Excerpts from Must Read Books & Articles
on Mental Health Topics
Articles- Part XXXVI
Jeffrey Toobin, The New Yorker- 10/4/2010
Few American college students in the mid-nineteen-nineties showed as much promise as Rachel Hall. In 1994, Glamour named her one of its Top 10 College Women. "Rachel Hall is a Truman Scholar, former White House intern, licensed massage therapist, onetime Virgin Islands lifeguard, varsity rower and chair of the United Nations' Global Federation Youth Cabinet," the magazine wrote. "A double major in Japanese and international relations, Hall recently transferred from UC - Davis to Stanford University. Her future plans include a graduate degree in Japanese and a career in international relations." The following year, Stanford endorsed Hall's application for a Rhodes scholarship. Hall's grades at both schools were "literally perfect," Peter Stansky, a history professor and the chairman of Stanford's Rhodes panel, wrote. "Ms. Hall is a very polished and mature candidate who has had a wide variety of experiences from which she has very intelligently managed to learn prodigious amounts." Hall won the Rhodes.
Lean and fit, with pale skin and a cascade of strawberry-blond hair, Rachel stood out, even on big campuses. "Rachel was the most remarkable student I ever had," Joyce Moser, who taught Hall in a seminar on literature and the arts her first year at Stanford, said. "Rachel wrote an imitation of Plato's Republic that I still have. It was so good that I kept it for fifteen years. Each of the students had to do a presentation, and Rachel did one on eighteenth-century music. She turned off the lights and put candles all over the classroom. She put Mozart on softly in the background. She had images to go with it. It was the closest thing you could do to create an eighteenth-century environment in a seminar room. She was just an unforgettable student."
In recent months, Rachel Yould (her married name) had been living an itinerant existence in Anchorage, where she shuttled, often in disguise, between safe houses established for victims of domestic violence. A group of local women, mostly domestic-violence survivors, cared for Yould; her "safety team," or Team Rachel, as the group was known, insisted that outsiders who wanted to meet her first sign a confidentiality contract, so that her father, who she claimed had abused her, could not find her. Yould saw her husband once a week, and her "big outing," as she put it, was a weekly trip to church.
On September 10th, Team Rachel escorted Yould to the federal courthouse in Anchorage, where she was treated not as a victim but as a perpetrator. There she was to be sentenced by Judge John Sedwick, of the U.S. District Court, for carrying out a complex scheme to defraud the governments of Alaska and the United States. Yould's life after Stanford had turned into a sprawling saga that unfolded in half a dozen countries on three continents. Documents relating to her fraud case filled an entire room of the U.S. Attorneys office in Anchorage. Before her sentencing, her supporters wrote moving letters asking Judge Sedwick for leniency. As one family friend wrote, "Rachel is a kind, loving person and her goal has always been to help others." A series of domestic-violence experts, retained by Yould's public defender, told the judge about the implications of the abuse that she said she had suffered. Dr. Eli Newberger, who is affiliated with Harvard Medical School, examined Yould and wrote in his report, "In my forty years of experience in this area of practice, I have never seen such a heartless and systematic torture of a child by a parent."
The prosecution presented a very different picture of Rachel Yould. In a hundred-and-twenty-page brief, RettaRae Randall, the Assistant U.S. Attorney on the case, wrote, "The case is not about abuse, but about lies and greed."
In another court filing, Randall wrote that the defendant "claims 'safety concerns,' needing a 'safety team,' being a `victim' of domestic violence, not only to manipulate the court, but also to defraud agencies which support true victims of domestic violence. No evidence, not even a proffer, of any legitimate threat to the defendant's safety since she arrived in Anchorage in January 2009, has been provided to the court or to the United States Probation Office. Yet the defendant has been allowed to take up space at a 'safe house' for domestic violence victims, to the detriment of those women who are truly fleeing a present danger and need a safe place to reside with their children." The question raised about Rachel Yould is, then, a simple one. Is she a brilliant, heroic survivor and a victim of injustice--or an incorrigible con artist?
Cheryl Davis grew up in a small town in Alabama and went to college at Auburn University. There she met Robert Eyre Hall, and the two were married in 1969, shortly before he graduated and enlisted in the Army. Hall was assigned to the Panama Canal Zone, where Rachel Eyre Hall, the couple's only child, was born, on January 3, 1972. After Robert Hall left the service, the family moved to Glendale, Arizona, where he attended business school at the Thunderbird School of Global Management. The family moved to Illinois, where Robert went to work for a company that sold agricultural products; in 1975, the couple divorced. Sheryl and Rachel moved back to Alabama. "He was never violent to me," Sheryl Davis told me, speaking of her ex-husband, "though he did throw a shoe at me once."
