♪ ♪ MIA YAMAMOTO: My story starts off with understanding that I was not like everybody else, so I thought of course I was sick.

I was mentally ill. And I believed it for probably half my life.

Today, I feel quite different, but when I first went into therapy, it was, like, "Somebody, please solve my problem."

And I spent a lot of years in that state.

♪ ♪ (compact closing) This one here, I think that's me over on the left-hand side here pretending like I'm happy.

My identity was, at a very early age, female.

I could see the world through my sister's eyes, through my mother's eyes, far better than I could understand the world of my father and my brothers.

I could hear my father saying, "Well, he's just going through a phase.

Mike's gonna grow out of it."

And my mom saying, "Well, maybe we should take him to a psychiatrist."

And when they realized how much it cost, that idea was never discussed again.

(chuckles) ♪ ♪ I felt completely alone.

And that feeling persisted until I read about the first transgender sex change operation, which occurred in 1952.

The headline was sensational, but for me, it was an epiphany.

And so I got the paper, and I remember going in to my mom, where I show her the paper, and I'm saying, "Look, I'm not the only one who feels this way."

And she looks at me, looks back down at the paper, and she just puts her head on the ironing board and starts crying.

And, um...

Determined I would never do that to her again.

I spent years after that trying to figure out what was wrong with me.

♪ ♪ ♪ ♪ NARRATOR: What is mental illness?

For centuries, religion offered spiritual answers, while science looked to the body and the mind.

Today, genetic breakthroughs and neuroimaging provide tantalizing clues into the roots of mental disorders.

But a simple answer for who is-- or isn't-- mentally ill remains elusive.

RONALD BAYER: It would seem to be pretty straightforward.

Sick is sick, healthy is healthy, what's the big deal?

But it turns out that in psychiatry, the boundary between illness and sickness is very fluid.

SUSANNAH CAHALAN: Where do we draw that illness line?

What is abnormal, what's normal behavior, what's illness, and what's the kind of, you know, broad swath of what it is to be human?

NARRATOR: There are no biological tests to diagnose mental illness, complicating the question who's normal and who's not.

KEITH WAILOO: Societies decide what constitutes behavioral norms, social norms, and where the lines of deviance exist.

♪ ♪ MICHAEL WALROND: God, we bless Your name on today.

We bless Your name on today, oh, God.

The hardest thing to do is to feel like you are walking through the valley of the shadow of death and there's no one with you.

You've been constant, oh, God.

But most of all, oh, God, You've been consistent in our lives.

So, God, we bless Your name right now.

In my 20s, I began to experience bouts of depression.

I never sought help, because that was not part of the common conversations that took place in my community growing up or in my house coming up.

In my 30s was the first time I had any suicidal ideations.

There were numerous days where I didn't want to preach, I didn't want to teach, I didn't want to talk to people, but I felt like I never had the option of not doing it because of the weight and responsibility of my call.

And so like so many people who battle with depression and other conditions, you suffer in silence.

'Cause I didn't want to be labeled.

"Nothing is wrong with me, I'm a pastor."

To say that, "Oh, I'm going to see a therapist," is tantamount to saying, "I don't trust God can do it."

"I don't believe that prayer can do it."

And no one wants to say, "I don't trust God and I don't believe in the power of prayer."

♪ ♪ But it became torturous that people saw me as representing some level of healing, and yet I felt no resolution within myself for that.

And it took a long time for me to actually reach out.

And I remember going to that first therapy appointment with all sorts of walls up, not wanting to admit that something was really wrong.

Because as a Black man, there's not a desire for one more label.

Oftentimes, there's a, a dangerous reductionism that takes place.

The individual becomes synonymous with the thing they're wrestling with.

So that when you see me, potentially, you don't see me, you see my thing.

You see, "Oh, he's depressed."

"Oh, he's Black."

♪ ♪ NARRATOR: Labeling as "other" has deep roots in American history.

The 1840 national census included a new category to count the mentally ill. At the time, many Black people were escaping slavery and settling in the North, and for some observers, their new freedom didn't seem "normal."

WAILOO: The census of 1840 is a quintessential example of how social judgment and medical judgment are intermarried at a time when slaveholders are arguing that Black people are incapable of managing themselves as free people, and at a time when others in free societies are asking whether freedom itself creates certain challenges for African Americans.

