Mapping the Mind

The Family Guide to Mental Health Careby Lloyd I. Sederer, M.D.

W. W. Norton & Company. 328p $25.95

I recently met with a young psychiatrist who said, “Five years ago, I wouldn’t have tolerated those behaviors,” referring to fairly typical symptoms of children and adults with mental illness. His candor was a little surprising—he had chosen to specialize in psychiatry—but not unusual. Many people continue to assume that these behaviors are chosen or, at very least, that they can be controlled.

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Dr. Lloyd Sederer has spent his impressive medical career in psychiatry and demonstrates both his knowledge and sensitivity in his book, The Family Guide to Mental Health Care. The subtitle identifies his intended audience: “Advice on helping your loved ones” because “every year, 1 in 4 adults in the United States will experience a mental illness...well over 50 million adults and children in the United States fall ill each year.” He offers another sobering figure: “An astonishing 80 percent of Americans with treatable mental disorders do not receive proper diagnosis and effective treatment.” He then provides families with information and tools to aid them significantly in making sure this harrowing reality can be changed.

In large measure because living brains cannot easily be opened and examined, as can other body organs, mental functioning remains mysterious. The brain is a very complex organ that directs and dictates much of body functioning. Since the expanded use of functional M.R.I. imaging, many brain processes are now better understood. The 1990s, called the “decade of the brain,” proved exciting but unfinished. Now research can better explain how genetic predisposition influences ease in life or onset of dis-ease. But genetic expression requires activation, and from infancy brains rely on input from the environments we inhabit, environments that are constructed with biological, psychological and social forces.

The etiology of mental illness has been challenging to understand, and the National Institute of Mental Health is increasing efforts through the recently announced Brain Initiative. There have been significant advances in pharmacological treatments, but most honest providers admit that the reasons for medical relief remain unclear and occasionally accidental, as evidenced by placebo effects. Richard Friedman, M.D., wrote in The New York Times (8/19) that: “knowing how a drug works in the brain doesn’t necessarily reveal the cause of the illness.” In child psychiatry, there is increasing reliance on off label use, prescribing medications to relieve physiological agitation and body dysregulation, suggesting that mental illness is felt in the body as well as the brain.

A second challenge is the exquisite interplay between brain functioning and mind influence. David Brooks, a New York Times columnist, recently warned against over-reliance on neuroscience to fully explain human functioning. “The brain is not the mind. It is probably impossible to look at a map of brain activity and predict or even understand the emotions, reactions, hopes and desires of the mind” (6/17). Our brains are capable of neuron misfiring, but our minds are also capable of feats of agency and meaning—making that block or facilitate change.

And finally, mental illness continues to trigger bias and prejudice. It is still common to hear that problems are “all in his head.” Mental illness is attributed to character failures. Emotional intensity remains suspect within many families and communities, especially when this intensity is paired with seemingly irrational behaviors. And often judgment replaces sympathy, as if the suffering person is fabricating disease, deserves disease or is, at the very least, unwilling to recover.

Dr. Sederer challenges these biases: “Mental illness is an equal opportunity thief that steals individual and family stability.” He offers ample and accessible information about diagnostic categories, about the course of illness and about both biological and psychosocial treatments that can alleviate symptoms and restore functioning. He addresses illness that may be situational and temporary, and illness that can be life-long and life-altering. He offers families the knowledge and the courage to demand good mental health care. He is open about deficits in the existing mental health system of care. But the difficulties of diagnosis (no blood tests, no mechanical tools for identifying cause) and challenges to find the best treatment are secondary to this persistent prejudice about mental illness and the painful difficulties of helping the person with mental illness accept that this is an illness.

Some years ago a colleague who was both a gifted psychologist and a person with serious mental illness explained how hard it was to accept well-intentioned advice when delusions are an active part of your illness, when your brain causes confusion, when your senses and perceptions are altered. Just as physical pain can alter one’s sense of reality, so can mental illness, but so much more since we must rely on our brains to orient us to what is going on.

Families and friends ask what they should do. The Family Guide to Mental Health Care provides steps toward kind support and guidance. Pervading Dr. Sederer’s book is a strong recognition that human company is a powerful mediator of pain and that relationship support can alleviate the desolation and isolation that are frequently companion symptoms of mental illness. His examples encourage better fluency when talking about illness and helping ill persons to recognize symptoms and behavioral effects that compromise functioning and disrupt important relationship connections. He uses this important phrase—wellness self-management—to describe the complex processes of recovery and stabilization and help families realize how best to support someone living with mental illness.

Recently, in another New York Times article (10/1), the New York chapter of the National Alliance on Mental Illness (N.A.M.I) reiterated the data Dr. Sederer cites: “Only 61 percent of Americans think it appropriate to tell family members about a mental illness diagnosis, 43 percent approve of telling friends about a diagnosis, and just 13 percent of telling co-workers.” Recognizing that mental illness remains a stigma, they initiated a public service campaign that includes this message: “1 in 4 Americans are impacted by mental illness. Make a promise to listen.” The Family Guide to Mental Health Care provides families with valuable resources, but maybe everyone should read it. To change attitudes about mental illness requires that everyone listen and understand.

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