After Silence: Rape and My Journey Back • Composing Myself: A Journey Through Postpartum Depression • Becoming Anna: The Autobiography of a Sixteen-Year-Old • Passage Through Trinidad: Journal of a Surgical Sex Change • Eclipses: Behind the Borderline Personality Disorder • Call Me Crazy: Stories From the Mad Movement

First-person accounts take us as close as possible to the experiences of people who have suffered mental illnesses or severe traumas, and we—whether we are mental health professionals, patients, or relatives of patients—can often be enlightened by them. Reviews of personal accounts by patients can alert us as mental health professionals to aspects of psychiatric care and treatment we might otherwise not hear about.

Six first-person accounts, all written by women, are reviewed here. Topics covered by these authors are rape, postpartum depression, the psychiatric treatment of an adolescent, transsexualism, dialectical behavior therapy, and the feelings of "psychiatric survivors."

After Silence

In After Silence, Nancy Venable Raine portrays the story indicated by her subtitle of Rape and My Journey Back. Ms. Raine was raped in her Boston apartment in October 1985, when she was 39 years old. Her history to that point included a Catholic upbringing, an adolescence in Germany, and a marriage that had lasted four years.

The book is beautifully and powerfully written. Raine joins others whose use of words is their livelihood—Raine is a poet and essayist—and who apply their skills to their own lives.

Raine's autobiography is interesting not only for her discussion of her experience of rape and her healing, including two and a half years of psychotherapy, but also for some of the book's techniques. Raine speaks from both the first- and third-person points of view. She discusses the process of writing about her experiences; she introduces research and epidemiologic data in the context of her story; and she focuses a great deal on shame.

Raine's language is powerful and often graphic as she describes her experiences. For example, about the immediate aftermath of the rape, she writes, "After satisfying themselves I was not seriously injured, the emergency room staff began performing the work of criminologists, collecting evidence that might be used in the court of law. My body was still not my own. It was evidence. I was not a patient whose wounds could be sutured. I was the scene of a crime."

About the rape itself, she writes, "The rapist had stolen something of the center of what I had known as myself… . The rapist himself might be caught but he could never produce the woman who had not been raped." And, further, "Although the neurological and psychologic response to war and rape may be the same, the fact that rape is the most intimate crime, usually a solitary and secret horror, that it is the only violent crime that tarnishes the victim as well as the perpetrator, and that it is primarily men who can and do rape may affect our willingness to acknowledge rape's inevitable long-term effects. By denying them, we deny survivors their voice and dignity."

About healing, Raine says, "The rapist had violated my most basic human need—my body right. By destroying my ability to control my own body, he had made my body an object… . Believing I was responsible for what happened to me that October afternoon actually supported the belief that I could be in control of my own life. It was the sole buttress for the span that could link my future and my past after the rape because regaining a sense of control over my life was the only way forward."

Part of Raine's treatment was eye movement desensitization and reprocessing (EMDR). She had four two-hour sessions with Francine Shapiro, the innovator of this form of treatment. Raine provides a patient's point of view that can be read in conjunction with Shapiro's own work (1).

The repeated images of powerlessness and lack of control emerged through the EMDR sessions just as they had haunted Raine repeatedly after the rape. She describes them quite vividly: "The most disturbing image was the image of myself blindfolded and bound. I started with this. I visualize myself lying on Pamela's bed with my hands taped up behind me, my eyes covered with duct tape, my body naked from the waist down, my bra unhooked, my shirt torn open. I saw myself as the rapist had seen me, as I had seen myself as I had fled from my body to 'watch' from above. What I saw was the image of the 'trussed chicken' that had come spontaneously to the policewoman after she had taken my report. To me, the image of a powerless, ugly, worthless object."

As Raine recounts her struggles to create After Silence, the reader is brought into both her rape experiences and her experiences in trying to write. She describes one point when she was having trouble writing as "not seem[ing] like writer's block. This is confronting again and again the limits of language as it struggles to create meaning out of what is incomprehensible. The rules of narrative—synthesis, continuity, causality—do not apply to ruptures of the moral order. Survivors instinctively understand that what they experience is different in kind from all other experience. This difference seems to destroy the threads of narrative the moment one tries to weave them."

Read this book. One is hard pressed to find a better treatment than After Silence of what it is like for a woman to be raped, for a woman to try to heal from that rape, and for a woman to try to explain both of those processes to anyone else.

Composing Myself

Composing Myself, subtitled A Journey Through Postpartum Depression, is the story of Fiona Shaw's plunge into depression after the birth of her second child in October 1992. The book is composed of four parts, the first one by far the most interesting.

