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--:-- Noelle King: Welcome to Today Explained. I'm Noelle King.
--:-- Noelle King: Today's show is about diagnosis. You get sick, go to the doctor, the doctor tells you what's wrong. You have been diagnosed, and then you get medicine, and then you get better. Or a different story. You're sick, you go to the doctor, the doctor tells you what's wrong, and then without even realizing what you're doing, you adjust your behavior somewhat to fit your diagnosis. So you're diagnosed with anxiety, and now you're an anxious person. Depression, and now you're a depressed person.
--:-- Noelle King: Rachel Levive, a writer for The New Yorker, found herself wondering whether a diagnosis of mental illness could lead a person to behave differently. More in line with the diagnosis, perhaps, than with themselves.
--:-- Noelle King: If you have ever been diagnosed with anything, you won't want to miss what's coming up.
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--:-- Noelle King: Adio says it also allows you to create those email sequences, those real-time reports, those powerful automations, which they claim can help you build what matters most, your company.
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--:-- Noelle King: We all have moments where we could have done better, like cutting your own hair. Oof, yikes. Or forgetting sunscreen so now you look like a tomato. Ouch. Could have done better.
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--:-- Noelle King: It's Today Explained. In her new book, Strangers to Ourselves, Rachel Levive looks deeply into the life of a man who changed the way that we and the field of psychiatry think about mental illness and about how we treat it.
--:-- Noelle King: Ray was a very successful doctor in the D.C. area in the late 70s. And he became depressed and sort of stopped being able to work at the level that he had been working in.
--:-- Noelle King: He was sort of stuck in this hole of rumination where he felt like he'd made a series of bad decisions related to his two children.
--:-- Noelle King: He had sort of let them go to Europe with his ex-wife and related to his business. He had sold a portion of his business, and he was, like, stuck in a thought loop where he kept rehearsing, like, the horrible decisions he'd made.
--:-- Noelle King: I could eat the most elegant food and not enjoy it. I could participate mechanically in sex and not feel a sense of enjoyment or transportment.
--:-- Noelle King: I was a man alone. I would say to myself, I'm living, but I'm not alive. I'm living, but I'm not alive.
--:-- Noelle King: He would pace. It was almost like the physical manifestation of his circular thoughts.
--:-- Noelle King: Now, not only could I not stop pacing, but when I'd lie down in bed at night, my feet would move. I would have restless legs.
--:-- Noelle King: He just couldn't sit still. He couldn't even sit still long enough to eat. He was just sort of going in circles, physically and mentally.
--:-- Noelle King: If somebody said to me, you must keep your feet still, I could keep them still. But their normal position, their baseline position would not be of rest. It would be of continuous motion.
--:-- Noelle King: He was ultimately told by his wife that he needed to check into a psychiatric hospital. And so he chose this hospital called Chestnut Lodge, which had a reputation for being the most sort of elite psychoanalytic hospital in the world.
--:-- Noelle King: And it was unusual in the sense that it was this hospital entirely devoted to analysis.
--:-- Noelle King: Tell me about what made it elite. What might I have seen or experienced if I were there?
--:-- Rachel Levive: It was almost utopian in the belief that no matter how sick you are, if you just sit in the therapist's office four times a week, the therapist will ultimately be able to understand what's going on and that you will ultimately be able to gain a sense of insight into what has been causing your distress.
--:-- Rachel Levive: And so there was just this incredible belief in the power of one person listening to another person and ultimately understanding how that person works and thinks and how to sort of help them move forward in life.
--:-- Rachel Levive: I remember one psychiatrist who was the former head of the American Psychiatric Association told me it felt like Valhalla. It was just like the place where the best people were going to unravel the mysteries of the mind.
--:-- Rachel Levive: How does Ray, himself a doctor, do among these doctors?
--:-- Rachel Levive: Well, he has a sense of his own status and he feels that he's being treated as a patient. And he quickly really deteriorates.
