Functional Pragmatism: Navigating Mental Health as a Critic
Part One: Pragmatic Diagnosis, or, Surviving Under Capitalism with Executive Functioning Issues
This essay has had many aborted beginnings, and even more twists and turns. Originally, this was going to be a one-shot made up of two parts. The first part, published here and now, is a description of my lifelong difficulties adapting to the rigors of life under capitalism and a look at the process of being diagnosed with ADHD. A second part, which will now be published separately due to length issues, will be a navigation of my ever-evolving views on mental health, the psychiatric system, and psychology.
Even starting this essay was a challenge. I took five minutes to come up with a title, then stared at a blank notepad document. Typed a sentence. Deleted it. Typed another sentence. Deleted that one. Gave up, scrolled through twitter. Tried a few more times, gave up a few more times. I typed these sentences, then paused again, fidgeted for a minute with a loose string on my shirt, and stared at my ceiling fan. Words weren’t coming easily to me. Each sentence was a battle between what I wanted to do and a dense mental fog. A headache thrummed beneath my eyebrows; the result of a day with barely any caffeine intake. I had taken my medication, but it had definitely worn off by this point. How topical!
The struggle I just described above is one of the many I’ve dealt with for nearly my whole life. When I was a kid, I managed to get A’s and B’s, but had a hard time focusing on anything for too long. I doodled in the margins of my notebooks, sneakily read my own books during classes instead of listening to lectures, and could only bring myself to do homework at the very last minute: sometimes, literally as the teacher was beginning to collect it. I was always disorganized: my room at home was a mess, and so was my desk in school. I lost things constantly. I was a good kid, for the most part (outside of a time I stole a roll of Smarties off of my teacher’s desk in second grade — why?? I didn’t even particularly like Smarties?!). If I ever received detention, it was in middle school, and it was for missing assignments. I was quiet, and as the years went on, I had less and less friends. I was very sensitive of even perceived rejection and cried at the drop of a hat. When I was in high school, the severity with which I felt negative emotions scared me so much that I decided of my own volition to go to therapy. I was treated for social anxiety disorder and major depression, and given SSRI’s: first citalopram, and then when that didn’t work, fluoxetine. Meanwhile, however, the “good student” façade I had been able to keep up for so long was continuing to crack in more and more places. One particular memory, or set of memories, always stands out in my mind: my AP English teacher in my senior year, pulling me aside after class (more than once), and asking me why I never did my work. His voice was always marked with a mix of concern and frustration. “You’re smart”, he would say, “I know you can do this. Why don’t you”? At the time, I didn’t have an answer for him.
Things got even worse when I got to college. I breezed through my first semester but fell very ill in the spring. I missed an entire week of classes and had to make up quite a bit of work. The experience felt insurmountable to me. I was eventually able to turn in most of my assignments late, but I never was able to bounce back to the performance I had my first semester. I grew more and more avoidant. If I didn’t complete an assignment on time (or if I forgot there even was an assignment to begin with), I would become so ashamed that I didn’t want to attend class the next day. If I skipped class, I was anxious that the professor would judge me for it. I assumed that all of my professors thought I was just apathetic and lazy, and that assumption made my avoidant tendencies worse and worse. By the end of my Sophomore year, I got an e-mail from the Dean informing me that my GPA had dropped to 1.95, and I was thus put under academic probation. If it dropped below 1.90, I would be expelled. That lit a bit of a fire under my ass, but it still didn’t make me a stellar student. It took me years to build up my GPA up to 2.70. I would often do well in one or two of my classes but flunk the other. I definitely couldn’t take more than three classes at a time. College simply never stopped being a struggle for me. That fact made me believe I was lazy and broken; that I wasn’t trying hard enough and that if I could just actually TRY I could do everything everyone else at college seemed to be able to do with ease.
My older sister was diagnosed with ADHD in her twenties (women are commonly diagnosed for the first time in adolescence and adulthood, whereas boys are more often diagnosed for the first time as children). It didn’t surprise me, as she was a very impulsive and disorganized person. She struggled in school too, and ultimately dropped out of college in her sophomore year. At times, we would talk about various frustrating experiences in our lives. The more we talked, the more she would tell me that I reminded her of herself. I believed her, but I still believed that “admitting” I had ADHD and taking medication would be its own sort of personal failure. I was also skeptical about how much medication would even help me: after all, the SSRI’s I took in high school didn’t affect me in any discernable way (I had impulsively decided to stop taking them, cold-turkey, in the beginning of my freshman year. Thankfully, I had no withdrawal symptoms: I wouldn’t recommend that other people do what I did!). Finally, though, in my seventh year of undergrad, I decided I didn’t have much to lose. At this point, I was beginning to question the essentialist, reductionist view of mental illness that was so common in “layman” discourse, but I didn’t want to be trapped in college forever either. I also understood that I tried every method I could to make it on my own without medication, and had gotten nowhere for years. At that point, the flawed way psychiatry conceptualized mental distress had less bearing on me than my immediate material problems and my own current experiences of mental distress. I was willing to be pragmatic.
