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Book Reviews: Personal Accounts by Users and Providers of Mental Health Services   |    
Women's Encounters With the Mental Health Establishment: Escaping the Yellow Wallpaper ? Voices of Hope: Conversations With Helen L. Shore ? Diagnosis: Schizophrenia: A Comprehensive Resource for Patients, Families, and Helping Professionals ? Children of Jonah: Personal Stories by Survivors of Suicide Attempts ? Walk With Me ? Nothing to Hide: Mental Illness in the Family ? Changing Minds: Our Lives and Mental Illness
Jeffrey L. Geller, M.D., M.P.H.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.7.837
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edited by Elayne Clift, M.A.; New York, Haworth Press, 2002, 217 pages, $14.95 softcover • Marlborough, Massachusetts, Employment Options, Inc., 2002, 83 pages, $22 softcover • by Rachel Miller and Susan E. Mason; New York, Columbia University Press, 2002, 248 pages, $17.95 softcover • edited by James T. Clemons; Sterling, Virginia, Capital Books, 2001, 127 pages, $15.95 softcover • by Sally C. Strayer; Pittsburgh, 2003, 89 pages, $16 softcover • by Jean J. Beard and Peggy Gillespie; New York, New Press, 2002, 320 pages, $29.95 softcover • by Rosalind Ramsay, Anne Page, Tricia Goodman, and Deborah Hart; London, England, Royal College of Psychiatrists, 2002, 160 pages, $56 softcover

Women's Encounters With the Mental Health Establishment: Escaping the Yellow Wallpaper is an anthology of previously published and unpublished contributions. Many of the previously published works are by well-known authors, including an excerpt from The Bell Jar, by Sylvia Plath; "You, Dr. Martin," a poem by Anne Sexton; and an excerpt from The Loony-Bin Trip, by Kate Millett. Other extracts come from first-person accounts previously reviewed in this journal, such as Lauren Slater's Welcome to My Country (1) and Martha Manning's Undercurrents (2). Two chapters were contributed by Mindy Lewis; these are included in Lewis' Life Inside (3), published contemporaneously with this volume. Perhaps the best-known work included in Women's Encounters With the Mental Health Establishment, which serves as the book's prologue, is The Yellow Wallpaper, by Charlotte Perkins Gilman.

The many contributions that appear for the first time in this collection focus on women who have less serious mental illnesses. There are several accounts on milder eating disorders, several from college health services, one on infertility, and one with a lesbian theme. Several accounts include discussion of electroconvulsive therapy.

The accounts are generally balanced in that they provide both positive and negative views on medications and psychiatric inpatient settings. The accounts of electroconvulsive therapy are mostly negative. Unfortunately, the collection includes no accounts by women with schizophrenia, dual diagnosis of mental illness and substance abuse, or dual diagnosis of mental illness and mental retardation.

Issues covered in the anthology include sexual abuse, battered women, homelessness, inadequate health insurance, living in an unsafe world, postpartum depression, being the child of a mentally ill mother, being the daughter of a psychoanalyst, sexual side effects of selective serotonin reuptake inhibitors, transference, and differentiating between sadness and depression.

As with most collections, the contributions are very uneven. The book's attempt to reach women who can obtain "support, affirmation, care, and strength that only another person who has experienced the same events can furnish" and the aim to address professionals so they can increase their understanding of "the anguish of mental illness" are only partially reached.

Apart from Charlotte Perkins Gilman's portrayal of her psychosis in the prologue, few if any of the other contributors reflect Gilman's acute disordered sense of reality. This anthology might better have been called "A Subset of Women's Encounters With a Part of the Mental Health Establishment."

Voices of Hope is a collection of conversations with Helen L. Shore, a researcher with a background in counseling psychology. The conversations, each one a chapter, are between Shore and 23 "ordinary people of extraordinary spirit who live with mental illness" and are clients of Employment Options, a clubhouse similar to Fountain House. There are also six conversations with staff of the organization.