--:-- Rachel Levive: He sort of loses a sense of who he is and what is meaningful to him in his life. He loses 40 pounds and sort of stops eating well, stops caring about any of the things in his life that he'd previously cared about.
--:-- Rachel Levive: When I say I play the trumpet, I practice two hours a night virtually every day religiously, okay?
--:-- Rachel Levive: I went for a year at the lodge with maybe picking up the trumpet once.
--:-- Rachel Levive: And after six months, when his mother visits him, she's essentially appalled by what a sort of husk of a man he is.
--:-- Rachel Levive: I would ask from my doctor, how do I get out? And the answers that were given to me were, when you stop using your shirt for a napkin, when you run out of money, and I couldn't give you the will.
--:-- Rachel Levive: It was a kind of hopelessness.
--:-- Rachel Levive: Does he say to them, guys, this isn't working. I'm going to need something different?
--:-- Rachel Levive: He did. He asked for antidepressants, and his mother asked for antidepressants.
--:-- Rachel Levive: And the psychiatrist there said, you know, he needs to learn how to stand on solid ground on his own. He needs to learn insight. And antidepressants would be maybe a temporary fix, but we're looking for something that is more, you know, holistic and complete.
--:-- Rachel Levive: You never used medication in this case, did you?
--:-- Rachel Levive: No, I didn't.
--:-- Rachel Levive: And why not?
--:-- Rachel Levive: Because I thought over the long haul that we get a better result if we did not use medication.
--:-- Rachel Levive: And I thought if he could begin to see that there was the possibility of organizing his life in another way in a way that was more comprehensible to himself, that he would have a better result.
--:-- Rachel Levive: And so they say, no, he cannot have antidepressants.
--:-- Rachel Levive: And what does he do?
--:-- Rachel Levive: After six or seven months there, his mother removes him against medical advice and transfers him to this other hospital in Connecticut that is more open to using psychiatric medications.
--:-- Rachel Levive: How common were psychiatric medications in the late 70s?
--:-- Rachel Levive: They were in use for a few decades, but they were still viewed with suspicion.
--:-- Rachel Levive: There was the sense, it sometimes got called pharmaceutical Calvinism, the sense that like, yeah, medications might work, but there was also something morally wrong or you'd have to pay for what you're doing in the future somehow.
--:-- Rachel Levive: It was just this general sense of suspicion, like the real good way to resolve your conflicts is through self-understanding.
--:-- Rachel Levive: And medications were still seen as a little cheap.
--:-- Rachel Levive: He gets them. He gets them, though.
--:-- Rachel Levive: And how does he respond to medication?
--:-- Rachel Levive: He responds really well. He suddenly stops pacing.
--:-- Rachel Levive: He previously felt like he could never be a doctor again. And he tries on his suit and suddenly feels like he's fit to return to work.
--:-- Rachel Levive: And he's discharged from the new hospital and sent home.
--:-- Rachel Levive: I think the first thing I noticed, the first change I noticed in myself was that there were other emotional things being opened to me.
--:-- Rachel Levive: And one of them was sadness.
--:-- Rachel Levive: And I thought about, my God, I haven't seen my kids in a year.
--:-- Rachel Levive: And then I started to weep.
--:-- Rachel Levive: Once he recovered so quickly with antidepressants, he was kind of consumed by anger that he'd been made to suffer for so long.
--:-- Rachel Levive: And so he decided to sue Chestnut Lodge for malpractice and for essentially causing him to lose his job and to lose contact with his children and sort of making him absent from life in a way that he didn't have to be.
--:-- Rachel Levive: Isn't that what you've alleged in this suit?
--:-- Rachel Levive: That had they given you medication, you wouldn't have had any of these problems.
--:-- Rachel Levive: Had they given me medication and treated the illness, then I would have been a functional person able to deal in the world.
--:-- Rachel Levive: The case then became this kind of cause for others.
