ALL IN YOUR HEAD: Illness as Identity, Trauma as Fashion, and the Desire to Be Disordered, by Fredrik deBoer
The ubiquitous human condition amorphously known as mental illness has always been with us. Yet it continues to be seen — as the recent trial of Lindsay Clancy demonstrated — as a moral aberration, defying sure judgment. Although we may no longer condemn it as we once did, consigning sufferers to asylums and punitive treatment, public understanding has not evolved a great deal.
Fashions in conceptualizing psychiatric disorders have come and gone, reflecting the cultural climate: Mental illness has been vaunted as a higher form of sanity (the Scottish psychiatrist R.D. Laing), glamorized as noble resistance to bourgeois values (Ken Kesey’s classic novel, “One Flew Over the Cuckoo’s Nest”), reduced to non-biological causes (the Hungarian American psychiatrist Thomas Szasz) and, lately, promoted by Gen Z online, where performative illness, however factitious, is rewarded, and terms like “neurodivergent” hold sway as admirably cool.
Fredrik deBoer’s book, “All in Your Head,” arrives as a welcome antidote to faddishness, casting much-needed light on our murky grasp of the subject. A writer and culture critic, deBoer begins his deeply informed and wide-ranging account by relating his own experience with bipolar disorder and its blighting effect on his life, including time spent in “loony bins” and “a decade and a half of constant instability, of shattered relationships and financial disasters.”
Yet his book is not a memoir. Instead, it is an impassioned yet cleareyed analysis of how disability activism, deinstitutionalization, romanticization of the mentally ill, and the anti-psychiatry movement (with its accompanying anti-medication agenda) have ended up harming the very individuals they propose to help.
Among deBoer’s many culprits for the ways in which the treatment of serious mental illness has foundered are individuals like Laing, who posited that madness could be understood as “a voyage of discovery” and “a path to enlightenment,” and Szasz, whose “brutish libertarianism” and grandiose belief in a policy of “benign neglect” toward the mentally ill are the cornerstones of the anti-psychiatry movement, as well as the Stanford psychologist David Rosenhan, who set out to prove that psychiatric diagnosis was hogwash and that mental hospitals were inherently dehumanizing places.
Rosenhan’s much cited 1973 article in Science, “On Being Sane in Insane Places,” reported the results of a study in which he and a group of “pseudopatients” feigned auditory hallucinations, thereby gaining admission to psychiatric hospitals, where seven were diagnosed with schizophrenia, the eighth with bipolar disorder, and all were hospitalized for an average of 19 days. (The study was debunked as a fraud in Susannah Cahalan’s 2019 book “The Great Pretender.”)
But deBoer indicts larger, more collective forces as well, such as public policies that facilitated deinstitutionalization, beginning with the Community Mental Health Act of 1963, the last bill President John F. Kennedy signed before his assassination. DeBoer notes that Kennedy’s decision was likely influenced by the experience of his sister Rosemary, who suffered from mood swings and violent outbursts, and at her father’s insistence underwent a lobotomy at 23 before being consigned to an institution.
With the development in the 1950s of psychotropic drugs, including Lithium for bipolar disorder and the antipsychotic Thorazine, patients who had previously been warehoused in psychiatric facilities could, at least in theory, live in halfway houses or be treated on an outpatient basis.
Other factors deBoer singles out for their unintended negative consequences are O’Connor v. Donaldson, a 1975 Supreme Court decision, and the Americans with Disabilities Act, signed into law by President George H.W. Bush in 1990. The court ruling limited involuntary institutionalization to individuals who were judged in a medical evaluation to pose an imminent danger to themselves or others, which, deBoer points out, meant that “psychiatrists would have to serve as amateur fortunetellers, trying to predict a patient’s chance of acting violently in the future.”
The A.D.A. sought to provide the disabled population with greater access to public spaces and services, a goal, deBoer concedes, that was “profoundly salutary” and “crucial for advancing the civil rights and integration of people with disabilities” — by requiring, for example, that wheelchair ramps be added to public buildings. But he decries what he claims are the law’s “perverse consequences”: By insisting that the mentally ill be treated in the “least restrictive” environment, it accelerated deinstitutionalization.
DeBoer’s strongest criticism, however, is directed at social media, which, he argues, promotes cartoonish representations of complex psychiatric diagnoses, and fosters imitative group identities based on little more than the wish for attention and validation. In describing the “fun-house mirror reality of mental illness in the 21st century,” he invokes the thousands of adolescent girls who took to TikTok in the early 2020s claiming to have dissociative identity disorder — otherwise known as “multiple personality disorder.” The “will to be ill” flourishes in a medium where illness can morph into “a kind of in-group status marker,” he writes, where truly grave conditions can be spun into a hashtag and there is gratification in gulling strangers within online support groups.
“All in Your Head” is a formidable and fearless entry into the high-stakes debate over how we treat the mentally ill. DeBoer rigorously (if a bit repetitively) makes his case that the seriously mentally ill continue to be misperceived or not seen at all. Some of the reforms he proposes, such as Medicare for all and continuity of care, are incontrovertible. Others, such as a return to the sort of gatekeeping in which psychiatrists are endowed with the authority to declare a person insane and involuntarily commit him or her to a mental hospital, would surely be met with resistance.
As someone who has suffered from severe depression and been hospitalized on several occasions, I have always been struck by the “othering” of the mentally ill, given that it is all around us in the form of family members or friends. I read “All in Your Head” with admiration and a sense of relief that here was a writer willing to go up against some of the bromides that doubtless make mental illness more palatable but ultimately ensure that those who suffer from it will not be attended to in a way that brings relief.
ALL IN YOUR HEAD: Illness as Identity, Trauma as Fashion, and the Desire to Be Disordered | By Fredrik deBoer | Simon & Schuster | 321 pp. | $30
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