Broken Bones and Psychosis: Psychosocial Causes and Testability

Imagine that you get assaulted. You are kicked in the leg and it is broken. You go to the hospital. Your leg is x-rayed, and casted. You are given crutches, and asked if you want to press charges.

That’s the way it normally goes, I assume, when you are assaulted and get a broken leg.

No one says you aren’t really hurt, even though your broken leg was caused by a social ill—a bad person assaulting you.

Now imagine you have a psychotic break. Your symptoms cause your family to call the police so you can be taken to a hospital. At the hospital, your blood is taken, you are given a CAT scan, and are, after a while, diagnosed with schizophrenia.

The tests in involved—taking blood, and CAT scan—don’t reveal anything. They are done in order to rule out other things. You are given an antipsychotic, and released from the hospital after seven days, when the doctors see that your medication seems to be working.

At home, you peruse the literature, and find that some people think your illness is not real the way a broken leg is real—because your illness, they think, has psychosocial causes. Perhaps you experienced a lot of adversity, or trauma as a child. These are things correlated with experiencing psychosis.

Not everyone who gets kicked in the leg will get a broken leg. That depends on a lot of things—where you were kicked, how hard you were kicked, if you were kicked repeatedly, and if your bones were prone to breaking.

Not everyone who experiences adversity or trauma will experience psychosis, either.

Both of these things can be caused by social illness, and social ills in combination with your makeup. If you have especially brittle bones, and some bad guy kicks you, you are probably more likely to get a broken leg. Likewise, if you “are prone to” (we don’t know what that means, but let’s not assume it means you are less “hardy”) psychosis and experience trauma, you are more likely to develop schizophrenia.

But no one says you aren’t *really* hurt when you get a broken leg this way.

Unfortunately, they do say this when you become psychotic.

There is no test, they say, for schizophrenia.

True, the biomedical markers for schizophrenia are not testable in most hospitals. They can’t, for every patient, check for chemical imbalances. Instead, they rule things out, try a medication, and see if that medication (in my case, regulating dopamine) works to restore health.

Not long ago, before the x-ray, they couldn’t *see* a broken bone, either. They had to do similar things in order to diagnose and treat a broken bone. The patient would, I assume, report symptoms and people could observe symptoms. That doesn’t mean broken legs weren’t real problems before the x-ray, just like it doesn’t mean psychosis isn’t real just because not everyone has access to MRIs.

Just because something may have a psychosocial cause, or can’t currently be directly apprehended in the hospital doesn’t make it less real.

Justice at Both Ends: Preventing and Treating Psychotic Disorders through Social Justice

Introduction

It seems like a cruel joke. People who are already in disadvantaged positions are, on top of that, vulnerable to brain disorders. Then, the society that produced the disadvantage (poverty, racism, sexism, etc.) stigmatizes the person for having an illness.

I want to be transparent here. I am diagnosed with schizophrenia. I live openly with my illness. I am also trained as a philosopher. I had my first psychotic break in graduate school, where I was studying ethics and political philosophy. My doctors told me to apply for disability, but I wanted to work. After a series of various jobs and hospitalizations, I finally applied for—and was granted—SSI. The day I was granted SSI, I cried. It had been an extremely rough ride.

One of the jobs I applied for, and kept until I was hospitalized, was as a case manager. As a case manager, I was trained to treat people in a holistic way. I was to look at each client from a variety of perspectives. But, also, I was trained to advocate for justice for my clients. That’s what I want to focus on here.

Theory and Practice

I want to set aside the theories of justice we learn about in school for a minute, however important and interesting they are. Although my academic training is mostly in philosophy, I have also done an assortment of different work. I have had time to think about—and live out—the issues I am discussing. So I’m not going to apply any certain theory of justice to the problems I am discussing. Besides, Bernard Williams would think applying a theory to a problem the way that is often done would be really uninteresting. And, of course, I want to be interesting.

I am also not going to get into a debate about psychiatry versus psychology. Brain versus mind. I think training as a case manager was good experience for me in diffusing that dichotomy. I am trained to deal with both medicine and psychotherapy, as a case manager. And I am trained to think about the soul and the brain, as a philosopher.