--:-- Rachel Levive: At that time, there were a lot of psychiatrists who were becoming a lot more interested in a biological approach.
--:-- Rachel Levive: And they sort of embraced Ray's case as a way to prove that psychoanalysis was sort of past its day.
--:-- Rachel Levive: When psychiatrists testified on Ray's behalf, what was the argument they'd make?
--:-- Rachel Levive: They were arguing that psychoanalysis was a kind of ideology and that biological psychiatry was science and that it was malpractice to sort of persist in this belief that talking would cure someone when there was a medication at hand that could do the job.
--:-- Rachel Levive: The lawsuit kind of represented like this ultimate collision between these two different approaches of understanding mental illness and the mind.
--:-- Rachel Levive: And Ray won. Essentially, he settled the lawsuit.
--:-- Rachel Levive: But that was because this arbitration panel ruled in his favor.
--:-- Rachel Levive: And it was seen as his victory.
--:-- Rachel Levive: Like, there was a lot of writing about the case at the time among psychiatrists.
--:-- Rachel Levive: And it was seen as, like, here is the proof that the tide needs to shift and that psychoanalysis is outdated and that the new way forward, the way we're going to understand the mind is biological psychiatry.
--:-- Rachel Levive: Meaning drugs.
--:-- Rachel Levive: If we've got drugs that work, we don't need people to sit with a therapist for hours a day or hours a week. We can just give them something.
--:-- Rachel Levive: Right.
--:-- Rachel Levive: The psychiatrist, Peter Kramer, described it as Roe v. Wade for psychiatry.
--:-- Rachel Levive: Just this sense of there's no going back, which I guess is a bad analogy at this point.
--:-- Rachel Levive: But that medication sort of renders the project of psychoanalysis futile and kind of silly.
--:-- Rachel Levive: That was the idea.
--:-- Rachel Levive: Do you think it changed the way the field of psychiatry thought about understanding one's self?
--:-- Rachel Levive: I think it crystallized a change.
--:-- Rachel Levive: I think that there were already changes going on.
--:-- Rachel Levive: And part of that was structural. Like there was this move to managed care.
--:-- Rachel Levive: And with managed care, you need to sort of quantify someone's improvement.
--:-- Rachel Levive: And so you look to symptoms. You don't look at something kind of inexpressible, like a person's insight about who they are and what made them suffer.
--:-- Rachel Levive: But that case also made people afraid, made psychiatrists afraid that if they didn't give medications to someone, it was malpractice.
--:-- Rachel Levive: So there was, I think, a fear that that lawsuit instilled in psychiatrists.
--:-- Noelle King: Up next, Ray Osharoff's case led to a world in which many of us are medicated. But should so many of us be?
--:-- Noelle King: Support for today's show comes from Adio.
--:-- Noelle King: What is Adio?
--:-- Noelle King: Adio is an AI-native customer relationship management system built specifically for the next era of companies.
--:-- Noelle King: They say it's extremely powerful, adapts to your unique data structures and scales with any business model.
--:-- Noelle King: According to Adio, Adio takes less than a minute to set up.
--:-- Noelle King: And within seconds, you will have your email and calendars synced.
--:-- Noelle King: You'll see all your relationships in a fully fledged platform, they say, all enriched with that actionable data.
--:-- Noelle King: And they say you can build AI-powered automations and use its research agent to tackle some of your most complex processes to seize so that you can focus on what matters, building your company.
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--:-- Noelle King: You can go to atio.com slash todayexplained to get 15% off your first year.
--:-- Noelle King: That's A-T-T-I-O dot com slash todayexplained.
--:-- Noelle King: Let be honest, are you happy with your job? Like really happy?
--:-- Noelle King: The unfortunate fact is that a huge number of people can say yes to that. Far too many of us are stuck in a job we outgrown or one we never wanted in the first place.
--:-- Noelle King: But still, we stick it out. And we give reasons like, what if the next move is even worse? I've already put years into this place.
