Misty Pratt’s ALL IN HER HEAD is a well-written, wide-ranging book that explores the issues women face in the medical system. Pratt focuses specifically on the propensity to diagnose mental illness and prescribe medication more often in women than in men, even when women may have physical symptoms that suggest something other than mental illness. Pratt helpfully outlines her terminology, noting that when she talks about women she means anyone who identifies as a woman, and the term ‘female’ applies to those assigned that sex at birth.
In clearly written prose, Pratt covers the external factors that can cause mental health issues, and that need to be addressed to help the surge in women with anxiety and depression. These external factors are summarized in the biopsychosocial model, which includes the role of biology (bodies and brains), psychology (thoughts, feelings, and emotions), and society (the environment we’re living in) on our mental health. While mental health practitioners purport to follow this model, it’s more likely that they follow the medical model, which sees mental illness as a chemical imbalance that can be solved with medication.
Pratt notes that modern psychiatry started with the idea of ‘hysteria,’ and says that “all mental illnesses were first constructed as feminine disorders.” She argues that schizophrenia and bipolar disorder prevalence hasn’t increased much over time, though my psychiatrist has noted that bipolar diagnoses are rampant and increasing because psychiatrists are diagnosing without rigour. Regardless, Pratt’s focus is on anxiety and depression, as these two illnesses have been on the rise, especially in girls and women (later in the book (p. 56) she says that diagnoses of anxiety have increased but those of depression haven’t changed, then in the next paragraph she says that anxiety and depression symptoms in teenagers doubled during the pandemic). Even though these disorders are likely to be diagnosed 2.5 times more often in women than men, there is a lack of knowledge of how depression/anxiety differ between the sexes. There is also the problem of the medicalization of normal experiences, which leads to the over-diagnosis of mental health issues, particularly in women.
“Gender bias in the diagnosis and treatment of women’s mental illness medicalizes our bodies and pathologizes our emotions without providing appropriate support for the underlying issues at play,” writes Pratt. Some of the underlying issues that she explores include the effects of hormones during adolescence, the perinatal period, and menopause (hormone replacement therapy can often address issues that might otherwise be diagnosed as mental illness), and argues that better social supports during these critical time periods could go a long way towards decreasing mental health impacts. She explores social factors such as trauma from sexual assault, or social media use leading to body dysmorphia. Gender inequality can cause stress, and burnout in the workplace. Capitalism is also a factor, as it downloads everything onto the individual, including responsibility for mental health. Mental health is also linked to what’s happening in the gut, with clear linkages between gut health and mental health; there’s also a connection between mindfulness and better anxiety and depression outcomes. Finally, there’s the patriarchy, which women fight on multiple fronts on almost a daily basis; for example, women’s ‘worry work:’ “anticipating the needs of those around them and acting to manage those needs…”. As Pratt says, “…sexism, racism, oppression poverty, and violence [are] all deeply embedded into our social systems.”
Some women who present with physical symptoms of illness are often misdiagnosed as having a mental illness, even though they are completely fine mentally. There are often barriers to mental health care, including long wait times between diagnosis and treatment, and a lack of access to therapy to help heal and become more resilient. It can be difficult to find a therapist you can talk to – and that you can afford. It also depends on what kind of therapy works for you: cognitive behavioural therapy (CBT) focuses on changing yourself, when often it’s society that needs to change.
Overall, Pratt convincingly outlines the societal overhaul required to better support women with mental illness, and to prevent spurious mental illness diagnoses that may be related to other factors, such as hormonal fluctuations, physical ailments, or environmental factors such as being in an abusive relationship.
The problem arises when Pratt incorporates her own illness into the narrative. She is diagnosed with depression in high school, after what she describes as an idyllic summer with no obvious triggers that could have caused it. But as Pratt writes, “What I later came to understand is that my mental illness wasn’t as random as it felt, and that the seeds were sown long before my life fell apart.” I assume she means the social and psychological aspects of mental health issues, though it would help if she linked back to clarify what those ‘seeds’ actually were.
Her illness presents as a series of physical ailments, all of which her doctors investigate but find no problems. Finally, they turn to depression as the cause of her symptoms. In this case, Pratt wasn’t pushed into the mental illness category by her doctors. They took her physical symptoms seriously and didn’t come to a mental illness diagnosis until after they’d ruled out everything else. This goes against the idea that physical symptoms are often translated into mental illness in women, though it’s just one example; many other women don’t have the same experience.
She also says that “my personal quest for answers [became]…a growing understanding that no one treatment could “fix” me. I had never been broken in the first place.” I was a bit confused by this statement, as if she’d never been broken in the first place, where did her illness and its symptoms come from, and why did the medication help manage it?
Near the end, Pratt says “There is no cure for mental illness, but there can be healing,” with which I completely agree. However, when she stops taking her medication, Pratt says that “pain and suffering still came, but I met them with more respect and reverence for what they were able to teach me, rather than what they would do to me.” This suggests that we take medication to avoid feelings, to mask things like pain and suffering. But for some people that pain and suffering is not a gift that teaches, it’s an illness that grinds them down.
Overall I enjoyed reading this book, and was not surprised at the depth and breadth of factors that affect women’s mental health and diagnoses of mental illness. Pratt has done her research and it shows. My quibbles with her personal mental health journey relate largely to my own experience with mental illness, which likely has roots in all the factors she discusses, but is also a biological disorder. Pratt writes that “the message I internalized was that mental illness was my fault, that I would always suffer from it, and that healing wasn’t possible.” I don’t think mental illness is my fault, but I do think I will always suffer from it and that healing will not be possible. I will just have to manage as best I can while keeping in mind the external factors Pratt outlines that can contribute to my mental health experience.