However, I am going to refer to schizophrenia as a brain disorder in this paper. Because that’s what it is, whatever, ultimately, causes it. There is something going on differently in my brain when I am psychotic. I’ll set aside issues of dualism, materialism, and so forth, and let other philosophers better trained in that area deal with those issues.

I am also going to set aside cultural differences. Although there has been interesting anthropological work on the differences in the expression of psychosis, there is also consensus that psychosis occurs in every culture. What I will focus on, however, is treating psychotic disorders in the United States. That’s where I live and am best trained.

“What happened to you?”: Social Causes of Schizophrenia

We know that social factors can be a cause in brain disorders. For example, Holocaust survivors are at an increased risk of developing schizophrenia. There is, we may say, only so much a mind can take.

This does not discount other factors involved in developing brain disorders. However, I want to discuss various abuses and forms of disadvantage at play in developing psychotic disorders.

Prior to taking up research specifically on psychotic disorders, I did a great amount of research in Native Studies. Native Studies is an interdisciplinary field, and I had to learn and read in many different fields—anthropology, psychology, sociology, history, law, criminal justice, philosophy, to name a few. In the social and psychological work I read, it was clear that the effects of colonialism had an impact on the minds of indigenous people. They are at an increased risk for many illnesses, including brain illnesses.

This informed my early notions of brain illness: that it’s mostly social. So, when I became ill, I didn’t know what caused it. (It could be, however, that I have, in fact, experienced a lot of hardship, and was prone to developing a psychotic disorder.)

I eschewed psychotropic medications, and psychiatry in general. I was held, for periods of time, in hospitals and told to be “compliant” (to take medications). I sought out therapy, however, and had a few wonderful counselors. Counselors, I knew, treated things differently. They are not medical doctors shoving, as it were, pills that caused me horrible side effects down my throat.

Eventually, however, I was given an antipsychotic that both managed my symptoms and didn’t cause side effects. I am now a firm believer in taking the appropriate medication at the appropriate dosage, along with therapy, case management, and so forth.

One of my good friends, who, for reasons to protect them, will remain anonymous and vague, works for the military. This is not a delusion. They really do work for the military, and they are not the kind of person you would imagine an ethicist would associate with. The fact is, it’s their job to kill people efficiently and effectively. They are not a soldier. They make the plans that others carry out.

Let’s just say that this person knows how to inflict all kinds of torment on people. (This does not carry out into civilian life.) This person once asked me the most important question anyone ever asked me about my illness: “What happened to you?”

They wanted to know what kind of torment, abuse or disadvantage I experienced that made me have schizophrenia.

I wanted to tell them that I was a teen parent, who had to fight for her education, and was treated very badly by, especially, conservatives as a teen parent. I was told I was going to Hell, and funding for my high school, which was my joy and hope in the world, was always threatened.

I wanted to tell them that I had experienced sexism in the field of philosophy that made me very uncomfortable.

I wanted to tell them that I experienced a lot of sexual harassment when I was working as a teaching assistant.

I wanted to tell them that academia is not made for parents, especially teen parents.

I told my counselor instead.

Stigma

There are at least three kinds of stigma: (1) Self-Stigma, (2) Other Stigma, and (3) Stigma by Association. The literature discusses each of these.

Self-stigma is when a person internalizes the stereotypes and “othering” the society holds about them. They may think they are, in fact, a bad person for having schizophrenia. They may think they are at risk for committing violence. They may think they should be punished, or closely watched. This can cause a person to have low self-esteem, live “in the closet,” and not seek treatment.

Other stigma is when people who do not experience psychosis have negative views and discriminate against people with psychotic disorders. This can include not wanting to date a person with schizophrenia, not wanting to have conversations or be friends with people with schizophrenia, and not wanting to work with people with schizophrenia.

Stigma by association is when people who are associated with a person with a psychotic illness feel shame about having that person in their family, school or workplace. They may lack education about people with brain disorders, and there is evidence that proper education about these issues can lessen stigma by association.

