of mind: “I still have certain things I believe about who I am and my destiny—there are still some mysteries, some questions in my mind—but I am able to put those thoughts on the back burner, so that I can be a good sister and daughter and mother; so that I can take a shower, have normal conversations; so that I can go to work. But meds don’t take it all away—there are certain ideas I carry with me” (pp. 175-176). What a sober and honest expression of her ability to mentalize about herself.
It is unclear what Naomi’s relationship to therapy was in the past or going forward. On the one hand, she has the skepticism that manifests the iatrophobic history of African Americans with the medical system.[vii] At one point, Naomi exclaims that “I need help and not the help that dry judgmental therapy sessions with PhDs give” (p. 154). It is fair to wonder what a difference it might have made if Naomi was able to work with a therapist who could balance legitimate concerns about diagnosis and treatment and still make the effort to listen closely to what the patient has to say about her experience in the social world. It is profoundly sad that Naomi, as many minoritized people, first encounter mental healthcare while incarcerated.
At the emotional heart of Aviv’s narrative is a story about another woman who killed her children. When Naomi first heard of Khoua Her, the Hmong mother who killed all six of her children, her reaction was hostile. She was surprised, while in prison, to be approached by Her. Naomi befriends her, and Aviv chooses to end her piece with this song written by Naomi:
When I came to prison, guess who held out her hand?
Guess who said: “If you need someone, I’m a friend?”
Guess who understands what no perfect mom will?
The same mom back in ‘98
I condemned Her
My friend (p. 176).
Both women are touched by tragedy and bear responsibility for their actions. Khoua Her helps to bring out the goodness in Naomi, and Naomi reciprocates this, celebrating the bond between them. Almost as poignantly, Naomi saw the film Beloved by Tony Morrison, while in prison, where a mother kills her own daughter after they run away and the daughter is about to be returned to slavery. The daughter later returns as a ghost to haunt her family. Naomi is inspired to talk to her own mother about trauma after seeing the film. Although it does not seem that her mother was so responsive, Naomi’s inclination to make sense of her life as impacted by the intergenerational transmission of trauma is striking.
If you are on edge hearing about the life of Naomi, so am I. There is no conclusion to be made, except to wonder if the tragedy could have been avoided. Her case forces our attention to how much human potential is wasted, how little opportunity exists for so many, and how much frustration and rage this must perpetuate. Naomi is currently an activist for mental health care in the black community. She continues to sing, and recently posted a video, where she reflects on being in prison: how she was influenced by reading Viktor Frankl’s book, Man’s Search for Meaning, which gave her a sense of hope. However, as she began to embark on her own journey of well-being, others saw her as being arrogant.[viii]
It was, I believe, during the Reagan years that ideas were put forward countering the changes of the 60s, postulating that while the civil rights struggle was legitimate in its day, we have done as much as possible to accomplish to level the playing field. This was a polite and disguised form of racism, and the truth is that the white nationalist movement grew significantly during the 90s, although the media largely ignored this development. Under Trump, the cat got out of the bag, and we are now seeing the kind of ugly racism that hark back to the days that preceded the Civil War. Surely our recent history cannot be summed up in a few sentences. My hope, though, is that this sketch might be enough to convince readers to worry and think about doing something about the consequences of failing to help people who really need our help. We hear a lot these days about the overwhelming need for mental healthcare; we hear less about prioritizing the people whose needs are the greatest and whose access is the most limited.
[i] The term “minoritized” is meant to connote that being part of a minority group is a product of how one is seen from the perspective of the dominant culture and differs from one’s self-representation, from how one sees oneself.
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[ii] R. Aviv (2022). Strangers to Ourselves: Unsettled Minds and the Stories that Make Us. New York: Farrar Strauss and Giroux.
[iii] Aviv discusses the case of Naomi from her book in an MPR interview:
[iv]https://mail.google.com/mail/u/0/#search/ashleyfeng714%40gmail.com/QgrcJHsHsHTtjRbDpWMQmCPLgKRnmLSjdcg?projector=1
[v] The Lafargue clinic was the subject of a previous newsletter:
[vi] For Hansen’s work, see J. Metzl and H. Hansen (2014). Structural Competency: Theorizing a New Medical Engagement with Stigma and Inequality. Social Science & Medicine, 103: 126-133. https://doi.org/10.1016/j.socscimed.2013.06.032.
[vii] H. Washington (2008). Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Anchor).