The thrust of Voices of Hope is to portray the interactions between clubhouse members, clubhouse staff, and the clubhouse structure. The 23 clubhouse clients all have serious and persistent mental illnesses, many have co-occurring substance abuse, and many have multiple DSM-IV axis I diagnoses, including schizophrenia, schizoaffective disorder, bipolar affective disorder, psychotic depression, obsessive-compulsive disorder, anorexia nervosa, and social anxiety disorder. Alcohol and most street drugs are represented throughout the sample. Most clients have lengthy psychiatric histories, including multiple psychiatric admissions. Some are parents, often single parents who do not have contact with their children. Some are the children of mentally ill mothers. A few report sexual abuse by a parent. Beyond their psychiatric disorders, the clients have concomitant disorders, including legal blindness, obesity, status postcerebrovascular incident, medical sequelae of a suicide attempt, and the concomitant medical problems of anorexia nervosa.

Nevertheless, Voices of Hope is indeed a story of hope. It is really a tale of rehabilitation and recovery told in an informal interview style. Each story tells of profound nadirs in life and the rise out of the depths facilitated by Employment Options. What is important is that the transformation of these lives, in a true clubhouse spirit, is facilitated as much—if not more—by the other members of the clubhouse as by the staff.

Among the jobs held by clubhouse members at the time they gave their stories—excluding transitional employment positions—are functioning as a research assistant, working in a specialty supermarket, running a karaoke business, providing services in elderly assisted living, working in day care, being employed in a fast food restaurant, running a snack bar at a local school, and working at the post office. A few of the clubhouse members are of retirement age; two are between 75 and 77.

Throughout the stories are descriptions of the interactions of these individuals with their psychiatrists, their struggles with psychiatric medications, and the integration of psychiatric treatment with the clubhouse's roles and functions.

Shore was assisted in her project by graphic artist Nancy Silverman and by photographers Amy Hamilton and David Pratt. Photographs of most of the clubhouse members and staff are included with the stories. Some members chose to have an alternative picture or no picture. The pictures do add to both the spirit of the stories and the message of openness and destigmatization.

Voices of Hope is a useful text for educating professionals about what a clubhouse in the Fountain House model is all about. Many in the field are unfamiliar with clubhouses, and, unfortunately, others are familiar only with bastardized clubhouse programs. Voices of Hope is also a useful text to share with patients in outpatient or inpatient settings, to encourage them to engage with clubhouses as part of their life as members of a functioning community. For many, the clubhouse can be a community within a community.

Diagnosis Schizophrenia: A Comprehensive Resource for Patients, Families, and Helping Professionals, edited by Rachel Miller and Susan E. Mason, is actually a collation of contributions by 36 patients with schizophrenia, two social workers, five psychiatrists, one nurse, two psychologists, and two rehabilitation counselors. The persons with schizophrenia are all individuals who participated in the new-onset psychosis program at Hillside Hospital, a division of North Shore-Long Island Jewish Health System. This program was a National Institute of Mental Health research project aimed at gaining a further understanding of the first episode of schizophrenia.

The book is organized by topics such as What is schizophrenia?; Why me?; medication; coping with positive and negative symptoms; coping with other symptoms and side effects; and vocational rehabilitation. Patient accounts ranging from one sentence to several pages are used to introduce topics. The editors indicate that the age range of those who contributed their accounts was 17 to 39 years, and there was a rich cultural diversity.

Diagnosis: Schizophrenia is ostensibly written for patients, with family members and practitioners as additional audiences. The editors indicate that readers should "feel free to skip around" and warn that "this book does not replace your doctor or therapist."

The information provided covers a wide range of topics and generally is clear and accurate. The reading level required, however, is rather high. For example: "One of the current theories is that the interaction of genetics and environment causes a psychiatric illness to emerge. According to interactionist theory, individuals who develop a psychiatric illness are genetically predisposed to it, but environmental or developmental factors may trigger its onset." The book does best when sticking with clinical information. When the material wanders into more legal or practical territory, it sometimes goes amiss, for what may be true in New York State is not necessarily true in other jurisdictions. Two examples of this are the section on advance directives and the section on government-sponsored housing.