Hall's career led him to live, over the next few years, in Puerto Rico, New Jersey, and, eventually, near Atlanta. Sheryl was a teacher, and she and her daughter moved often as well; by the time Rachel was in sixth grade, she had lived in six places and gone to five schools. In 1982, Sheryl married Glenn Denkler, a Vietnam veteran, who enrolled in the Culinary Institute of America, in Hyde Park, New York. In 1985, after he graduated, the couple decided to move to Anchorage, where Denkler became a cooking teacher at a vocational high school, and Sheryl also taught school. Rachel came with them, but, from the time she was five, she spent a few weeks with her father every summer.
As part of her defense, Rachel Yould wrote an autobiography of sorts, which was circulated among her supporters. It consists of more than fifty single-spaced pages, and is composed in her characteristic torrential writing style-- an intense conglomeration of detail and explanation that is evident even in her routine correspondence, which often runs to thousands of words. "I have no memory of a life without abuse," the account begins. "Among my earliest recollections are disjointed montages of heavy breathing and touching and thrusting and pain and nausea and an unsettling inability to reach that place inside me from which tears would, for most people, issue forth." She goes on, "My childhood was peppered with moments of clarity and desperate cries for help, but they were fleeting and failed to save me."
Robert Hall has always denied abusing his daughter in any way, but Rachel's account is full of detailed recollections. "I remember refusing to allow a doctor to examine me during a childhood doctor's visit to diagnose one of countless urinary tract infections," she writes. "I told my mother quietly that it was because of daddy and she conveyed to the doctor that I was resisting the pelvic exam because of problems we'd had with my father. I was spared the exam but little else. My mom took no action to investigate my assertion or curtail my visits with my father, who was no longer living with us at that time."
In a letter to the judge, Sheryl described Rachel as an "anxious, emotionally excessive" child. "She was a loving, gentle child—not a discipline problem—whose angst was early and internal." According to her mother, Rachel saw a series of counselors but never received a diagnosis. Sheryl says that Rachel never told her of any abuse. "I think Rachel tried to tell me many times, but she was not heard," Sheryl told me. "At a certain point, she just stopped trying."
The report assembled by Eli Newberger, the medical expert retained by the defense, includes an account of an incident in Yould's adolescence. "On one occasion, after Ms. Yould had a mole removed without first seeking Mr. Hall's permission, she described having awakened tied up, and recalled his saying, 'If you want less flesh on your hip, I'll show you less flesh,' " Newberger wrote. "Ms. Yould described that Mr. Hall took out a knife and a second implement with a curved protrusion at the end and 'started carving, pulling out this long plug of skin, fat, and muscle.' She described how strange it was to feel and then see a part of her no longer being a part of her. Her pain on this occasion was deeper and more sustained, and she said she bled more than usual. She noted shivering consistent with shock and persistent bleeding, and lapses of consciousness."
In a written statement to the court, Yould recalled seeing something in the basement of her father's house. "I walked close and stared and then suddenly felt like a cosmic jolt had just vacuumed all of the air out of my chest," she wrote. "It was a hunk of desiccated flesh pinned to the wall and I knew from the approximate size and shape and just the nature of life in that house that it was mine. It was a piece of me pinned to the wall."
Yould said that she took refuge from the abuse by excelling at school. "My elixir was superstar achievement," she wrote. "I was a top honors student, an athlete, and president of everything. I was a community volunteer, a creator of civic programs, an advocate of social causes The crushing pace required to keep these countless responsibilities aloft, while destructive to my ailing spirit, rendered life manageable." Still, she wrote, she was plagued by "flashbacks," which sometimes caused her to drive off the road: "The two realities that I had spent a lifetime cleaving into two separate people—the bad, scary me that haunted my nights versus the light, accomplished me that carried me through each day—came crashing together." By the time she graduated from high school, her nightmares "had reached new heights as had the sleep-deprivation and anxiety that would render me persistently ill for years to come."
