Psychiatry and Mental Hospitals

So mental hospitals and psych wards have been mentioned a few times now. Psychiatry, and mental health in general, can be very delicate subjects for a lot of people, and this delicacy is something I do keep in mind while writing. All the same, though, I want to take a moment to comment more extensively on the prevalence of these topics, and on the tone with which they’re handled in the story. I will note, a priori, that I am an extremely biased source here. I have extensive experience of the mental health system, and my experience has not been good nor normal. I’ll comment on that further later, but I feel I should stress this up front, because it does heavily impact how I write about this topic. Additionally, all of my experience has been in the United States. This kind of information is very hard to really get from the outside of a culture, so I do not know nearly as much about how the system works in Japan. This caveat is significant and likely unavoidable in impact when I’m describing her experiences in Tokyo, particularly with how long ago those were. That said, and with the additional caveat that this note is on the long side, let’s dive in.

Prevalence and Elements

The first, and likely most significant, reason for how prominent these themes are is the classic adage “write what you know.” This is a principle I apply a lot and have commented on before, and as per usual, there are some caveats with me. I’m applying it more often than you might think. My life has been an unusual one, and it has given me some interesting experiences, many of which show through in the story as well.

Among these has been an exceptional amount of time in inpatient psychiatric treatment. At a guess, I’ve had about sixteen stays in locked-door facilities, that is, places that take involuntary patients who are legally not permitted to leave custody. Those facilities tend to work very differently than milder settings; as soon as there are patients on involuntary holds, the whole nature of the facility has to change, because legally it’s acting as a prison. There is more restriction, and a greatly elevated need for security. These facilities tend to be harsher in some ways, and they tend to have patients who are hard to be around as well. I know this, in part because there have been times I was one of them. Cumulatively I’ve spent over six months in this kind of facility, almost all of it as an involuntary patient legally barred from leaving.

I have also spent extensive time in milder settings meant to deescalate crises which have not reached that severity, and which do not take involuntary patients. Some of them have been facilities intended for longer stays, with the longest having been about three months. I can recall six of these stays, with a cumulative duration of about eight months divided between them. These facilities are still pretty intense as a treatment option, but they tend to be a little easier to be in, a little less stressful.

I mention all of this for a few reasons. One is simply that my experience of mental illness and psychiatry is perhaps the biggest reason that these themes are present in my writing to such a great extent. Another is that it gives me a certain position with which to comment on the topic. I’m not a big fan of the idea that someone who is a part of a group can say something which someone outside the group cannot. I don’t think it grants me some special right to say things about madness, just because I’m quite mad. But it does mean that I have this experience on which to base interpretations.

So, that’s why insanity is prominent in this story. Why are these people the kinds of insane that they are? For that matter, what kinds of insane are they? Characters, Kyoko included, have commented on various people being insane. But there have been relatively few details, and that might create some wrong impressions.

In particular, there’s a common tendency in authors to say that a character is insane, but it doesn’t actually mean much. It might refer to whatever pattern the author happens to be writing, with little other thought involved. It also might be a largely informed quality, that is to say, something which is present as a description in dialogue and narration, but never displayed. Both of these, in my opinion, are rather poor tradecraft, and now that it’s more apparent what tone this story takes about the topic, I want to clarify some things about that.

Psychiatric diagnoses are a complex and troubled thing. You can find a list, and pop sci descriptions of how you can know whether someone is whichever diagnosis is being considered. The reality is distinctly murkier, though. There are multiple diagnostic standards in use. The two major ones are the Diagnostic and Statistical Manual, currently using the fifth edition as the primary one; and the International Classification of Diseases scale. The former is focused on psychiatric diagnosis, and it has more commentary on specific features. The ICD has less strict definitions on the whole, more of a focus on description (often for insurance purposes) than on suggesting treatment approaches. They differ in significant ways.