Stigma can lead to discrimination by making people treat one differently. As someone who has dealt with gross amounts of stigma, I can say that people have treated me as a potential threat, a wild-eyed disarray, and needing to be “compliant” and tamed. This, even when my symptoms, which have never been threatening, were at bay. Stigma leads one to “see” you differently. It leads to bias in how your actions are interpreted.

I have learned to deal with stigma by living openly and “calling it out.” I risk all kinds of things doing this, but it’s the only thing I know to do.

Justice at Both Ends

We may live in a world where luck is involved, but there’s luck and there’s luck. We have the ability to change our world, to make things better for other people and ourselves. We have the ability to reduce the amount of negative luck people experience. For example, if we alleviated poverty, there would be fewer brain disorders, just as if we reduce child abuse, there would be fewer cases of child PTSD. If we want to reduce the amount of brain illness in the world, we need to be committed to justice.

At the same time, there are people who do and will continue to suffer. For those people, we need justice at the tail end—we need justice for people with brain disorders. This means making people feel OK with accepting government benefits, increasing government benefits so that people with brain disorders are not living in poverty, and, of course, reducing stigma.

I hope I have made a case for justice before and after psychosis.

Why I Am an Asset, Even Though I Have Schizophrenia

Although it’s illegal to discriminate against people with mental illness during hiring, it is well known that discrimination still occurs. People with disabilities are disproportionately living in poverty (partly because SSDI and SSI, if they are on that, provide you with just that—poverty) and cannot find work.

Previously, I hid my mental illness from people, especially people I worked with. These days, I live openly.

Let me tell you a few reasons why I am an asset due to my mental illness. Maybe this will change the way people view people with mental illness during the hiring process.

Firstly, having a mental illness, and wanting to be well, makes me, de facto, responsible. I have to go to the doctor once a month for a shot of Abilify. I cannot miss this appointment. It is important that I get my shot on time. The consequences of me not doing this are that I may suffer a psychotic break—considered one of the most disabling forms of disability. So, I am used to both being responsible, and having a huge risk involved in this responsibility.

Secondly, I have been hospitalized eight times. Eight times. How, you may wonder, does that make me an asset? I’ll tell you: Mental illness strikes every income bracket, education level, race, ethnicity, gender, sex, religion, sexuality. Each time I have been in the hospital, I have made it a point to associate with the other patients. I have met people with PhDs from Harvard, teachers, train engineers, gangsters, Christians, atheists. I have bonded with people of every different color and creed.

Thirdly, I have to associate with many types of professionals. My condition has put me dead center in the middle of medicine. I have to have fruitful relationships with (1) my Nurse Practitioner, (2) my General Practitioner, (3) my therapist, and other medical professionals, including nurses and psychiatrists. If these relationships are not fruitful, I don’t get better and they can’t do their job well.

Fourthly, I have had to navigate government bureaucracy. I have been on SSI for a couple of years now. Getting on disability requires that you, even though you may be very ill, navigate a huge system that may seem impersonal and mechanistic. There’s the paperwork, the doctors’ notes, the phone calls. This continues even after you get on SSI. I am required, for example, to give an accounting every six months about how I have spent my money.

Fiftly, I know what it’s like to struggle and to succeed. I have had to learn how to become “scrappy.” A scrapper. It’s not below me to do entry-level work, even though I have a great education and experience beyond entry-level duties. Mental illness knocks you on your butt, quite often, and people like me have had to re-learn how to perform basic acts, like self-care (hygiene, eating, brushing teeth). It is very humbling to be on top of things and then, suddenly, have to remember that you need to wear shoes when you go outside. My success has not been handed to me on a platter. I have earned it.

Sixthly, I know how to manage stress. In fact, I went to counseling for six months one time just focusing on how to manage stress. This is because stress, for me, can cause flare ups in my schizophrenia. I’m not the only one prone to stress-related illness, though. There’s a whole body of research on how every day stress affects most people. Most people. Not just me. However, I have had expert education and training in managing stress.

Seventhly, I am creative. It’s not just me who is creative. Anyone who has had to deal with a serious, chronic illness has had to get creative sometimes. I have had to try different treatments, different doctors, different therapists. And I have had to be open to different and new treatments, therapies, solutions. Sometimes, I have proposed my own solutions to these challenges. I have discussed treatments with scholars who work in the area of psychiatry.

