In his autobiographical book Can't Be Trusted, Bart Johnson, PhD, aims to explore the implications of the label of mental illness. Dr. Johnson, who earned a PhD in electrical engineering from MIT, had aspirations to fly airplanes. In pursuit of his piloting license, however, a Federal Aviation Administration (FAA) psychiatrist diagnosed him with schizophrenia, a diagnosis that automatically bars one from piloting an aircraft.
The book, with the exception of the first two chapters, generally follows the author's life in chronological order. The first chapter explores general information about FAA medical certificates and regulations relating to piloting. The second is a brief description of the author's suicide attempt, a jarring and puzzling inclusion that is not explored in any further depth in the remaining chapters. The author then chronicles his family history (Chapter 3), childhood and adolescence (Chapter 4), college and graduate studies (Chapter 5), and work history (Chapters 6 and 7). Chapter 8 is entitled “Psychosis” and is devoted to an unfortunately brief exploration of the author's experience with psychotic depression. Chapter 9 is devoted to a lengthy but comprehensive discussion of the history of psychiatric treatment, including many classes of medication and the emergence of electroconvulsive therapy. The penultimate chapter again discusses FAA regulations as well as some historical examples of rare tragic incidents related to pilot mental illness. Chapter 11 reflects the book's generally disparate themes and purposes, repeating some history, the author's frustrations over FAA regulations and his disagreement with his diagnosis of schizophrenia, among other points. Two appendices take up much of the remaining pages, one of which includes the formal reports relating to his psychiatric evaluations, while the other goes into further detail about the engineering topics he explores throughout the book.
The purpose of the book and its audience is multi-faceted. Dr. Johnson claims he wrote the book for “mental health experts, victims of depression, aviators, the FAA, Yale University, engineers, physicists, and computer scientists” (Introduction, page unspecified). As one can imagine, with such a broad audience, the book's content and purpose often wanders. At times, it reads like a treatise against the mental health industry and FAA regulations. At other times, it reads like a physics textbook. Dr. Johnson points out in his introduction that by including his accomplishments, projects, and engineering interests in the book, he sought to juxtapose the FAA's claim that he, according to his wording, is a “dangerous paranoid schizophrenic” (Introduction, page unspecified) or “crazy” (e.g., p 99).
Dr. Johnson's decision to chronicle his life and mental illness is a brave one. I found his chapter on the history of psychiatry to be well-researched and enjoyable. Dr. Johnson's occupation as an engineer shines through in this chapter with its meticulous attention to detail. I was also grateful for the vulnerable description of his psychotic episodes. As a member of the mental health clinician audience he wished to reach, I found myself wishing there was more of this content.
Unfortunately, the book has several shortcomings. It would have benefited from a professional editor, whose guidance could have focused the themes and narrative. The chapters themselves felt clunky and unfocused. Dr. Johnson's inclusion of technical physics and engineering content is difficult to follow. I also bristled at the use of “crazy” and “head shrinker” throughout his prose. His use of these colloquial terms seemed to undermine his contempt of the stigmatization of mental illness and made me feel defensive of my patients who may not appreciate such terms. Further, in his final chapter, he encourages patients who are currently receiving or may receive treatment in the future to reconsider their acceptance of medication and hospitalization; such encouragement makes his book one I would be wary of recommending to patients, who may have otherwise benefited from a sense of solidarity between their and the author's experiences.
Chapter 2 introduces a jarring narrative of a suicide attempt. The episode is brief with little context. In another work, I might wonder if the lack of context and jarring nature is meant to mirror the typical nature of suicide, which often leaves the loved ones of the deceased perplexed and unsure. In an autobiographical piece, however, the account begs for a more thorough understanding.
Although the book is not necessarily targeted at forensic psychiatrists, the author introduces some important points germane to our practice. Dr. Johnson claims that an expert used the second edition of the Diagnostic and Statistical Manual (DSM-II) to diagnose him with schizophrenia. The author points out that the DSM-II was outdated at the time of his evaluation, thus leading to an erroneous diagnosis. Such a claim certainly reflects the importance of careful use of DSM in our evaluations, including applying its criteria based on the field's most current understanding of diagnostic phenomena. This is especially true in cases of psychological fitness evaluations when certain diagnoses are exclusionary. In the case of the author, even if a different diagnosis were warranted, it would not have led to an alternate outcome; Dr. Johnson had other factors in his background, such as a suicide attempt, that precluded his ability to obtain a medical clearance (a fact he acknowledges). Nonetheless, it was a good reminder to me as an early career psychiatrist that a prudent and thoughtful forensic clinician should be careful when applying diagnostic labels and should acknowledge when diagnostic criteria fail to capture the presentation.
For many of its shortcomings, the book was a good exercise in confronting my own sense of stigma and bias. As I read, I reflected that I was seeking clinical criteria in the writing and story that may provide diagnostic clues. While I tried to keep an open mind as to the nature of the diagnosis, I reflected that the author's acknowledgment of mental illness placed it front and center in my consciousness, as opposed to the narrative he was attempting to tell. As I read, I attempted to consider any bias that I as a clinician introduced into my reading and found this a useful exercise in self-reflection. It may be so for other forensic readers interested in reading this piece.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2023 American Academy of Psychiatry and the Law