NARRATOR: With no clear standards, white marshals decided who to label mentally ill. Free Blacks in the North were identified as insane ten times more frequently than those enslaved in the South.

In many Northern towns, all the Black residents were counted as insane.

To critics, the bias was obvious.

But to pro-slavery advocates, the census was evidence that freedom made Black people mentally ill.

The Medical Association of Louisiana endorsed this view with a self-serving new diagnosis.

ANGELA COOMBS: In the 1800s, you see an illness called drapetomania, which was described as an illness that led enslaved people to seek freedom.

So instead of people saying, "Okay, these are human beings who are trying to be free of being enslaved," it's conceptualized as an illness.

And of course, the treatment for it was to be whipped and to be beaten.

♪ ♪ NARRATOR: Drapetomania highlights enduring questions in psychiatry: where is the line between cultural judgment and medical diagnosis?

Are psychiatric labels helpful or harmful?

COOMBS: When we look at who gets labeled and what the service or functioning of that label is, that's what's really meaningful.

Are we saying and diagnosing people to get them a recovery-oriented and humanizing kind of care that, that, you know, really affirms people's humanity?

Or are we using it in a way to treat people as less than human?

RYAN MAINS: I didn't think mental illness was something that happened to normal people.

When I thought of mental health issues, I thought of the stereotypical, straitjacket, padded room-type things.

You know, somebody, uh, like, in a vegetative state, on meds, just laying in a bed.

NARRATOR: Ryan Mains is a veteran and first responder.

Like many, he has struggled to accept his diagnosis of post-traumatic stress disorder, or PTSD, and its associated stigma.

MAINS: There's a term in the ultra-running community called "brutiful," combination of brutal and beautiful.

(chuckles): And I so much love that term.

It's pain and it's glory and it's, "How long can you push yourself?"

My next run is going to be 130 kilometers.

That distance specifically, because over 130 firefighter-paramedics died by suicide last year.

That's not something that's known.

That's not something that's talked about.

NARRATOR: Ryan served in the Army for four years and was a frontline medic during the U.S. occupation of Iraq.

When he returned home, he joined the fire department in Woodstock, Illinois.

MAINS: That's when it kinda hit me.

♪ ♪ I'd have intrusive thoughts about my time in Iraq.

(faint explosion) You just, you see things that are hard to forget.

(siren wailing) And, um, they'd kind of overlap with intrusive thoughts from things that happened at work.

I would lose my temper and start yelling, and that happened a lot, and I didn't see it at the time.

I started avoiding work, calling off sick for a few shifts.

NARRATOR: When a fire department counselor diagnosed PTSD, Ryan rejected the label.

I said, "Go (bleep) yourself.

That's not for me."

I had a tremendous amount of shame.

(sighs) What I didn't realize was, I was just setting myself up for a bigger fall later.

NARRATOR: More than a century ago, millions of soldiers like Ryan endured trauma, and their struggles forced the nation to confront the question: who is normal and who is not?

(artillery and guns firing) After the brutality of combat in World War I, many who escaped physical harm still appeared damaged.

Doctors referred to their mysterious condition by many different names, and wondered: why were only some soldiers exhibiting a debilitating reaction?

ANNE HARRINGTON: A lot of the young men presented with physical symptoms of paralysis, or mutism, or blindness.

We would call it trauma, we would call it PTSD.

NARRATOR: Doctors searched for the source.

Perhaps explosions caused tiny tears in the spinal cord.

Or cerebral hemorrhages.

But the brain was still mostly a black box.

X-rays, surgery, and even autopsies provided few clues.

As World War II dawned, the military was determined to weed out vulnerable recruits.

But how?

Without any reliable physical tests, they turned to the mind and the work of Sigmund Freud.

ALLEN FRANCES: World War II to a very strong degree was a legitimization of Freud.

Freud's theory was based on the fact that the combination of instinct and experience dramatically influences our lives.

But these are not always available to consciousness.

And a lot of the things we do we do for reasons we don't begin to understand, for motivations that are not accessible to our conscious thinking.