But even if you pick one standard, there are numerous points where there’s no actual consensus. In some cases this split is between clinical psychology and cognitive neuroscience, which have very different interpretations of some things. To use dissociative identity disorder as an example, in clinical practice the condition is stigmatized and somewhat regularly discredited as a fictitious disorder. Meanwhile, fMRI studies consistently and strongly disagree, finding things that are unique and in many cases impossible to fake. In other cases, even the fMRI studies disagree with each other, as do clinical perspectives.

Another factor is that those diagnostic criteria were simply not designed with the intention of accommodating magic. You may recall that I said something similar, as did Kyoko, about the question of whether she has epilepsy. The answer seems clear enough to say that she does, but the main diagnostic tool is completely impossible to use on her. No formal diagnostic workup is going to give the kind of clear answer it should at that point. This is like that, but far more so.

To start with, it’s not being applied to humans. Kyoko is human enough that much of human medicine can be applied, but that’s not the case for everyone in this story. Mentally it’s even more pronounced, and it’s systemic. Kyoko herself doesn’t entirely notice this, but there are a few key points that have come up already.

Capinera seems very cavalier about the prospect of assassins. She also has an assumption that people are shallow, are manipulative, are cruel. She assumes, as a matter of course, that any given person might have a secret agenda that she won’t understand for years, but which is a possible threat at all times. These could be signs of a personality disorder in a human. But for someone born and raised in the Unseelie Court, expecting long cons, malicious actions, and a shallow engagement with other people is normal. This is a response that Capinera has precisely because she was sane while immersed in a society that seems markedly insane to humans.

Personality disorders are pretty arbitrary in their definitions. But even diagnoses that are often thought of as more objective, for conditions that are more neurochemical in nature, start breaking down. I touched on this some in the Mages and Humanity essay, describing why mages are so insane, and repeating that would be redundant. Multiple factors from that discussion will be even more pronounced with nonhumans.

Figuring out whether Kyoko has ADHD requires adjusting for the intensity and breadth of her perceptions. But does Saori have ADHD? Well, you’d probably need a full cohort of full-blooded kitsune to even guess. She certainly seems like it to a human, but might not be impaired at all by the standards of her species.

So that’s the in-universe difficulty, and much of why labels aren’t used. What about metatextually? What would I, as the author, describe them as?

Out of the core cast, Kyoko is the by far the easiest for this question. Her diagnostic workups have actually happened, and she’s close enough to human both genetically and socioculturally for the labels to apply better. Thus, I can comfortably say that she has type 1a bipolar w/ psychotic features, autism, severe and complex post-traumatic stress disorder. She also meets the criteria of depersonalization/derealization disorder and possibly borderline personality disorder, both the product of that PTSD.

It’s not really possible for me to assign diagnoses to most other characters. The question returns null, mu, unask the question. Kyoko doesn’t list them in the narration because they cannot be meaningfully defined.

Tone

Tone is perhaps the more important part, and there are a few key details for this. The first, which is important enough to address first, is that this is a very value-laden subject for a lot of people. And the characters in this story are not talking about psych wards in complimentary ways, not at all.

But look at the characters that are having this conversation. Kyoko and Pepper have qualities that I associate with worse outcomes, just based on my observations and experiences in these settings. Their conditions are complicated, don’t fit diagnostic molds very easily, and are hard to fully parse or characterize. They are both confrontational bordering on aggressive in how they deal with psych professionals; Kyoko was much more like this in the past, particularly with authority figures like psychiatrists.

It’s not hard to see where things started going wrong. In part because they do both have serious mental health problems.

Kyoko is, in short, a mess inside. As she freely admits, she has some serious psychological issues, and while they were worse in the past, she’s well aware that she still meets the criteria for bipolar and PTSD, and her historic diagnosis of autism seems accurate to her in-universe as well as to me metatextually. None of those three conditions, particularly with the intensity and complexity of her PTSD, are the type that go away. And some of her hallucinations and paranoia have been genuinely psychotic in nature; she sleeps so poorly that she has in the past deprived herself of sleep until she was fully psychotic from it, not uncommon in bipolar patients even without hellish nightmares. Her mania has innate psychotic features on occasion as well, which is not uncommon in type 1a.