The real question for me in considering Diagnosis: Schizophrenia is who actually would use this text. Of the 36 patients for whom enough information is provided through their own first-person accounts, the average age of 14 females is 23.5 years and of seven males is 22.4 years. Many, if not most, grew up in intact families; many, if not most, have had some college education. This cohort of patients is not representative of the individuals that I see with diagnoses of schizophrenia who are served at a community mental health center. I do not see how the patients whom I treat—who come from dysfunctional or nonexistent families, who have extensive substance abuse histories, who may or may not have histories of head injury, who may or may not have made it even into high school much less through high school—will be able to relate to the 36 individuals whose stories are told throughout this text. Perhaps the way that Diagnosis: Schizophrenia can be most useful is for a psychiatrist to have it on his or her bookshelf to pull off so that certain sections can be reviewed with a patient, either using the book as written or translating terms into those that a particular patient might better understand.

The book includes a directory of client assistance programs by state, a vocational rehabilitation directory with listings by state, and a listing of other resources in both the United States and Canada. These appendixes can serve as a useful resource compendium.

James T. Clemons, the editor of Children of Jonah: Personal Stories by Survivors of Suicide Attempts, is founder and president of the Organization for Attempters and Survivors of Suicide in Interfaith Services (OASSIS). He is professor emeritus of Wellesley Theological Seminary and an ordained minister of the United Methodist Church. In Children of Jonah, Clemons has gathered together seven first-person accounts and added a final chapter he himself wrote that discusses Kay Rayfield Jamison and the biblical figure Jonah.

The seven accounts, which are as follows, were gathered mostly through Clemons' interpersonal interactions and speaking engagements.

The first account is of a female of Icelandic heritage who attempted suicide at the age of 13 by cutting her wrists. Other suicide attempts included throwing herself in the ocean from a pier, attempting to overdose through intravenous drug use, and an attempted hanging. The last two of these attempts occurred during a pregnancy.

Next is the account of an African-American male who is a graduate of Brown College and the UCLA Graduate School in Psychology. This individual had many suicidal ruminations and accompanying dangerous behavior, including crossing the Interstate, sitting on rooftops, and sitting on the road. His mother and a sister had attempted suicide.

Another account is of a Pakistani male whose uncle, a United Methodist pastor, killed himself by hanging. This individual had three periods of feeling suicidal; no actual suicide attempt is reported.

Then there is the account of a prison guard who made a suicide attempt by using gas in 1979. And of a 42-year-old Jewish woman who attempted suicide at the ages of 22, 37, and 39, when she attempted suicide twice within a 72-hour period by overdosing.

There is also an account of a woman whose mother died in a bombing in Germany in World War II, when she was ten years old. She had moved 17 times during her first ten years. She married an American who was in the military. She has one daughter and one son. She first attempted suicide with 12 "mild sleeping pills" and immediately told her husband; her second attempt was a serious overdose.

Finally, there is an account of a male psychiatrist, who at the time he wrote the account was the medical director of a dual diagnosis-psychological trauma program. His suicide history began in 1971; in 1976 he experienced a serious amitriptyline overdose; between 1976 and 1981 he attempted suicide by hanging four times; and in 1982 he overdosed on dilantin and phenobarbital. The result was that this psychiatrist was treated in the intensive care unit of the hospital at which he worked before being transferred to a freestanding psychiatric facility.

In much the same way that the intended audience for Diagnosis: Schizophrenia was not clear, it is not clear how Children of Jonah will be particularly useful for treaters or patients. This is a rather idiosyncratic collection of individuals who have attempted suicide, most of whom do not appear to be afflicted by serious and persistent mental illnesses. Perhaps the most psychiatrically burdened of the seven is the psychiatrist-patient, and he hardly demonstrates the downward social drift that chronic mental illness so often contributes to.

The accounts are not particularly well written, nor terribly moving. There are occasional passages that powerfully deliver either affect or content. For example, one author states, "The inclination towards suicide is like an addiction. Like alcoholism, it is a temptation from which some of us are never fully cured … . It means a sometimes daily decision to walk in a different direction, a decision to take responsibility for overcoming the barriers that hold us back."

Part of the message of Children of Jonah is the importance of community in its literal and figurative senses. One suicide attempter writes, "There is no medicine that can substitute for community, for the power of empathy, the best therapist I ever had didn't offer me the greatest insights, but gave me a companionship of empathy through my struggles."