Part 1, "Hold Me Now," the account of Shaw's postpartum depression, is excellent and is worth the purchase of the book. The author's description of her symptoms, and, more poignantly, her response to them, is powerful. For example, she writes, "My mind's eye contracted, till it contained only a loathsome vision of my own self." Or, "I wasn't depressed, I told myself. I had nothing to be depressed about. I simply despised myself." Shaw fails in her attempts to keep functioning both as wife and as mother, saying, "On Saturday I capitulated. The sheets and pillows, bars and baubles of our brass bed became my prison. I could not leave it."

Shaw's experience of abandoning her two children reawakens in her the sense of abandonment she has carried since the departure of her father. Her parents had separated very early in her life, when she was between one and two years old. This section is alive with Shaw's sense of the repetition of events and also obviates the need for the material in the succeeding three sections.

Also in part 1, Shaw provides a vivid description of the electroconvulsive therapy she underwent. She describes the treatment's aftermath: "The loss inflicted on me by ECT went far beyond ordinary forgetting. As though suffering from a form of aphasia, I lost the language of recollection, the capacity to give narrative shape or continuity to my life."

The author describes in equally powerful language her interactions with psychiatrists. Of one, she says, "She always seemed to me less interested in finding out what I thought or felt than in having confirmed some assessment she had already made. And in that environment, organized around her own style of communications, all her statements were self-confirming."

At the end of part 1, the reader has a very good sense of Shaw's symptoms, the phenomenology of her depression, and her pain and agony. The book easily could have stopped here.

In part 2, "Planting Tears," Shaw recounts her childhood. She seems to be struggling to make some sense of her adult experiences by examining or reexamining her developmental years. While this exercise is evidently very useful to Shaw, it provides little new information to the reader. We do find out that her childhood and adolescence were not free of what would be considered psychiatric symptoms, including bulimia and malingering. At the end of this section, she says, "It's taken me the actual writing of this book to make me realize what I didn't realize when I started it—that all my life I have been displacing what I found impossible to bear."

Part 3, "In Search of an Illness," focuses on Shaw's education about psychiatry. One of her observations about psychiatrists is that "by imposing their 'scientific' language on someone, they could make sense of and contain all the fever and the fret." The final section, "The Desk," is really an epilogue.

Composing Myself should have been a long article focused on Shaw's postpartum depression, not a book about her other struggles as well. However, I encourage readers to seek out the book to read the first part, which is the heart of A Journey Through Postpartum Depression.

Becoming Anna

Written by Anna Michener between her 16th and 17th birthdays, with an epilogue at age 19, Becoming Anna is the story of parental abuse and mistreatment and the attempted remediation of who Anna was through psychiatric hospitalization. The book is a rather remarkable first-person tale of an adolescent in the psychiatric system written by the patient during her adolescence.

Michener receives abusive treatment from her grandmother and her mother. About her grandmother, Michener writes, "My grandmother had a Ph.D. in child psychology. She had worked for about thirty years at a center for children with 'emotional disturbances' and 'behavioral disorders.' That meant that if she believed I was crazy, she was not going to be disputed… . My grandmother claimed to love me, however. She used to say that if she did not love me she would not have bothered to try to 'save' me. She would not have pointed out everything I did wrong and explain how everything I did well could have been done better… . She would not have had me bend over the sofa or hold out my hand so she could inflict numerous welts across the bare flesh on my arms and legs with a thin, metal knitting needle that had a heart welded on top."

About her mother, the author writes, "Each year, as I grew older and more articulate, she grew ten times more abusive… . Always I fared the worst in these endless battles. She was an adult, and I was a child who only wanted my momma to hold me and make the pain stop."

Michener first saw a psychologist at age 13, after she wrote a short story about a girl who did not fit in anywhere, was hated by her family, and was forced to live in the garage. Michener's first psychiatric hospitalization began in May 1991, when she was 13 years old and was admitted to an adolescent ward.

The author's descriptions of treatment she received portray psychiatric hospitals as hardly better than the abusive family she had come from. She writes, "I can describe in this book all the horrible things that were said and done to me, but I can never even begin to describe the true horror of mental institutions, the never-ending, sanity-stripping monotony, the subliminal implications of this endless routine and always having some hateful stranger watching you endure it, or perhaps be driven mad by it, whichever the case might be."

By Michener's description, any positive aspects of her psychiatric admissions occurred only by exception. She writes of a trip off the ward: "For a few glorious hours we were no longer the despised rejects of society, sitting pale and listless on our little ward as we were trained to; we were humans, young and free, laughing, flinging our limbs in the summer breeze and the swirling waters as the sun glinted off the droplets in our hair."

Michener's second psychiatric admission commenced in October of the same year, when she was age 14. This hospitalization lasted until August 1992 and forms the basis for most of the material in the book. Descriptions of this second admission are not dissimilar from those of the first. For example, Michener writes, "When I had someone to talk to or play with, I was distracted from the cold, gray walls around me, from the noise and confusion, from the bars and locks and shackles, from the endless demeaning rules and the sharp presence of those who enforce them."

