970x125
An extraordinary thing happened recently, when I flew across the country. Or, more accurately, one extraordinary thing started to happen, then didn’t, and another extraordinary thing did.
At the time I was doing talks and answering questions about psychiatric diagnosis, including the way mental health practitioners once considered conditions like depression, anxiety, and even psychosis likely to be temporary.
A shift to long-term thinking happened toward the end of the last century. In the late 1960s, the Diagnostic and Statistical Manual (DSM) used to diagnose psychiatric distress in this country went from using the label “reaction” to the label “disorder.” A “depressive reaction” became a “disorder,” and “temporary” hardened into “permanent.”
And gradually, with that shift, came the concept of disease “management,” generally defined as a lifetime of medication, rather than “cure”—though clinicians from Hippocrates in 400 BC to Sigmund Freud to those in the U.S. for most of the 20th century considered cure the correct goal in mind care.
Back to the plane. As we boarded, two men on this flight from Seattle to Atlanta got into a fight. One was seated to my left, one directly behind me, so at one point a hand was flying through my hair.
Flight attendants busied themselves elsewhere. The man to my left had been rummaging around in the overhead bin, and apparently, he shifted the backpack of the man behind me to make room for his own and moved several coats.
The rummaging enraged the other man, who I’d guess was in his early 30s, and who began screaming, “Why do you think your luggage matters more than my luggage? What are you doing? Why are you such a #@!%!” (I don’t recall the insult used, just that it was a bad one).
The man beside me, a little older, yelled back to calm down. But he sounded angry and the other man couldn’t let go. He continued to grab the man beside me by the shoulder (hence the flying fist) to ask him what he thought he was doing and why he thought other people’s luggage didn’t matter.
The flight happened this November, during the shutdown. TSA agents worked unpaid, many people were hurting financially, and the airport felt tense. I use a cane for long hauls due to rheumatoid arthritis, a carved wooden cane a TSA agent developed an instant antipathy for. I laid my cane in the bin, got yelled at, pulled it out of the bin and laid it on the belt, got yelled at, and tried to carry it. Nothing I did placated this agent, who grabbed the cane away from me and disappeared, finally throwing it to me at the end of the belt.
Back on the plane: as we took off, the man behind me finally sat down. He continued to badger the man beside me, and my guess was we’d make it across the country and the pair would be at it again.
But about an hour later, the man to my left turned around, looked the man behind me in the eye, and calmly and sincerely said, “I am really very sorry. I shouldn’t have done that. I shouldn’t have moved your stuff.”
The other man accepted his apology, gruffly at first. Then after a few minutes, he patted the shoulder of the man beside me—tapping, not grabbing—and said, “Hey, I just blew up for no reason. I’m so sorry.”
And later on, he did that again.
At the end of the flight both men got up and elaborately, thoughtfully, intentionally helped the people around them. The man on my left got my cane and suitcase, made sure the latter was close to me with the handle raised, and kept an eye on me as I got up. Then he began helping other people, many of them women flying on their own, with their suitcases.
The younger man did the same. He thoughtfully, intentionally helped people. It was as if both men had seen something in themselves they didn’t like, and simply resolved to alter that something.
I read recently an interview with Allen Frances, the psychiatrist who oversaw the fourth revision of the DSM but has strongly critiqued the current revision, the DSM-5. He critiqued the 5 partly for this reason—humans change, sometimes greatly.
“People change from week to week,” Frances says, and “people usually come for help at their worst moment, and how they look at that moment may not be characteristic of their past or predictive of their future.” Diagnoses, he said, should be “written in pencil.”
Not only have psychiatric diagnoses been written in permanent marker, doling them out has become as much a social practice as a medical one. We diagnose politicians. When I taught at a university, it disturbed me how often and how confidently faculty labeled their students—to the point, I once wrote, “that describing a class and hearing a psych eval didn’t sound very different.” Students weren’t uninterested, changeable, disagreeable, awkward; they were borderline, bipolar, schizoid, autistic.
Psychiatry Essential Reads
I think anyone sitting near me on this plane would assume both men had anger issues. And they did have anger issues—for some minutes. Until they didn’t, at which point, both replaced those with kindness issues.
Another point from Allen Frances: “the symptoms we see in the very ill aren’t necessarily inherent to their condition, but rather may be a reaction to the social context in which they’re living.” As these men’s initial belligerence probably reflected the airport, and their own version of having canes snatched away from them.
Flying’s stressful. Taking stress out on others is understandable, though we shouldn’t. Choosing to look around and meet the needs of those around you, just to be a better person? That’s extraordinary.
Frances writes, “80% of medication is dispensed in primary care practice, often after visits of less than 10 minutes.” That’s probably just enough time to get things wrong.
