Deconstructing Sarah Fay

Cliches become well-used before they get known as clichéd for good reason: They express near-universal truths, to venture into the land of clichés. And, the best of them never become hackneyed.

With that? 

"Trying to have one's cake and eat it too" is the best I can think of on Sarah Fay's attacks on the DSM, the Diagnostic and Statistical Manual of Mental Disorders, the "bible" of counseling psychology and psychiatry, in her books "Pathologized" and "Cured." Hers is not by any means the first such attack; indeed, as noted on my Goodreads review of "Pathologized," which expanded to cover both books when I noted, via her website, that "Cured" is being published for free reading (in part?) in Victorian-type serialization on Substack installments, (See near the end for specific takes on specific chapters.) I long ago wrote a long, detailed blog post about Asperger's being "schizold disorder of childhood" until DSM-IV.

Pathological: The True Story of Six Misdiagnoses by Sarah Fay
My rating: 2 of 5 stars

This is kind of a hard book to rate. Or, it was, until I hit Fay's website and became more agog at what I read.

I will spell out in more detail, wrapping up with heading back to selected portions of the review, how it earned that 2-star rating, including warnings to readers of this book or her in-progress sequel, "Cured."

Hers is also not the only attack on the pharmaceutical industry in general and its psychotropic wing in particular.

That said, despite some Overton window shifting in her referencing a "recovery model" of mental illness, she seems to not only accept the need for such medications for herself, but to accept such need willingly, not grudgingly.

Just one problem. Such medications are prescribed based on a mental illness diagnosis. Such diagnoses are based on mental illnesses mentioned in the DSM, however imperfect it may be. To want such medications without accepting an accompanying diagnosis? More specifically, to want a doctor to prescribe without offering an accompanying diagnosis? That is essentially asking a doctor to commit medical malpractice.

If this is not the impression you intended? You've got a Ph.D. in English, creative writing or similar. I suggest you contact yourself or your editor if that's not the impression you planned. But, you can't have your cake and eat it.

Fay's story has other issues, some about her story, and some about her understanding of psychological counseling. The calls of her, and other people, for patient centered counseling?

Has she, and have they, never heard of Carl Rogers and his client-centered approach? It's like she (and others whose shoulders she stands on) are reinventing the fucking wheel. "Pathologized" never mentions his name, nor do the parts of "Cured" already available for reading. I would have checked the anti-DSM website of hers listed on the dust cover, but? It's expired. (Also interesting.) She loses claims to credibility right there. It's not entirely her fault; the therapy world today seems to be "meds here, cognitive behavioral therapy there." Other counseling modalities (she does mention dialectical behavioral therapy once) get ignored. Group therapy, gestalt, etc? Not mentioned. The broader humanistic psychology (which does not generally include gestalt) also ignored. Not all elements of humanistic psychology work well with more serious mental illness, even when medications come first. Nonetheless, for neurotic-level depression, alone or with hypomania, neurotic-level anxiety and other issues? It can be very good. 

As for patient involvement in general? Did you really not get involved in dialogue about your medications for 20 years or whatever? That may be something symptomatic of women's treatment in mental health. If it is, you really didn't discuss it, even as a couple of Goodreads reviewers noted this, race, etc., have long been "problematic." On the other hand, you mention at least one female psych and other female counselors. If not asking questions for 20 years reflects other obsequiousness to authority? That's not a mental health problem but it may be a personal development one.

Otherwise, what the new "recovery model" focuses on in one way is also just like the old humanistic psychology, and can be summed up in one word, a word I nowhere see in Fay's writing: "acceptance." It's that simple.

Then, there was her reply to me on Substack. She said "Cured" "isn't an advice book, it's a memoir." The two aren't mutually exclusive. "Pathologized" is a memoir, but it has an epilogue, which most memoirs do not, and that epilogue is very much an advice book.

I also found interesting that the circle wasn't closed in "Pathologized." Fay, if not full-on anorexic, had some sort of eating disorder as an adolescent, during the run-up and through her parents' divorce. Relations as an adult seem somewhat strained with her mom at times and more so with her dad before in the end of the book, she seems to indicate all is hunky-dory with both. But, she never talks, even in generalities, about how that happened, given that the relationship was clearly "distanced" per later parts of the book. And, at the same time, after her parents split, during high school, she bounced back and forth between them. Color me skeptical. She also talks about the "murky pit" already in the first chapter. That may not quite be Churchill's "black dog," but it sure sounds similar. So, two of the six misdiagnoses she alleges don't seem to be misdiagnoses.

That's even more true when one reads her essay "On Suicidal Ideation". "Interestingly" (that's scare quotes, Sarah) much of its material did NOT make it into "Pathologized." That includes not only details of the frequency of her ideation, but that she had a less hateful take on the DSM. And, that's not ancient history. It's 2019, and "Pathologized" went to press in 2022 and was surely in writing a full year or more before that.

And, while not a counselor myself, she strikes me as a "highly sensitive person," not just in the sense of the book of that name, but more. She seems to have a highly developed sense of interoception, which in turn then would influence her high emotional sensitivity. None of that is either good or bad; it simply is. That said, it should be noted that interoception that is off the norm is associated with many mental illnesses.

And, with that, on to extracts from my Goodreads review.

Near the end of the book, Fay does slightly nuance her diatribe against the DSM, and against mental health diagnoses.

I give you the last two sentences of the Epilogue:

Before you accept a DSM diagnosis, pause. That doesn't mean you don't seek treatment or take medication or ultimately decide that having a diagnosis, no matter how tenuous (at least for now), serves you, but you do so knowing the truth.

