Interesting article on several levels by a psychologist concerning a couple of activists involved in the George Floyd protests. I would offer a summary, but feel I might inadvertently frame this subject and potentially influence what other posters might say. I’m hoping to hear your feelings this article may arouse:
Beyond the Rubble of Lake Street — Minds in Crisis in a City in Crisis
List of authors.
- Rebecca Grossman-Kahn, M.D.
It is May 2020 in Minneapolis. Covid-19 reached us a few months ago, bringing daily routines to a halt. The few cars on the roads speed by, but the city is hushed. We are still wearing sweaters indoors, biding our time until summer heat arrives and until life returns to normal.
Then George Floyd is murdered on the street, and the city ruptures. Bursting out of their Covid cocoons, people unfurl their rage and flow into the streets. Summer heat arrives overnight. The threat of Covid fades in comparison to the weight of injustice.
The protests center on Lake Street, a commercial thoroughfare of South Minneapolis. Nearby, beyond the rubble of the burned storefronts, is the hospital where I’m training to be a psychiatrist. I treat people whose thoughts have become too jumbled, overwhelming, or terrifying for them to perform their daily tasks.
One morning, I meet a man whose wife brought him in the previous night. His hair is thick with grease and grime from Lake Street, where he’s been protesting for a week since George Floyd’s murder. He sits erect, his eyes scanning the room. “I need to leave,” he pleads. “I have important work waiting for me out there.”
As a psychiatry intern, I’d heard such entreaties before when initially meeting a patient — “I have to get out of here because your computer is controlling my thoughts” or “Let me go before the underground fumes poison us all.” But this plea sounds different.
“I am needed out there in the fight for racial justice. I’ve been chosen as the leader.” The man stands up and paces the exam room with electric energy. “I’ve never been a political person,” he continues, his words pulsing in time with his steps. “I don’t know much about activism, but when this started I drove downtown and watched the throng of people. I went home that night and the words on all those marching cardboard signs…they kept flashing in my mind. I tucked my son into bed and thought, What will be different for him?”
I listen as he explains that our society needs treatment, not him. He doesn’t pause between thoughts, so I have to interrupt to ask, “What worried your wife enough to bring you to the hospital?”
He replies, “All I know is I’m showing up on Lake Street, and I’m needed there.” He walks toward the door. “What will change if we don’t act today? This can’t wait!”
He’s right. It can’t wait. Why is he at the hospital for raising his voice against injustice? My impulse is to thank him for his leadership and send him back to the protest. He denies being sick with the same fervency with which he calls on Minneapolis to face racism. “I feel amazing,” he says. “I’m finally fighting for my children’s future.”
One devastating symptom of psychosis can be anosognosia, the lack of awareness of one’s symptoms. I have been learning the heart-wrenching calculus of determining when someone’s mental illness puts them or others at such high risk of harm that they should stay in the hospital, even when they disagree. Sometimes it’s clear — a woman with a delusion that her partner is poisoning her attacks him in perceived self-defense; a man drives 160 miles an hour, unaware of potential consequences. But when changes are more subtle, making the decision involves long conversations with the person and the family. What will this man’s wife say? I settle into a chair to learn more.
“Things have been tough since Covid,” she starts. “He lost his job. He was drifting, without purpose. The protests were the first time he’d left the house in weeks. But then the protests became unpredictable. When the city curfew went out — home by eight — he thought it was a dare meant especially for him. He said he wouldn’t be coming home, because he’d decoded a message in blinking street lights that told him he’d be safe.”
She trails off, and I can see her uncertainty. She supports his mission, but barely recognizes him.
“You have to understand,” she adds. “He stopped eating. He thinks he doesn’t need food.”
I learned in medical school that psychotic symptoms may reflect current headlines. I might have expected to hear patients describe an elaborate, implausible plan to eradicate Covid, so I shouldn’t be surprised to see patients with symptoms related to George Floyd’s murder. But I am taken off guard, viewing a timely commitment to social justice through the lens of mental illness.
The man is only the first. A few hours later, I see a teacher whose husband brought her in, saying, “This isn’t my wife.” Initially, she stayed up late coordinating meals for protesters, but then she stopped sleeping altogether. She brought their small children to confront the line of police in riot gear. Suddenly, she withdrew everything from her son’s college savings account and piled the cash on their front lawn for anyone to take.
“We don’t need our money as much as others do,” she explains excitedly. “What have I done all my life except perpetuate inequality? This one thing I can do!” Her story comes tumbling out almost too fast to follow. She had been depressed in the past, she says, but not anymore. “After 29 years, I found my path.”
Both stories lead me to suspect a manic episode caused by bipolar disorder. Explosive energy despite lack of sleep, euphoric mood, periods of depression, rapid speech, risk taking — all are textbook criteria. But another standard diagnostic consideration gives me pause: behavior should be a significant change from one’s baseline. True, these people had never acted like this before, but the country had also changed overnight. We saw yet another Black man murdered by police, and a movement crystallized. The script for diagnosing mania asks me to compare these people’s current behavior with their behavior before Floyd’s murder. But change is imperative. As we reckon with racist, violent policing, how can we judge what an expected response might be? The moment deserves expansive emotions; it demands urgent action, including raising our voices and taking risks.
Observing the man with a newfound mission, his bloodshot eyes on high alert, I wonder, How can I prescribe a medicine that might soften his voice demanding change? It would get him sleep, but will he think I’ve diagnosed his activism as mental illness? Psychiatry has a history of exerting control over people, policing behavior. Psychiatric diagnoses have been wielded as tools to silence political dissidents and social activists around the world.
1 The ghosts of my profession’s past haunt me.
To distinguish idiosyncrasy from illness, we diagnose disorders partly on the basis of someone’s own subjective distress or impairment in daily functioning, rather than social acceptability.
2 Since the concept of daily functioning is itself shaped by social norms, I seek to understand each patient’s unique goals for what a day should look like. But goals may change in a changing world.
In the ED, I watch the teacher’s thoughts jump from topic to topic like a rubber ball in a cement room. She confides she fears going to bed, convinced that sleep will kill her. The man can’t explain his decision to forgo food, except to insist that the streetlights told him he would survive. Illness clearly robbed them of full control over their actions, independent of how much their goals had changed in a week. I am brought back to my role: to care for minds in crisis amid a city in crisis. I have seen untreated mania wreak its own devastation, tangling the threads of a life, creating only knots and the gnawing worry of loved ones. I admit the man and woman to the hospital. Treatment should help the man see he needs food and help the woman find sleep to sustain her efforts over time.
Training has taught me to recognize the signs of mania and psychosis. But nothing prepared me to ask courageous protesters to put their crucial work for change on hold due to mental illness. As I walk back to the resident room, I think, these patients acted in what feels like the only way to respond in this moment. Rolling into the streets every night, refusing sleep until we see change. We have important work waiting for us, and it can’t wait. Shouldn’t we all be running, hair a mess, frantically sharing our wealth and shouting for justice?
Disclosure forms provided by the author are available at NEJM.org.
Identifying details have been changed to protect the patients’ privacy.
This article was published on April 3, 2021, at NEJM.org.
Author Affiliations
From the Department of Psychiatry, University of Minnesota, Minneapolis.
https://www.nejm.org/doi/full/10.1056/NEJMp2034060?query=WB