During her summertime visits to her father, Yould said, she became close to her stepbrother John (Robert Hall had remarried), who fell ill with AIDS-related symptoms in 1990. She learned to perform massage therapy on him, and ultimately began a program to provide massages to AIDS patients in Sacramento, which is near U.C. Davis. "When my step-brother was ill with AIDS, I began writing to Mother Teresa as an outlet for my grief," she later wrote. "I honestly didn't know if anyone read my letters, and I certainly did not expect that they were reaching Mother." After John died, in 1993, "I received a letter inviting me to come work in Mother's Home for the 'Dying, to care for her terminally ill patients as I became accustomed to being unable to care any longer for my brother. I traveled to India for a short time while in college to do just that." According to a letter written in 1997 by Brother Vinod, an associate of Mother Teresa, "Among the hundreds of patients who Rachel has personally diagnosed and treated during her three-month stay here, I have observed marked improvements.... Rarely in my career have I encountered such dedication to contributing professionally for the benefit of the poor." A subsequent job as a massage practitioner at a spa near Sacramento ended less happily, when, according to her employer, she left shifts uncovered and once skipped work "due to her visiting a male friend not kidney cancer as she told us."
Yould always drew extreme reactions, sometimes even from the same people. Peter Duus, a professor of Japanese history, knew Yould at Stanford. "I felt that there was something phony about her, not in the sense that she was fraudulent but that she was excessively insistent in talking about her accomplishments, her skills, and her ambitions," Duus told me. "For example, at various times she told me that she had spent a year nursing her brother through a devastating illness, and that she had been treated for ovarian or cervical cancer and would never have children. I took her behavior to reflect the fact that she had lived a harder life than other students had—and was trying to compensate for that."
In 1993, Yould's father agreed to pay for a summer program at Georgetown, in Washington. "I was not spared what had become my annual hospital stint, but it did not dull my enthusiasm for the experience," she wrote of that summer, when she also worked part time as a White House intern. "Toward the end of my program, there emerged an acute problem with one of my vaginal glands, a common byproduct of childhood trauma to the genitalia," she wrote. "It required immediate surgery and a hospital stay."
According to Yould, Robert Hall came from his home, in Georgia, to attend the closing ceremony for the Georgetown program. Hall took his daughter to dinner and ordered "bottle after bottle of champagne." Rachel passed out asleep on the one bed in her father's hotel room, while he went to sleep on the couch.
"I awoke that night with my father on top of me," she wrote. She said that he raped her. The next morning, she returned to her dorm room. "I may well have remained sitting in that dorm room for more than two days without moving. I lost all sense of time. The only sensation of which I was aware was the life bleeding out of me." She went on, "My reverie was broken by a summer Resident Adviser knocking to inform me that my airport shuttle had arrived. I had packed before the ceremony and followed my escort compliantly down the corridor to the van, not having even showered since the rape. And off to the airport I went." She next saw her father in Georgia, the following year. During that encounter, she later said, "he took a vise and chiseled out a treasure map onto me so I saw every time I get undressed where he is going to stab me." Father and daughter have not seen each other since the mid-nineties.
Yould won the Rhodes in late 1995, 1 but delayed going to Oxford for a year, because of health problems, which she later described as "unpredictably intermittent bouts of significant pain." Notwithstanding the health problems, Yould entered and won the Miss Anchorage pageant in 1996 and also took a summer internship, as part of her Truman scholarship, at the Pentagon. This was extended with an unpaid consultancy, which included a trip to Japan. Brett Yould, her boyfriend, joined her in Washington; the pair then hoped to be hired as paid consultants. When an offer was not forthcoming, Rachel wrote a lengthy letter to a superior at the Pentagon, reflecting a remarkable sense of entitlement:
“Clearly, there are situations when age is not an inherently relevant criterion for capability assessment. Just as I struggle with the complexities of possessing a genius-level IQ, medically certified photographic memory, and fluency in several Asian languages at such a young age, Brett grapples with being a recognized computer genius in an industry that considers age a factor.”
Rachel and Brett met as high-school classmates in Anchorage, and they started dating when both were home on breaks from college. 'We saw each other at a cotillion reunion dance during my freshman year," Brett told me. "We danced to `Stairway to Heaven.' We were instantly head over heels for one another." Brett had majored in psychology at Colorado State University; he had a job in computer training. Cautious where Rachel was bold, besotted but also bewildered by Rachel, Brett was content to live in her shadow.
Rachel and Brett spent some time in Portland, Oregon, in 1996, and Rachel later told the police that she began receiving "obscene phone calls from Robert Hall several times a day." She said that during those calls her father told her that he was watching her and that she could never get away. One day, according to Rachel, there was a break-in: "The lock on my baby chest had been broken and someone had rifled through all of my baby memorabilia. The only item stolen from the sizeable unit, which contained a variety of valuable items, was an Elvis Presley album. Elvis Presley is Robert Hall's favorite musician."