--:-- Noelle King: And maybe the most common one. Isn't everyone kind of miserable at work?
--:-- Noelle King: But there's a difference between reasons for staying and excuses for not leaving.
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--:-- Noelle King: So don't leave your career to chance. Take action and own your future with a professional coach in your corner.
--:-- Noelle King: Go to strawberry.me slash unstuck to claim a special offer.
--:-- Noelle King: That's strawberry.me slash unstuck.
--:-- Noelle King: It's Today Explained. We're back with Rachel Levive, author of the book Strangers to Ourselves.
--:-- Noelle King: Ray Oshroff is best known for the lawsuit that he filed against the psychiatric hospital that wouldn't give him antidepressants.
--:-- Noelle King: But you kept reporting on his life after that. What ended up happening to this man?
--:-- Rachel Levive: You know, his story was that he did stay on medications for the rest of his life, but he also really struggled to maintain a connection with his children, to have a job.
--:-- Rachel Levive: He essentially got involved in, like, criminal activity as it related to insurance fraud with his job.
--:-- Rachel Levive: And he was constantly trying to figure out like why the life he felt entitled to and the life he felt he was supposed to live just sort of ended like 30 years earlier than it should have.
--:-- Rachel Levive: And he was writing this memoir for years and he wrote thousands of pages.
--:-- Rachel Levive: And he just kept it was almost as if in the process of writing that memoir he became more and more closed to other understandings of himself and more and more tied to the sense that like Chestnut Lodge was the thing that had derailed his life.
--:-- Rachel Levive: Is Ray's story told still in the field, either in the books that college students have to study or graduate students have to study?
--:-- Rachel Levive: It's sort of like told in three paragraphs in textbooks as this very important case that signaled a shift in psychiatry.
--:-- Rachel Levive: You know, I see my chapter about him as a correction to the history that's been told, but I don't know how much it's changed.
--:-- Rachel Levive: You know, at this point, the way that it appears in textbooks is like, this man triumphed thanks to antidepressants.
--:-- Rachel Levive: You follow the story of a young woman who is very much living in Ray's world. She is medicated to the hilt.
--:-- Rachel Levive: Tell me about her.
--:-- Rachel Levive: Her name is Laura, and she grew up in Greenwich, Connecticut, in this very wealthy family.
--:-- Rachel Levive: She was like one of the best squash players in the country. She went to Harvard.
--:-- Rachel Levive: Beyond the closed doors of my home, I had no space to release what I was holding within me.
--:-- Rachel Levive: So I eventually began to release it all onto my parents through screaming and cursing and physicality.
--:-- Rachel Levive: I just didn't know what else to do.
--:-- Rachel Levive: Not long after, I'd be sent to my first therapist, who would conclude I was too serious of a case for her, and refer me instead to Dr. P, a psychiatrist.
--:-- Rachel Levive: After 50 minutes, Dr. P would tell me that my explosive anger was a sign of mania, that I had a lifelong brain disease called bipolar disorder.
--:-- Rachel Levive: She would hand me two prescriptions for Depakote and Prozac, and tell me to have my mom call her to schedule next week's appointment.
--:-- Rachel Levive: But what she really did that day was plant in me the seed of a belief that I was fundamentally broken and would have to spend the rest of my life trying to fit into the human race.
--:-- Rachel Levive: I was 14.
--:-- Rachel Levive: And then over the course of about 10 years, nothing was quite working.
--:-- Rachel Levive: And so her psychiatrist kept prescribing more and more medications.
--:-- Rachel Levive: And eventually she realized she'd been on 19 medications.
--:-- Rachel Levive: And she just wasn't sure she was feeling any better than she had when she began the process.
--:-- Rachel Levive: What ends up happening?
--:-- Rachel Levive: I mean, I think she realized like she no longer knew who she was before the medication.