The diagnosis process was a rather elongated one. First, I saw a school therapist. Then, a school psychiatrist, who referred me to the only ADHD testing facility in the state that took my insurance. The testing consisted of questionnaires, surveys, tests of spatial understanding, and activities that measured my short-term and longer-term recall. As a psychology student, I had decided to not only participate in these tests but analyze the structures of the tests themselves as I took them. One of the surveys I got — a depression scale — asked me if I felt various negative things over the past two weeks, but never asked me if I had any ongoing life events that might explain those phenomena(for example, it was finals week when I filled out the scale, and that was certainly stressing me out). Didn’t that affect the validity of that scale? Did the fact that I recognized the recall tests from my cognition class affect my overall test performance? And how old was the initial computerized screening test, anyway? If I said that I distrusted authority, would that give me a point in the “Conduct Disorder” category? Or were those trick questions put in there to throw me off? Despite all the questions I had regarding the proceedings of my ADHD testing, I still completed it all as honestly as I could. Two weeks later, I had an official diagnosis: ADHD, Inattentive Type. The entire process — from initial therapist meeting to the end point of diagnosis — took about four months to complete.
While I was able to get a diagnosis in January, I wasn’t able to get properly medicated until late April. My final semester was nearly done: I had hoped I would be able to experience at least one semester with actual treatment. I was a bit disappointed, but still curious about how much levo-dextroamphetamine (AKA: Adderall) and bupropion (a dopamine-norepinephrine reuptake inhibitor — more for my mood) would actually help me. The effects were noticeable: when I finally got myself around to writing an essay in the past, it would take me all day. I would type a paragraph, then get so mentally exhausted that I’d take a 20 to 30 minute break to scroll through social media sites. With levo-dextroamphetamine, I was able to complete my anthropology final essay in a few hours and felt no need to take any breaks. In fact, I was able to keep myself motivated the entire time. I wouldn’t call it miraculous, but it was certainly relieving. Reading also became a far easier affair, for similar reasons. I also felt a bit more in control of my emotions: I didn’t cry at the drop of a hat as often, and if I did panic, I was able to calm down far more quickly than before. Things aren’t perfect, however: I can still sometimes get overly emotional about things, I still have panic attacks every so often, and I still have a hard time getting myself organized. In short, medication didn’t solve all my problems. Thankfully, I didn’t expect it to. I still have to figure out how to implement strategies to make myself organized and keep a more level head, and I’ll likely get the help of a therapist for that.
With all that said, there is still one more elephant in the room. Over the past year, due to wondering how a Marxist should interpret psychiatry and psychology as fields, I’ve studied various critiques of the psychiatric system. Some have simply called for reforms to what currently exists: revised diagnostic criteria, for example (Horwitz & Wakefield, 2007). Others have considered totally rejecting the construct of the psychiatric diagnosis (Bentall, 2005; Parker et al., 1995) or leaving psychiatry behind completely (R.D. Laing, David Cooper… and also Thomas Szasz, but he was an asshole libertarian, so let’s pretend I didn’t mention him). Medication is often a red button issue: over-prescription, questionable efficacy (Moncrieff, 2008; LaCasse & Leo, 2015; Fried, 2016), the influence of pharmaceutical corporations (Cosgrove & Wheeler, 2013), and a history of psychiatric-drugs-as-social-control (Parker 1995; Cohen, 2016) are topics that often come up in this debate. Are all of these worries equally valid? Is some of this an overreaction, or a type of sensationalism? Is there a way to synthesize the more reformist streams of critical psychology with the more radical, abolitionist bent, or must we choose a pre-existing side? And — the most relevant thing to this pair of essays— how does my experience as a communist, critical-in-some-fashion-of-the-psychiatric-system, person-who-consented-to-being-diagnosed-and-given-medication fit in with all this?
References (in order of appearance, for ease’s sake. fuck apa….)
Horwitz, Allan V. & Wakefield, Jerome C (2007). The Loss of Sadness: How Psychiatry Transformed Normal Sadness into Depressive Disorder. New York, NY: Oxford University Press.
Bentall, Richard (2005). Madness explained: Why we must reject the Kraepelinian paradigm and replace it with a ‘complaint-oriented’ approach to understanding mental illness. Medical Hypotheses, 66, 220–233.
Parker, Ian (1995). Deconstructing Psychopathology. London, UK: SAGE Publications.
Moncrieff, Joanna (2008). The Myth of the Chemical Cure: a Critique of Psychiatric Drug Treatment. New York, NY: Palgrave Macmillan.
LaCasse, Jeffrey & Leo, Jonathan (2015). Antidepressants and the Chemical Imbalance Theory of Depression: A Reflection and Update on the Discourse. The Behavior Therapist, 206–213.
Fried, Eiko I (2016). Depression — More than the sum of its symptoms. The Psychologist, 29. Retrieved from http://thepsychologist.bps.org.uk/volume-29/january-2016/depression-more-sum-its-symptoms/
Cosgrove, Lisa & Wheeler, Emily (2013). Industry’s colonization of psychiatry: Ethical and practical implications of financial conflicts of interest in the DSM-5. Feminism & Psychology, 23, 93–106.
Cohen, Bruce M.Z (2016). Psychiatric Hegemony: A Marxist Theory of Mental Illness. London, UK: Palgrave Macmillan.