The above text covers the first three pages of this nine page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.
Can a Stressful Childhood Make You a Sick Adult?
Paul Tough, The New Yorker- 3/21/2011
Monisha Sullivan first visited the Bayview Child Health Center a few days before Christmas, in 2008. Sixteen years old, she was an African-American teenage mother who had grown up in the poorest and most violent neighborhood in San Francisco, Bayview-Hunters Point, a bleak collage of warehouses and one-story public-housing projects in the city's southeastern corner. Sullivan arrived at the clinic with ailments that the staff routinely observed in patients: strep throat, asthma, scabies, and a weight problem. The clinic's medical director, Nadine Burke, examined Sullivan and prescribed the usual remedies - penicillin for her strep throat, ProAir for her asthma, and permethrin for her scabies - and at most clinics that would have been the end of the visit. But Burke, who founded the center in 2007, was having a crisis of confidence regarding her practice, and Sullivan was the kind of patient who made her feel particularly uneasy. Burke was diligently ticking off each box on the inner-city pediatrician's checklist, but Sullivan's problems appeared to transcend mere physical symptoms. She was depressed and listless, staring at the floor of the examination room and responding to Burke's questions in sullen monosyllables. She hated school, didn't like her foster mother, and seemed not to care one way or the other about her two-month-old daughter, Sarai.
Burke is charismatic and friendly, and her palpable concern for her patients disarms even the toughest cases. It helps that she is dark-skinned, like most of her patients, and young—just thirty-five. But her childhood was very different from theirs. The daughter of Jamaican professionals who moved from Kingston to Silicon Valley when Burke was four, she attended public school in Palo Alto, where the kids were mostly white and well-off, and where girls cried in the cafeteria if they didn't get the right car for their sixteenth birthday. Like many children of immigrants, Burke has learned to move fluidly between cultures. She now lives in a house in an upscale part of Potrero Hill, a San Francisco neighborhood, with a closet full of designer clothes, and she has a fiancé who is a wealthy solar-energy entrepreneur. But she seems just as comfortable among the mostly poor families she sees in her examination room: laughing, gossiping, hugging, and scolding, in Spanish as well as in English, in a full-throated alto that echoes down the hall.
At the clinic, Burke gently interrogated Sullivan until she opened up about her childhood: her mother was a cocaine addict who had abandoned her in the hospital only a few days after she was born, prematurely, weighing just three and a half pounds. As a child, Sullivan lived with her father and her older brother in a section of Hunters Point that is notorious for its gang violence; her father, too, began taking drugs, and at the age of ten she and her brother were removed from their home, separated, and placed in foster care. Since then, she had been in nine placements, staying with a family or in a group home until, inevitably, fights erupted over food or homework or TV and Sullivan ran away—or her caregivers gave up. She longed to be with her father, despite his shortcomings, but there was always some reason that he couldn't take her back. For a long time, she had the same dream at night: taking the No. 44 bus back to Hunters Point, walking into her father's house, and returning to her old bedroom, everything just as it used to be. Then she'd wake up and realize that none of it was true.
When I met Sullivan, last September, she had recently turned eighteen, and three days earlier she had been emancipated from foster care. She was now living alone, in a subsidized apartment off Fillmore Street. In California, emancipated foster children are given a summary of their case file, which meant that Sullivan had just been handed an official history of her rootless adolescence. "It brought up a lot of emotions," she told me. "I read it, and I kind of wanted to cry. But I was just, like, 'It's over with.' "The most painful memory was of the day, in fifth grade, when she was pulled out of class by a social worker she had never met and driven to a strange new home. It was months before she was able to have contact with her father. "I still have dreams about it," she told me. "I feel like I'm going to be damaged forever."
I asked Sullivan to explain what that damage felt like. For a teenager, Sullivan is unusually articulate about her emotional state—when she feels sad or depressed, she writes poems—and she evoked her symptoms with precision. She had insomnia and nightmares, she said, and at times her body inexplicably ached. Her hands sometimes shook uncontrollably. Her hair had recently started falling out, and she was wearing a pale-green head scarf to cover up a thin patch. More than anything, she felt anxious: about school, her daughter, even earthquakes. "I think about the weirdest things," she said. "I think about the world ending. If a plane flies over me, I think they're going to drop a bomb. I think about my dad dying. If I lose him, I don't know what I'm going to do." She was even anxious about her anxiety. "When I get scared, I start shaking," she said. "My heart starts beating. I start sweating. You know how people say, 'I was scared to death'? I get scared that that's really going to happen to me one day."