--:-- Rachel Levive: She'd lost a sense of what her baseline self was.
--:-- Rachel Levive: I no longer believed that I could grow and evolve or that my life had options because I had an incurable, lifelong, serious and persistent mental illness.
--:-- Rachel Levive: And so after trying like every solution that Segyatrate offered her, she decided to try to see what it was like to go off the medications.
--:-- Rachel Levive: There I was, curled in the fetal position on my family's couch, days unshowered, miserable and out of my mind in early withdrawal.
--:-- Rachel Levive: Toxic smells emanated from my skin as my body pushed out lithium.
--:-- Rachel Levive: After she finally went off the medication she felt like she was able to have relationships like romantic and sexual in a way that she hadn't previously been able to.
--:-- Rachel Levive: Like that she felt like as if there was something synthetic about her interactions with people and she wondered if that was because she was on so much medication that she really wasn't feeling so for her going off the medications did feel healing.
--:-- Rachel Levive: And I think in part because she also connected to a community of people who were in very similar situation as her, where they had been on medications for a long time and they were sort of helping each other get off them in a reasonable way and in a way that made them feel sort of more ownership over their emotions.
--:-- Rachel Levive: I felt myself opening up to a glimmer of camaraderie, solidarity, that beautiful sense of being a part of something.
--:-- Rachel Levive: And so to go back to your original point, what you have in Laura is a woman realizing she is more than a diagnosis.
--:-- Rachel Levive: Yeah. I mean, I think with Laura, she felt as if the diagnosis explained everything about her for a really long time.
--:-- Rachel Levive: It was like she was bipolar and that was who she was.
--:-- Rachel Levive: And every time she felt sad, it was because she was bipolar.
--:-- Rachel Levive: And after she went off medication, she started rethinking that kind of narrative, the sense that like she was doomed to this life of illness because of this diagnosis.
--:-- Rachel Levive: And she was able to like create a new kind of story for what her life could look like.
--:-- Rachel Levive: Laura in some ways is like the outgrowth of the kind of world that Ray and the psychiatrists who supported him were pushing for.
--:-- Rachel Levive: She should have been the success. Like look how quickly she got medications. Look how knowledgeable her doctors were in giving her these medications.
--:-- Rachel Levive: And I think what felt profound was that that's just not enough.
--:-- Rachel Levive: She felt like no one was actually interrogating why it was that she was in such distress.
--:-- Rachel Levive: And instead, she was being given like one after another medication.
--:-- Rachel Levive: And there was this belief that like if they just found the right medication, she would finally be at peace.
--:-- Rachel Levive: In the book, you also write about your own experience getting on and then trying to get off of psychiatric medication.
--:-- Rachel Levive: Can you tell me your story?
--:-- Rachel Levive: Well, I was in my late 20s and I was having various forms of social anxiety.
--:-- Rachel Levive: And my friend recommended the psychiatrist she really liked.
--:-- Rachel Levive: And I went there and in the first appointment, he said that he thought I would benefit from Lexapro, which is an SSRI.
--:-- Rachel Levive: And I kind of was willing to try and tried.
--:-- Rachel Levive: And it was like this incredible experience where I felt like I was just like liking my brain more.
--:-- Rachel Levive: Like I was sort of feeling more warm and outgoing and all these things.
--:-- Rachel Levive: And then after six months, I had the sense that it was a six-month trial.
--:-- Rachel Levive: So I decided to go off.
--:-- Rachel Levive: It worked well, but like the logical leap was not.
--:-- Rachel Levive: And so therefore I take it for the rest of my life.
--:-- Rachel Levive: So I went off and then it was this very confusing experience of going off and then feeling as if I was experiencing something that was depression in a way that I had never experienced depression.
--:-- Rachel Levive: And it was hard to know, is it that I had just gotten used to like a different level of living life and therefore this felt more acute to me?
--:-- Rachel Levive: Or was it some kind of experience of withdrawing from the medication that is not well documented, where it just takes far longer to recover from the experience of going off the medications.