NARRATOR: Freud died just as World War II began, but his ideas had revolutionized psychiatry.

He believed there wasn't a clear line between mental health and mental illness.

Everyone lived on a spectrum because the conscious mind was always in conflict with unconscious desires and repressed memories.

If unresolved, this conflict could cause neurosis, which he claimed was often the root of mental illness.

Practitioners of Freud's theories called themselves analysts and used his talk therapy techniques to treat these neuroses.

MAN (in film): Psychoanalysis is a long and difficult process of reconstructing from fragmentary recollections a picture giving the patient a correct insight into the forces at work within him.

JEFFREY LIEBERMAN: Beginning in the 1930s, every major department of psychiatry in the country was chaired by an analyst, and every president of the American Psychiatric Association was an analyst.

NARRATOR: Analysts developed a system to help the Armed Forces evaluate soldiers in an effort to prevent psychiatric casualties.

HARRINGTON: Not everybody in World War I broke down, but some did-- what's the difference?

So if you could identify the pre-existing vulnerabilities, you could maybe then avoid a repeat of the, of what happened in the First World War.

Maybe the people that have the combat neuroses were fragile to begin with.

People really started to talk about things like this.

MAN (in film): You will be interviewed by a psychiatrist along with all the rest.

They've got to know how you'll adjust yourself to the Army-- if you've got what it takes to make a soldier.

FRANCES: Freud's first theories were that childhood trauma is a precursor to mental illness.

Psychiatric problems came from family trauma.

HARRINGTON: They would ask questions like, "Do you wet your bed?"

Ask about your relationship with your mother.

"Do you find yourself getting irrationally angry?"

Do you like going around with girls?

HARRINGTON: Being homosexual was believed to both be a mental illness and also be potentially a disciplinary problem in the military.

BAYER: In the psychoanalytic worldview, the normal course of development was, you passed through your bisexual phase into your heterosexual phase.

So that becoming homosexual meant there was sort of an arrest in the developmental process.

NARRATOR: Using a list of potentially "pathological" behaviors and "neuroses," psychiatrists rejected one out of eight draftees-- nearly two million men.

But the screening strategy didn't work.

(bombs roaring, guns firing) ANDREW SCULL: During the Second World War, America's psychiatric casualties were double and triple what they'd been in World War I.

And in combat situations, sometimes half of all the casualties were psychiatric casualties.

(mumbles): I just can't stand seeing people killed, sir.

- I can't hear you.

- (louder): I can't stand seeing people killed.

- Did you see people killed?

- (voice trembling): Lots of them.

- What?

- (louder): Lots of them.

NARRATOR: The battle-weary soldiers proved it wasn't so easy to predict who would or wouldn't be vulnerable to trauma on the front lines.

PSYCHIATRIST: What I'm going to do is send you back to another hospital, where you can get more rest and more treatment.

NARRATOR: But the military once again entrusted psychiatrists, this time to rehabilitate these psychologically wounded soldiers, and commissioned films to convince the country the right treatment would help them return to "normal."

- A display of emotion is all right.

- I'm not doing this deliberately, sir, please believe me.

- Of course you're not, I do believe you.

HARRINGTON: All this is being filmed to convey this message of, "Psychiatry knows what it's doing, and there's nothing to fear with these men."

MAN (in film): Under the guidance of the psychiatrist, he is able to regard his experience in its true perspective as a thing of the past, which no longer threatens his safety.

♪ ♪ HARRINGTON: And at the end, they all go back to, allegedly, a happy life.

What's not to like?

YEHUDA: People really believed that soldiers could start to sort of take their place back into a society that they left.

What they didn't realize was that the effects of combat could last in perpetuity, could last for years and decades, rather than for weeks and months.

NARRATOR: The camera crews didn't follow these vets home to see how they adjusted to civilian life.

But the message was clear: they should be able to overcome their trauma.

This message reverberates today, and fuels stigma for millions of PTSD patients.

(indistinct chatter) MAINS: I have a lot of self-stigma about my diagnosis and my struggles.

Irritability, poor sleep, rash decision-making.

When I started to have those feelings, I just ignore it.

(siren blaring) But the thought of being on an ambulance was overwhelming.

I was unable to find the motivation to do anything, to bathe, to take care of myself.