Eightly, I have a unique perspective. This is because, when you are ill, you come to a point where you are free to think differently than most people who are going about their daily lives. Not often do we have time to pause and reflect on the important things in life. But I have. Not just as a philosopher, but as an ill philosopher. Illness forces you to pause and take stock of things. As an ill philosopher, I have been forced, on top of my choice, to take a perspective of reflection and mulling over what’s important in life. This has given way to creative and unique thinking.

These are but a few reasons why I may be an asset to an organization. I’m sure that other people with mental illness have similar ways in which they are assets. Think about that next time you are hiring.

How We Treat Mental Illness

I read an article recently about the current method of treating mental illness, which was referred to as “the shotgun approach.” Basically, when you have a mental illness, they try different medications on you until they find one which works (hopefully). They do this even though the medications used to treat, say, bipolar or schizophrenia work in different ways.

In schizophrenia, at least, the current theory is that there may be different underlying causes for the same symptoms. So, the reason I have schizophrenia may be different than the reason someone else has schizophrenia. The underlying issues with the brain, or past trauma, or environmental factors, may all be different. That’s why Abilify may work for me, but not for someone else. And that’s the reason why other medications I have tried, which react in the brain differently than Abilify, have not worked for me.

So, people with schizophrenia may present with similar symptoms, such as hearing voices, paranoia, and so on, but the reason they have these symptoms may be completely different.

For me, it’s really hard to tell why I have schizophrenia, with the exception of looking at the drug Abilify and seeing how it works in the brain. Of course, there may be environmental factors at play with me that triggered things (it wasn’t easy being a teen mom, for example, and conservatives, who kept telling me how I was going to Hell or cutting funding for my high school, didn’t help), but there may just be something organically different in my brain. (Not structurally, though. I’ve had CAT scans.)

There are genetic and other tests they use for people who do not respond to medications which can give doctors more insight as to why someone has a certain disease, but these are not readily available. In my opinion, they should be. Too often, as in my case, several years are wasted trying different medications to no avail. Often, it takes years to find the right medicine. That’s wasted years for many people—when they could be productive years…if they had the right medication.

That was the point of the article: there must be some way to get people the correct treatment much sooner than what is currently happening. I know, in my case, it would have been helpful to have the right medication much sooner. I may have been able to keep working, or, at least, finish some projects I was working on. At any rate, I would have more sooner been able to enjoy a Spring day like today.

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Self-Care

Eating better and exercising has really made me feel better. I didn’t know just how bad I felt until I started feeling better. It’s not just getting healthier, though. I have struggled with a little depression over the past, say, year or so. Even people close to me haven’t been able to tell. But I know it’s true.

I go to the doctor again soon and will discuss it then, but I’ve had problems with things like self-care and getting out of bed. Over the past two weeks or so this has gotten so much better. I feel like a new woman.

One of the reasons my doctor and I decided for me to not work is because I have had serious problems with self-care (from schizophrenia) even when I’m not working. When I do work, I end up in the hospital. This has happened eight times—the amount of times I have been hospitalized—and she wants me really good and stable before I even think about working.

I’m doing really well on Abilify, but progress is slow. I’m just now at the point where I’m caring again about taking care of myself. I have been showering each day, brushing my teeth, eating right, exercising, getting out, etc. This is progress, but my doctor and I are taking it very slow.

I’m lucky to have so many great people in my life who understand mental illness. One of them suggested that I make a list of my daily cares and check them off each day so I do them and don’t forget. This has helped me.

It has also helped that I have been fortunate to have so many wonderful people in my life. I recently “came out” to everyone in my life–including people on Facebook, etc–about having schizophrenia. I just couldn’t bare having such a big secret. I was welcomed and accepted by all of them. I cannot say enough how helpful it is to have people in your life who are supportive and do not hold stigmas about mental illness.

Medications

Today, I went to get my medications. I am on Abilify right now. It seems to work well for me. I get a shot every month. I always have to turn my head when I get the shot, but it didn’t really hurt this time, which is good!