--:-- Rachel Levive: And so eventually I went back on, and I would experiment with going off and on.
--:-- Rachel Levive: And I felt like I confronted this problem of feeling like the medication had sort of allowed me to operate at a kind of higher level.
--:-- Rachel Levive: And then you build a life on that higher level and then you kind of like feel like in order to continue being the person you are, you need to keep taking that medication.
--:-- Rachel Levive: So that was sort of this weird like existential confusion of like, is this medication making me a better person than I'm supposed to be somehow or a better person than like who my essential self is.
--:-- Rachel Levive: God, that is such a freaking interesting way of putting it.
--:-- Rachel Levive: Are you still taking medication?
--:-- Rachel Levive: I am.
--:-- Rachel Levive: And, you know, I've sort of tapered down.
--:-- Rachel Levive: And then I think at some point, like last year, I was like, what am I doing? Like, what is the point of this?
--:-- Rachel Levive: What am I trying to prove?
--:-- Rachel Levive: And I think I thought a lot about like, who am I to my kids? Who do I want my kids to remember me as?
--:-- Rachel Levive: And, you know, I could even reflect back on like my parents and sort of how they might have been different with this.
--:-- Rachel Levive: But it's something I still feel uneasy about.
--:-- Rachel Levive: And I just think that we sort of know the way it works medically, but it just raises a lot of questions about personality and choices about who we are.
--:-- Noelle King: Over the past 40 years, the story that we tell ourselves about mental health and how we get it and mental illness and how we beat it, it keeps changing.
--:-- Noelle King: But none of the stories are completely adequate for explaining the fullness of human experience.
--:-- Noelle King: At the end of the day, how do you reckon with all of this without getting very frustrated by the fact that it's been 40 years?
--:-- Rachel Levive: Like, we've had chances here. Science has advanced. Psychiatry has advanced.
--:-- Rachel Levive: And yet we still seem stuck in, like, black or white to some degree.
--:-- Rachel Levive: Right.
--:-- Rachel Levive: I mean, I guess one thought that comes up when you say that is, you know, Laura is so different from Ray.
--:-- Rachel Levive: And so why do we expect, like, the same solution to work for both of them.
--:-- Rachel Levive: I think it has been presented as the story of the field to a large extent is swinging from these different overarching explanatory theories.
--:-- Rachel Levive: And I think one of the most important ideas for me was that it's not usually like one explanatory theory that works for someone.
--:-- Rachel Levive: Sometimes someone can believe that they're having a mystical experience, but also that they need medication and that both of those sort of ways of explaining their experience can be necessary for them to start to get better.
--:-- Rachel Levive: There has been this like either or dynamic in psychiatry where we're looking for like one sweeping fairy.
--:-- Rachel Levive: And there have been, you know, for 40 years, scientists have been looking for some sort of like genetic marker that will correspond with the diagnosis.
--:-- Rachel Levive: And that really hasn't led to any discrete successes in that regard.
--:-- Rachel Levive: So why wouldn't we start to think about, you know, all the facets of suffering that are kind of not captured by the theories that are sort of supposed to explain why someone is mentally ill?
--:-- Rachel Levive: Like, we sort of localize people's troubles in the brain and think less about, like, the relationship between the brain and the community that that brain exists in and the way in which mental illness is a kind of relationship between, like, a person and the community in which they live.
--:-- Rachel Levive: And not just the mental illness, but also like the way that a community responds to the illness also shapes the trajectory of that person's life.
--:-- Noelle King: Today's show was produced by Miles Bryan and edited by Matthew Collette.
--:-- Noelle King: It was engineered by Paul Robert Mounsey and fact-checked by Laura Bullard.
--:-- Noelle King: I'm Noelle King.
--:-- Noelle King: It's Today Explained.
--:-- Noelle King: Support for this show comes from Macy's.
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