You know, I'm laying in bed with suicidal ideations.

NARRATOR: Like many traumatized veterans and first responders, Ryan spent a few weeks at a psychiatric facility specializing in PTSD.

MAINS: At the time, I thought that I was cured.

But it's pretty peaceful there, and then you come back to real life with your kids and, and work, and bills, and...

It was a pretty rude awakening.

All those dark, empty feelings started creeping back.

The therapist at work told me that I was unfit for duty.

I couldn't go back.

Now it wasn't just, "I need to take some time to get myself right."

It was, "I can't do the job anymore."

It reinforced some of that stigma.

NARRATOR: Ryan is one of many military vets to feel responsible for his inability to overcome his traumatic experiences.

World War II psychiatrists contributed to this misconception.

One of the ways psychiatry persuaded its military superiors during the war that it was doing such a great job was, it produced statistics on how wonderfully it was doing.

Those statistics were made up and bogus.

NARRATOR: Military psychiatrists treated more than a million soldiers for psychiatric disorders.

Some doctors claimed a cure rate of more than 80%, but fewer than one in ten actually returned to active duty.

SCULL: And yet, for the military, psychiatry was seen as one of the success stories.

And those early military classification systems formed the foundation for, after the war, the American Psychiatric Association beginning to create a system of diagnoses.

NARRATOR: In 1952, the American Psychiatric Association, or A.P.A., published the first edition of what was to become the bible of the field: the "Diagnostic and Statistical Manual of Mental Disorders."

The DSM attempted to standardize diagnostic labels, but it became a repository of how the profession, and the culture of the day, viewed mental illness.

The first DSM briefly described nearly 100 disorders and drew heavily on Freudian concepts of neurosis and psychoanalysis.

MAN (in film): ...the patient freely associating ideas, dreams, memories, under the guidance of the therapist, until underlying conflicts are identified... NARRATOR: This approach relied on each practitioner's interpretation of each individual patient.

SCULL: Oddly enough, psychoanalysts didn't believe in putting people into different boxes.

MAN (in film): Tell me more about what you are thinking.

FRANCES: People could see the same symptoms, but diagnose them in different ways.

So, diagnostic reliability was close to zero because everyone had their own ideas.

NARRATOR: As always, these ideas were shaped by culture.

In the face of the perceived communist threat during the Cold War, the nation embraced patriotism and conformity.

HARRINGTON: This is a period when people are obsessed with being normal.

Freudian-inflected psychiatry intermingles with a lot of social conservativism and sometimes gets called into service of that social conservativism.

MAN (in film): Parents who are mentally healthy bring up their children to be mentally healthy, too.

Take Tommy Clark there.

NARRATOR: Psychiatrists latched onto the notion that early life experience shaped personality and could lead to neurosis.

And while Freud believed most people lived on a psychological spectrum, the DSM tried to make clear who was normal and who was not.

The feeling of being born in the wrong body was so far outside "normal," the DSM and psychiatry didn't even have a label to describe what people like Mia were experiencing.

YAMAMOTO: You are a sexual deviate, which nobody in society likes very much.

There were a lot of years where I was trying to figure out some way to just kind of end it, because every single person that tells you you're crazy, so you feel like you don't belong in the world.

This is another picture from my unit in August 1966.

Um, that's me.

NARRATOR: Mia enlisted in the Army during the Vietnam War, when she was 23 and her name was Mike.

YAMAMOTO: The military always seemed like a beacon to me.

It was something that I could do that would satisfy the demands of the male gender.

If I had lost my life in war, that it would be an honorable exit from this life, my family would never learn my secret, and people would honor my memory.

This impersonation, I took it a long ways, and I got as far as I could go with it.

NARRATOR: Society wasn't ready to accept Mia's reality.

(protesters chanting) But the Vietnam War sparked a historic cultural shift and a protest movement that would alter how psychiatrists understood who was "normal" and who was not.

MAN (in film): One out of three of you will turn queer.

If you don't get caught by us, you will be caught by yourself, and the rest of your life will be a living hell.

LAWRENCE HARTMANN: Young people now can hardly believe that gayness was considered a major illness and crime to the extent that people who were gay couldn't let you know they were gay.