Michener criticizes not only the treatments and the conditions imposed on her, but also the entire way in which adolescents, who may or may not have psychiatric problems and who may or may not conform to the norms, are treated. She indicates, "If mental institutions are not allowed to keep anyone who is not truly mentally handicapped, their business will be cut by more than half. When only caring, educated people are allowed to work in mental institutions, a lot of people will be out of jobs."

Reading through Michener's descriptions, one develops a profound empathy for her life and her perceptions of it. About her six-month mark at one hospital, she says: "Six months hardly seems like a long time anymore. Six months just fly by in a normal or happy life. But six months in a state hospital might as well be six years. Six months of waking at 5:00 a.m., taking a shower in fifteen minutes, sitting on the day hall, eating, sitting at school, eating, sitting at school some more, sitting on the day hall, eating, sleeping in my cell, waking at 5:00 a.m., showering, sitting, eating, sitting, sitting, sitting… . All the while the staff was yelling, insulting. The kids were fidgeting, arguing, bored out of their fucking skulls, but if they moved around too much or were too loud they were told to go to the cell."

Michener celebrates her 15th birthday as a psychiatric inpatient. All that she experiences as being done to her finally puts her in a state of uncertainty about her mental health: "I was often forced to wonder if the problem was really me rather than her [her mother]. What if what she said was true, that there was this enormous herd of 'trained professionals' who unanimously agreed I was a 'violent, uncontrollable, manipulative, delusional, irrational psychotic' and believed I required 'years of residential care'? If that wasn't true, then why was I in that terrible place? … . Could I be crazy and not even know it?"

Becoming Anna is well worth reading by professionals of all disciplines. What is perhaps most powerful about the book is that it is about a teenager's years as a psychiatric patient written not by an adult but by that teenager.

Passage Through Trinidad

Claudine Griggs is a legal secretary from Irvine, California, who celebrated her 38th birthday a few days after a male-to-female transsexual operation. Her book, Passage Through Trinidad, is not an autobiography of her life nor an explanation of her experiences as a transsexual, as many previous books by transsexuals have been (2,3,4). Instead, as the subtitle indicates, it is a journal of a surgical sex change.

The book, which covers the period between December 1, 1990, and July 24, 1992, is a day-by-day, item-by-item accounting of Ms. Griggs' experiences as a patient of Dr. Stanley Biber at Mt. San Rafael Hospital in Trinidad, Colorado. Writing journal entries by time of day, Ms. Griggs attempts to recount every single thing that happened to her during her hospitalization. Included are some medical events that preceded hospitalization and a chapter on the aftermath of surgery.

Occasionally Ms. Griggs provides a commentary on her life as a transsexual and on her thoughts about surgery per se. About the implications of a transsexual operation, Ms. Griggs states, "I have always generally liked myself—who I am, my basic psychology—and seek only to alter my body to fit my mind; but I realize surgery will alter my mind to some degree as well, because it will change my life. That's part of the reason I'm here, part of the reason surgery was prescribed. What I don't know is the ratio of effects. How much positive? How much negative? How much neutral?"

Ms. Griggs comments several times on stigma. She writes, "I'm not used to kindness once people know I'm transsexual. I've been hit, spat on, raped, defiled with every profane adjective-and-noun combination imaginable, disowned by family and friends, had my life threatened—all in the name of righteousness and good taste… . I am perceived as less than human, a 'thing.' … Since transsexuals are not persons, since they 'deserve' whatever grief comes their way, they are allowed to suffer without sympathy."

However, such reflective comments in Passage Through Trinidad are rare. Mostly the book is a tedious rendition of analgesic administrations, dilatation, sanitary napkin changes, genitalia checks, and bowel movements. Claudine Griggs' Passage Through Trinidad would have made a fascinating article; there is not enough here to sustain a book.

Eclipses

Melissa Ford Thornton has written a quirky, slight book that is part autobiography, part biography, part didactic about psychiatric inpatient treatment, and part encomium for dialectical behavior therapy.

In 1992 Thornton was released from Highland Hospital in Asheville, North Carolina, after receiving treatment for borderline personality disorder. This book is her experiential account of being a patient on a dialectical behavioral therapy unit at this private psychiatric facility.

Simultaneously, Thornton provides an account of four other women who were patients on the same unit. Of the five women, four of them were married, and two of the four had children. None appear to be impoverished or have a dual diagnosis. Eclipses may well mislead uninformed readers if they attempt to generalize from this small cohort, which is hardly typical.

Thornton also provides some information about another private psychiatric hospital, the Westchester Division of Cornell Medical Center, where some of the five women had been patients. Her comments are of some historical interest because these two institutions were among a declining number of freestanding, private psychiatric hospitals in the early 1990s. Highland is now defunct, and Thornton gives it an obituary. Cornell's psychiatry department has merged with Columbia University's department, which may or may not change the shape and scope of the Westchester Division.