Sadly, especially given my further digging around, it's too bad those words weren't in the first two sentences of the Prologue or Introduction.

That said, she's more close to right on the DSM, and the DSM's evolution, than many 3-star reviewers give her credit for. On the other hand, that has to be seen in light of her suicidal ideation essay, which frankly raises questions of "why the shift."

Beyond the DSM, although she doesn't go into it a lot, she's right as rain, including her own experience, of too many doctors still peddling too many benzos for anxiety. Or antipsychotics. Anti-depressants are another option (especially if used in low doses with talk therapy).

She doesn't square the circle with her opening chapter. Whether she had full-blown anorexia or not, she had some sort of eating disorder that appears to have been in part a reaction to her parents' divorce. And, while she says she's got a good relationship with her dad at the end of the book, she never talks, even in generalities, about how that happened, given that the relationship was clearly "distanced" per later parts of the book. And, at the same time, after her parents split, during high school, she bounced back and forth between them. She also refers to the "murky pit" in the opening chapter, which sounds like depression to me. And, wanting to stay on an SSRI, plus the suicidal ideation, would certainly point to that.

So, that would mean that a minimum of two of her six diagnoses weren't wrong. They may have been partial, or incomplete, but they weren't wrong. That's even more true when one reads her essay "On Suicidal Ideation." "Interestingly" (that's scare quotes, Sarah) much of its material did NOT make it into "Pathologized," though the essay is referenced.

Now, more of a review of "Cured."

And, guess what, Sarah? Your diatribe against group therapy lost you another star, and gets a "recommend against further reading" as part of this review. (In a reply to me, she claimed she wasn't "dissing" group therapy; I differ, without begging.) In the words of scientific skepticism, you've now clearly ventured into "n=1" territory. And, you could be contributing to someone else's mental harm, not cure. Also, her chapter on recovery models of therapy comes off as glib:

Psychiatric “symptoms” like depression and lack of interest and anxiety and ruminations are part of the human condition—even psychosis. (I used to think psychosis was different but as someone I know who hears voices explained, “Ever had a song stuck in your head? That’s not the same, but it gives you an idea.”)

The chapter after the one dissing group therapy has two issues. First, "Staying on the Course" is largely a recycle plus some expansion from this book. And, she talks about Patricia Deegan being "healed" from schizophrenia. Deegan talks about "recovered," but I'm not sure she would use the word "healed." She uses the word "heal" for herself in Chapter 9, and it again seems clear that this is NOT "cure" as in the Latin root meaning "care," as she says in this book, but ... "cure."

And, Fay undercuts herself on this:

As she healed from schizophrenia, Deegan developed her own personal medicine: “Medications were just one tool in an entire set of recovery tools I slowly pulled together for myself. I built my recovery toolkit over time, intuitively, and without even having heard the word ‘recovery.’”

Time after time, it's shape-shifting from her on the issue of medications. Or? Whether better or worse, the political phrase: Overton window shifting. She'll imply or insinuate that recovery models of mental illness somehow move beyond medications .... until there they are! And, why are they there? Because of a diagnosis.

What does Fay want from her movement, anyway? If it's to be "more than a label," I think she's tilting at windmills. I don't think the majority of mental health patients, and certainly not the majority of less severe ones, identify themselves as a label. And, if she really accepted much of her psychs' advice passively for years? See above, about humanistic and client-centered therapy. I am halfway dumbfounded at this.

As for labels, and "healing"? In both schizophrenia, and in chronic depression, and in both sides of bipolar, etc., symptoms can flare up and die down. That doesn't mean the underlying condition has gone away. Happens in some physical ailments, too, like multiple sclerosis, and nobody but a sicko or a self-delusional person would talk about being "healed" from MS.

If a mix of relabeling and refocusing helps Sarah Fay, more power to her. But, this isn't magic. Nor, as I risk moving from skepticism to cynicism, is this about being a "brand." Stopping short of cynicism, there's intellectual dishonesty toward the public, and maybe toward herself, in not describing the "shift" between her state of mind at the time of the suicidal ideation essay and the start of writing "Pathologized" two years later. 

My guess on that, again at the risk of moving beyond skepticism to cynicism, or at least as being perceived as doing such? I think that some time in that two-year gap she became converted to the "recovery model" of mental illness and mental health and then became an evangelist. And, I use "converted" and "evangelist" quite deliberately. (Sidebar: I don't like the descriptor "recovery model" as it sounds too much like addiction and sobriety, where recovery generally means something quite different. It may be riffing on AA's "daily reprieve" statement, but still, beyond that, there's not a lot of parallels in the details. Sidebar 2: I could have riffed further on conversion into conversion disorder ...)

And, given that both her books are advice books as well as memoirs, and knowing there are better, more scientifically grounded, yet still personally focused, critiques of the DSM, I write this in fear that she could, with some of what she says, be a danger to others as well as being some degree of hypocrite, as I see it. On the danger part? I, along with a couple of reviewers who specifically mentioned this, wonder if some readers didn't get halfway through "Pathologized" and think they could just toss their pills. Or, per "Cured," pills or no, people thinking that schizophrenia can be cured.

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Side note: The punctuation part of the book, trying to riff that into the different diagnoses, seemed forced. That said, it perhaps emphasizes that the rest of the book is split, per the "splitting" that Fay talks about in herself but never describes in detail (lest she get a dissociative identity disorder diagnosis?) between memoir that could have been better yet if more fleshed out, and the lurking anti-DSM screed.

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