But she also has perceptions that other people don’t, but which aren’t hallucinations. I run into issues with this with synesthesia, trying to explain that yes I have hallucinations, but also I can see sound and that’s not hallucinatory. People tend to assume that one or the other is false, that is, either I don’t have hallucinations and am just overdramatizing the synesthesia and dissociation, or the synesthesia is actually psychosis. Each is in its own way seriously problematic. Adding Kyoko’s additional perception of magic and emotional resonances would make this even worse.

So no amount of medication was going to make that stop. Antipsychotics are very effective in some cases, but they can’t remove Kyoko’s issues when large portions are not psychosis to begin with. This led her to be seen as nonresponsive to treatment, and possibly as malingering or inventing the experiences she was having, which isn’t great. This met her baseline hostility and aggression and became a particularly confrontational relationship. The result got really bad a couple times, and cognitive bias leads her to remember that more than the times that were okay.

Some of the details about Kyoko’s experience are directly drawn from my own. For example, when she mentions having flashbacks from having to ask someone else to let her in and out of a building, that’s something I personally run into. Spending weeks at a time on tight enough restrictions that I needed to ask staff for permission to go to the bathroom is one of the clearest memories and strongest triggers I have from these stays; it somehow registered very starkly as dehumanizing and demeaning to me.

It might seem small, and her emphasis on it might seem unreasonable, but it’s directly based on which parts of the experience I have flashbacks or emotional dysregulation about. This is in part because I write for the sake of emotional processing on my own part. It is also in part because this is a case where I have spent long enough in those environments to have a pretty good sense of how they impact people, myself and others both. It’s often small things which end up having the strongest presence in someone’s lived experience.

Similarly, Pepper’s experiences owe a lot to my own. Because she does have psychotic symptoms; hers more clearly resembles the patterns associated with schizophrenia rather than my (and Kyoko’s) bipolar-with-psychotic-features. Pepper does have some serious psychotic traits. She is prone to hallucination and delusion, and in a lot of cases her delusions of paranoia and persecution are totally unfounded in reality. She knows this, but that often doesn’t make it easier to dismiss. Being unable to readily tell psychotic experiences apart from real ones is one of the hallmarks of schizophreniform psychosis.

But Pepper also does have horrible life circumstances happening. These things are both true, and trying to treat her as though only one is will not work well. Some of the things she was saying in the hospital really were just paranoid ranting completely unrelated to reality. Some of what she was saying about being severely mistreated was real. If you assume everything is real you end up confused and with a very strange understanding of her life; if you assume all of it is psychosis, you end up dismissing her very real suffering.

Psychiatric professionals, in my experience, can be pretty prone to the latter, particularly when she was a kid and she was confrontational or aggressive about it. Antipsychotics are already used routinely to control outbursts in patients who have that kind of aggressive behavior or impulsive lashing out. When she also did need something to help her manage the psychosis, it was inevitable that she would get treated with a lot of them.

This is a case where I can comment more directly again. Her psychosis is not of the same pattern as mine, but I was given the same drugs. I have spent years on various antipsychotics, primarily risperidone but with intervals of aripiprazole, lurasidone, and clozapine, all as maintenance drugs. I am not currently on any, but I’m very aware I might need to be again in the future, and the idea frightens me badly. They had a severe impact on my life.

Because her descriptions got dismissed as paranoia and early-onset schizophrenia, there was also no real action taken about the abuse she was experiencing, which severely damaged her trust in the mental health system as a whole.

Notably, both of these characters had these conditions set in quite early in life. Bipolar disorder is rarely diagnosed before late adolescence or early adulthood, and schizophrenia typically sets in somewhere near age twenty. For reasons both neurochemical and psychosocial, earlier onset is associated with worse impacts on someone’s life in either condition, independently of how severe the condition ends up being. It’s sort of like how epilepsy has impacted Kyoko’s life. Because it set in before she was old enough to be forming many memories, she has no experience to contrast it against. She has always been this way. She has also been having manic episodes since she was about ten, making it difficult for her to entirely tell that they’re not a normal part of life experiences.