Another message that comes through under the editorship of Clemons is that of the potential impact of suicide on other individuals. This message comes out best in the foreword written by the singer Judy Collins, who says, "A failed suicide could have saved my world. My son took his own life, plummeting mine into the search for an answer to the unanswerable questions that suicide raises. My own failure in killing myself when I was 14 saved my world, and the world of my father and mother, who, I think, could not have survived the death of their oldest child."

Children of Jonah is one instance in which Clemons, as editor, might have done a better job using the words of the survivors of suicide attempts to write his own book rather than editing an anthology of first-person accounts. Clemons' aim, in part, is to remove all traces of blame and shame around suicide and to destigmatize those who have taken their own lives by eliminating the term "committed suicide." For "attempters," he endorses the use of the word "survivors." Unfortunately, Children of Jonah does little to advance Clemons' ends, because the accounts seem to be held together by no more than the book's binding.

Sally C. Strayer, the author of Walk With Me, is the chaplain at a state hospital in Pennsylvania who believes it is her calling to bring to the patients of this facility "a measure of hope, healing, and acceptance; to enable them to experience the love of God, and to encourage them to live their lives with as much meaning as possible." In this book she presents 39 vignettes that show her fulfilling her mission.

Strayer's writing is very much steeped in her Christian faith, and many of her vignettes end with such statements as "my heart overflowed with thankfulness to God," or "I thank God that I can be this connection to show his love and concern." Walk With Me does portray a chaplain's interactions with patients of a state hospital, many of whom appear to have significant psychopathology. That Strayer roots her interactions with patients in her religious beliefs does not trouble me. However, that she provides misleading, stigmatizing information that is often as much stereotyped as it is individual is of concern. For example: "Borderline Personality is difficult to diagnose. There are many facets to this disorder and sometimes it is very difficult to treat. This disease seems to affect women more than men. Extreme sexual abuse is almost always present in a majority of cases." Or, "Ron is severely schizophrenic and is frequently out of control. It is wise to be very careful with him."

Expressions like these, in some cases, may have validity if they are used within a context that explains them. Often, however, it feels as if Strayer is simply making assertions. She certainly errs in referring to people by their disease, such as repeatedly calling individuals with schizophrenia "schizophrenics."

Strayer's message is not to eschew medical treatment. In fact, she endorses treatment, including medication. Her message, however, is how fundamental Christ is to healing. Strayer writes, "They are called by the names, disabilities, retardation, handicapped, and mental illness … [they] have broken, fragmented lives, they too, can be brought together by the body of Christ, touched and healed by His people in the form of treatment and medication. But the most important of all is love… . There may be cracks here and there, but nothing makes a life sweeter than the cracks in life that help us grow and mature in Jesus Christ."

Walk With Me points out that we often do a poorer job of translating what patients have to say than the patients can do if left to speak for themselves. Strayer's accounts are generally weaker than most first-person accounts provided by patients. Only once in her book, in a chapter titled "Anonymous," does she allow a patient to speak. That is unfortunate. Strayer's message is not terribly dissimilar from that delivered by Correll in Overcoming OCD With Schizophrenia and God in My Life (3). Correll's is much more powerfully done.

Nothing to Hide: Mental Illness in the Family is a project of interviews by Jean J. Beard and Peggy Gillespie as well as photographer Gigi Kaeser, all of western Massachusetts. The project began in 1997 and resulted in an exhibit that began touring the country in 1998 as well as this book, published in 2002.

The interviews and photographs are of 44 "families"—in some cases, the "family members" are not actually related. The number of people in each family varies, as does the number of individuals in the family who are identified as having mental illness. In one instance, in a case from Massachusetts, five family members discuss one individual who had mental illness and was a suicide victim.

Rural and urban areas across a diverse set of states are represented, including Massachusetts, California, Louisiana, New Hampshire, Ohio, New York, Pennsylvania, New Mexico, Texas, Wisconsin, Tennessee, Florida, and North Carolina. Massachusetts is heavily represented, which probably reflects the location of the interviewers and the photographer.

The range of mental illnesses is equally as extensive, including schizophrenia, bipolar affective disorder, schizoaffective disorder, unipolar depression, obsessive-compulsive disorder, anxiety disorder, attention-deficit hyperactivity disorder, and, in a few cases, psychopathology that has never been diagnosed.