Sullivan encountered Nadine Burke at a moment when Burke was just beginning to think deeply about the physical effects of anxiety. She was immersing herself in the rapidly evolving sciences of stress physiology and neuroendocrinology, staying up late reading journals like Molecular Psychiatry and Nature Neuroscience. Burke had just learned of a pioneering study, conducted in San Diego, on the long-term health effects of childhood trauma, and its conclusions had led her toward a new way of thinking—not just about her clinical practice but about the entire field of pediatric medicine.
As she listened to Sullivan, Burke found herself inching toward a diagnosis that, a year earlier, would have struck her as implausible. What if Sullivan's anxiety wasn't merely an emotional side effect of her difficult life but the central issue affecting her health? According to the research Burke had been reading, the traumatic events that Sullivan experienced in childhood had likely caused significant and long-lasting chemical changes in both her brain and her body, and these changes could well be making her sick, and also increasing her chances of serious medical problems in adulthood. And Sullivan's case wasn't unusual; Burke was seeing the same patterns of trauma, stress, and symptoms every day in many of her patients.
Two years after Sullivan's first visit, Burke has transformed her practice. Her methodology remains rooted in science, but it goes beyond the typical boundaries of medicine. Burke believes that regarding childhood trauma as a medical issue helps her to treat more effectively the symptoms of patients like Sullivan. Moreover, she believes, this approach, when applied to a large population, might help alleviate the broader dysfunction that plagues poor neighborhoods. In the view of Burke and the researchers she has been following, many of the problems that we think of as social issues—and therefore the province of economists and sociologists—might better be addressed on the molecular level, among neurons and cytokines and interleukins. If these researchers are right, it could be time to reassess the relationship between poverty, child development, and health, and the Bayview clinic may turn out to be a place where a new kind of pediatric medicine is taking its tentative first steps.
"With someone like Monisha, we can help her recognize the neurochemical dysregulation that her childhood has produced in her," Burke told me. "That will reduce her impulsivity, it will allow her to respond more calmly to provocation, it will help her make better choices. She'll have a better life."
In 2005, when Burke completed her medical residency, at a children's hospital on the campus of Stanford University, she was an idealistic twenty-nineyear-old with a medical degree from the University of California at Davis and a master's in public health from Harvard. She was recruited by the California Pacific Medical Center, a private hospital group, to take on a vaguely defined but noble-sounding job: identifying and addressing health disparities in San Francisco, where the poverty rate for black families is five times as high as that for white families. Much of the city's African-American population lives in Bayview-Hunters Point, a largely industrial area that has a sewage-treatment facility and a sprawling Superfund site. Rates of congestive heart failure are nearly five times as high in BayviewHunters Point as in the Marina district, a few miles away. Before Burke's clinic opened, there was only one pediatrician in private practice in a community with more than ten thousand children.
At Harvard, Burke had studied health disparities, and she knew what the public-health playbook recommended: improving access to health care, especially primary care, for low-income families. She persuaded her new bosses at California Pacific to let her open a clinic in Bayview-Hunters Point that would accept all patients, regardless of their ability to pay. She found some empty office space on Evans Avenue, across from a giant mail-sorting facility, and had the place remodeled and repainted in bright colors.
When the clinic opened, in 2007, Burke focused on health issues that particularly plagued poor children: asthma, obesity, vaccination rates. In just a few months, she made significant headway. "It turned out to be surprisingly easy to get our immunization rates way up and to get our asthma hospitalization rates way down," she told me. And yet, she explained, "I felt like we weren't actually addressing the roots of the disparity. I mean, as far as I know, no child in this community has died of tetanus in a very, very long time."
Burke found herself thinking increasingly about the problems that she couldn't immunize her patients against: homelessness, gang violence, physical abuse, and sexual abuse, as well as absent fathers, fathers beating mothers, brothers shot to death on the street, uncles sent to prison. These problems were, technically, none of her business. If you want to tackle violence and abuse and deprivation in the inner city, you don't go to public-health school; you become a social worker or a judge or a cop. What did the field of medicine really have to offer kids like Monisha Sullivan, besides a little ProAir and permethrin?
The above text covers the first two pages of this seven page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.