So to consider the tone or the qualities being attributed here as a whole, they’re not dishonest and not exactly wrong. But they’re biased because the characters who are discussing it are people who had unusually bad experiences as an inevitable product of their specific situations. They’re also biased because I’m the one writing the story. Inpatient treatment in particular merits some deeper consideration.

I have spent a great deal of time in inpatient psychiatric treatment. I would estimate I have spent roughly five months, over my lifetime, being involuntarily treated in an inpatient setting. This wasn’t great, but did at least mean that I can confidently say I am certifiably insane. I know this, because the jurisdiction I spent most of that time in still calls the court order permitting involuntary stays longer than 72 hours a certification. I have been certified at least ten times at a guess, including at least once each under all three permitted categories (imminent danger to self, imminent danger to others, and grave disability). I don’t recommend this, but I was oddly proud when I got the trifecta.

In my experience psychiatric inpatient care is highly variable in quality. Sometimes, particularly in lower-security facilities and in facilities which just care more about patients, the experience is actually quite beneficial. For most, less so. At first it’s a disorienting and frightening experience. After enough trips, it stopped being that, but it didn’t get better. The baseline state just went from a confused blur to a tired, too-familiar apathy. Occasional spikes in the intensity, for any of a wide variety of reasons, were familiar, but still bad. These middling-quality stays had some significant bad effects on me.

Spending a month on constant emergency-level doses of lorazepam and haloperidol (respectively a strong sedative and the harshest antipsychotic still in use) while largely in something like solitary confinement but worse? That had a worse one. I have tics now, convulsive movements that never really went away. Eye tics are the worst, where one eyeball twitches and vision becomes disorienting; those largely stopped but I have actual palsy on one eye now, so it sort of evens out. I also have permanent memory problems, and while it’s difficult to fully establish the causes of my chronic pain, there are decent indications that it at minimum involves receptor paths damaged by lorazepam withdrawal.

There are also moderately strong indications of sexual abuse while too heavily drugged to form memories, in another facility, as well as a stay somewhere negligent enough to be shut down by the state, in addition to countless smaller incidents. All of this is part of why I include so many of these themes, as well as a serious influence on the tone I use about them. I write to process trauma, and these efforts to cure me were among the biggest things I now need to process trauma from.

I don’t want to come across as discouraging people from seeking that treatment. And so I try to make a specific note when I discuss my own experience that it is not representative. I have had some truly horrifying experiences in the mental healthcare system. But the majority of people who receive psychiatric treatment will not have anything this bad happen to them. Most people do not end up in the hospital, and most trips to the hospital do not involve the things I’ve just mentioned. These things are far, far more common than people like to think, but most people will not have those experiences.

My situation, like that of the characters in this story, is such that I had a number of unusually bad experiences. I don’t sugarcoat those experiences because I think that openly acknowledging how bad things can get is important. I don’t care for being silenced or made to feel that I should pretend I haven’t had the experiences I have, in this or other areas. But I also try to make a point of saying that I am an outlier and that people shouldn’t feel too worried about possibly having similar things happen, because it is unlikely they will have the kinds of experiences I have.

In this case in particular, because the narration is first-person and subjective and because Kyoko has specific traits that I associate with worse experiences and worse outcomes, the story emphasizes those darker elements of the system. These elements are prevalent, and they have these tones, because I am the person writing this story. As for purpose, well, madness is a strong theme in this series, one which has a lot of perspectives on it being presented by various characters, not always with the explicit mention that it is what they’re presenting.

In the very first note in this story, the one associated with the first prelude, I mention that translation is a major theme. How do you translate the whole of someone’s experience, with all its nuance and history and context, into something someone else understands?

How much harder does it become, when you’re both out of alignment with reality in deep ways, and not in the same directions?