The racial, ethnic, and cultural representation is also wide, including "Latino, African American, Asian, and multi-racial families."

Each family is shown in an opening portrait of all members, and pictures of some or all family members in other poses are dispersed throughout each account. One difficulty with the book is that in some of the formal photographs, which have names listed underneath, it is difficult to match the names with the faces.

Each family has spokespersons who represent some or all of the individuals described in the opening paragraph of each account. A major criticism of the text is that the individual statements read as if they have been overedited to create a consistent form and style, an approach that sacrifices richness and vividness. On the other hand, I personally know a few of the families portrayed in Nothing to Hide, and I can say that the way they come across in person is very much they way they come across in this book.

Nothing to Hide could easily be relegated to the status of a coffee table book. That would be a terrible loss, because there is much to be learned from this book about the challenges faced by families, the fortitude shown by families in the face of mental illness, and both the losses and triumphs that result from sustenance and perseverance. As one family member said—which might be a good summary for this book—"When you've gone to hell and back, what else can life do to you? Curiously enough, it gives you a certain freedom."

Changing Minds: Our Lives and Mental Illness, is an unusually constructed anthology edited by Rosalind Ramsay, Anne Page, Tricia Goodman, and Deborah Hart, the first of whom is a psychiatrist, the second and third associated with the West London Health Promotion Agency, and the fourth the head of external affairs of the Royal College of Psychiatrists. The book is the result of a five-year campaign by the college "to combat the stigmatizations and discriminations against people with mental illness."

The book is divided into sections of stories about stigma, personal stories, stories about particular issues, and "living with _____" stories. These four sections are followed by a glossary that lists organizations that can help, references, and recommended reading. The organizations are predominantly London based, with a few from places other than England.

Each section is formatted the same way. There are stories by persons who suffer from mental illness and commentaries written by individuals from the mental health field, predominantly psychiatrists. A story is generally followed by a commentary, but sometimes several stories are followed by one commentary, or one story is followed by several commentaries.

The issues faced are wide reaching and include mental illness and employment, mental illness and the media, depression and alcohol, living with obsessive-compulsive disorder, eating disorders among men, and the roles and places of care taking. Most of the stories are written in prose; three contributions are poetry.

Although the practical aspects of this book relate more to England than to any other country, the messages of stigma, discrimination, and the fight against these malevolent forces are universal. Unlike Nothing to Hide, the ethnic and cultural variations by both sufferers of mental illness and caretakers of those with mental illness appear to be quite narrow. The mixture of mental illness with other issues is, however, quite broad. One of the more moving of these is Mark Paige's portrayal of "being a gay carer."

In many cases, the stories make the reader stop and reflect on the degree to which we have been unknowingly guilty of the same insensitivities that these persons with mental illness portray. An example is a poem by V. I. Oliver, which is untitled:

The audience waits, medical students about to (they hope) see a Soul dissected in the way they themselves once dissected rats.

I enter. I am aware of the Professor, of them, of their interest and their boredom. A simmering rage at the humiliation, scorn at their presuming to Understand, rage at my impotence—all comes out as Gibberish. It is clear that wherever my reality lies, it is not here. But this Is happening to me.

Questions: a sense of someone reaching out to my inner space to meet me. But to meet me not in order to rescue me, but to tag, label, Identify. I am a process, an item in a taxonomy, not someone to meet. This, not the humiliation, was the real betrayal.

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School in Worcester.

Geller JL: Welcome to My Country [book review]. Psychiatric Services 47:658—659,  1996
Geller JL: First-person accounts of psychiatric illness and treatment: reviews of recent books. Psychiatric Services 46:1080—1087,  1995
Geller JL: When mental illness comes and goes [book reviews]. Psychiatric Services 54:1044—1046,  2003


Geller JL: Welcome to My Country [book review]. Psychiatric Services 47:658—659,  1996
Geller JL: First-person accounts of psychiatric illness and treatment: reviews of recent books. Psychiatric Services 46:1080—1087,  1995
Geller JL: When mental illness comes and goes [book reviews]. Psychiatric Services 54:1044—1046,  2003

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