Thornton's technical information gets mixed reviews. When describing dialectical behavioral therapy, she does a fine job. However, when attempting to provide information about psychiatry in general, she provides considerable misinformation. She describes emergency detention as appearing before a judge. She says that "psychiatric units do not normally handle specialized diagnoses such as Borderline Personality Disorder." She indicates that the use of medications such as antidepressants and antianxiety drugs is referred to as "pharmo-psychotherapy" and that borderline personality disorder is "ascribed to emotionally desperate, self destructive people; [it] lies between neuroses and psychoses." Thornton also unfortunately refers to individuals with borderline personality disorder as "borderlines."

To whom is Eclipses addressed? Thornton seems to struggle with this issue. The book is clearly best read by patients and families considering dialectical behavior therapy. In fact, Thornton sometimes addresses her prose directly to such individuals, referring to the reader as "you" when describing different treatment options or different responses to treatment.

Eclipses has little bits to offer a wide range of readers. The real question is whether the general reader or the mental health professional will go through the text to get smidgens of information that might be of interest. Professionals might best use this book when referring a patient to dialectical behavioral therapy and the patient says, "What's that?" Thornton also supplies names, addresses, and phone numbers of individuals whom one might contact to get more information, thus providing a very real service. Overall, she does not provide a balanced view of dialectical behavioral therapy, but does offer an informative one.

Call Me Crazy

In Call Me Crazy: Stories From the Mad Movement, Irit Shimrat has written from the perspective of "psychiatric survivors," but does so without the stridency and single-mindedness that would immediately put off potential readers who do not embrace the philosophy of the author and her colleagues about psychiatry. Thus Shimrat, who was the editor of Phoenix Rising: The Voice of the Psychiatrized from 1986 to 1990 and helped found the Ontario Psychiatric Survivors' Alliance, should be able to at least reach, if not convert, the unconverted, not just those who already endorse her positions. This book should be grabbed by orthodox mental health practitioners for the opportunity to hear from a cohort who feel wronged by many of the services they have received.

Shirmrat's basic thesis is presented in the introduction: "Psychiatric treatment seeks to help (or make) people conform to social norms. It aims to produce successful, productive people who can function and fit in. But what if success, productivity and 'normal' functioning can sometimes be achieved only at the expense of creativity and critical thinking? What if social norms need to change in order for the world to become a better place? What if change is better than stagnation, and nonconforming people are an important source of change?"

To respond to these questions, Shimrat tells her own story and also presents interviews of people in the Yukon, British Columbia, Ontario, and Quebec, most of whose views are congenial with her own. Because the interviewees speak in the first person, we have the sense of many individuals talking directly to the reader.

Mental health professionals, especially psychiatrists, certainly receive their share of criticism. For example, insight is defined as "the psychiatric term for agreeing with your doctor about what is wrong with you and what should be done about it." And, "Psychiatrists react less to their patients than to drug companies, families, the media, and insurance companies." Further, "If you have experienced psychosis or whatever one wants to call it, you've experienced the medications and they are both awful; you have the right to choose which awful thing you want." And, "People who have been psychiatrized have often had their lives totally controlled and monitored by others."

Shimrat and most of her peers simply want to be left alone. The message is, "My craziness is my problem, and I can cope fine with that. I have my own strategies for it. I'm just worried about being in four-point restraints [tied up by the wrists and ankles]; being locked up and shot-up and fucked-up." In fact, this group of authors argue that they are not "consumers" of "services." They prefer instead to be called "crazy."

To those who have accused Shimrat and her peers of stigmatizing themselves by choosing this label, her response is, "But the label 'mentally ill' has been used against us by powerful people (psychiatrists, police) to put and keep us in our place: to hospitalize, drug, silence, and belittle us. If we're mentally ill, there's something wrong with our minds and we need to be fixed. But if we're crazy, that's not necessarily the case. There's no possible good connotation to mental illness, but it is possible to be dancing like crazy, crazy about something or someone, or crazy happy. Labeling ourselves crazy is an act of defiance."

The author includes ways in which the Canadian Mad Movement has changed people's lives for the better and success stories of those who have, from their points of view, escaped from organized psychiatry and moved forward with their lives. The mission of the author and her colleagues ends the book: "In celebrating our weirdness and letting ourselves be the strange people we are, we set ourselves free. And with that power and that freedom, surely we can work together to make neuroleptics and electric shock a thing of the past. Surely we can create a thousand things that really work, not for settling people and making them normal, but for relieving them of pain and freeing them to think, feel, and do."

If you are sympathetic with the messages and missions expounded in Call Me Crazy, this well-written book by Shimrat will expand your knowledge. If you are turned off by those messages and missions, read the book, for it will expand your horizons.

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