BAYER: There were laws in the United States, across the United States, they were called sodomy laws.

If two men were caught having sex together, they could go to jail.

So psychiatry took shape under those conditions.

MAN (in film): Your feelings do change to some degree from time to time.

There have been periods when you've felt... - Mm-hmm.

- ...quite strongly heterosexual in your interests.

- Mm-hmm.

HARTMANN: Even though Freud had taken a more agnostic point of view about gayness-- Freud had said, "We don't know, really, but we're learning something about it"-- psychiatrists and analysts tended to consider gay people as deeply sick.

NARRATOR: In mid-20th-century conservative America, one renowned psychoanalyst and psychiatrist was Charles Socarides.

The aim of the homosexual act, paradoxically enough, is to seek masculinity.

He is attempting to achieve the very thing that he felt he was so lacking in childhood.

BAYER: Socarides believed that people became homosexual because they had overbearing mothers and distant fathers.

So he was the person who said, "Our goal as psychoanalysts "is to make them happy and to make them fulfilled "and to allow them to be the men they were born to be, "which is to be straight and to have heterosexual relationships."

SOCARIDES: The whole idea of saying "the happy homosexual" is to, again, to create a mythology about the nature of homosexuality.

HARTMANN: Socarides said that he had treated and cured hundreds of patients.

I think that he was a scoundrel and a liar.

I saw several of the patients that he thought he had cured whom he had not cured.

♪ ♪ Those of us who wanted to reform psychiatry and gayness got some of our courage from Vietnam War protests, women's rights, and Black civil liberties protests.

We said, "Is psychiatric labeling and diagnosis simply a way of society saying, 'We don't like it'?"

In psychoanalysis, the goals are love and work.

They love, they work; why are we defining them as sick?

NARRATOR: Was society once again shifting the boundary between the so-called ill and the so-called healthy?

WOMAN (in film): At first, I was very guilty.

And then I realized that all the things that are taught you not only by society, but by psychiatrists, are just to fit you in a mold.

When I rejected the mold, I was happier.

BAYER: The American Psychiatric Association became targeted as gay people began to say, "We're not sick, we're normal, and you are oppressing us."

NARRATOR: And then, at the 1972 A.P.A.

conference in Dallas, a panel called "Psychiatry: Friend or Foe to Homosexuals?"

featured a man calling himself Dr.

Anonymous.

KENT ROBINSON: Our next speaker is Henry Anonymous, MD.

Obviously a pseudonym.

He is a... (laughter) He is an A.P.A.

member, board-certified psychiatrist.

Dr.

Anonymous.

ANONYMOUS: Thank you, Dr. Robinson.

I'm a homosexual.

I am a psychiatrist.

Cease attempting to figure out who I am and listen to what I say.

HARTMANN: Big mask, microphone to disguise even his voice, and he said, "I'm a psychiatrist and I'm homosexual."

It was unheard of.

Nobody knew or acknowledged that there was such a thing.

ANONYMOUS: This is the greatest loss-- our honest humanity.

And that loss leads all those others around us to lose that little bit of their humanity, as well.

For if they were truly comfortable with their own homosexuality, then they could be comfortable with ours.

HARTMANN: He was a psychiatrist just about my age.

I was much more closeted than he, but I think it was 21 years before he said, "And my name is John Fryer."

NARRATOR: John Fryer had already been fired By two university psychiatry departments for his sexual preferences.

Though he didn't acknowledge his role as Dr.

Anonymous until 1994, his actions laid the groundwork for a revolution.

On December 15, 1973, the A.P.A.

voted unanimously to remove homosexuality from the DSM.

Being gay was now on the spectrum of "normal."

HARTMANN: I was one of the ones who wrote the wording that said gayness should not be considered an illness.

I was pleased that people would reconsider, what do we mean by diagnosis?

What do we mean by trying to help people?

Good evening.

Tonight, "The Advocates" looks at a question which raises both civil rights and moral issues.

Specifically, our question is: should homosexuals be permitted to marry?

NARRATOR: While stigma and prejudice against gays didn't disappear, the approach in the world of psychiatry continued to evolve.

THOMAS ATKINS: Dr. Charles Socarides... NARRATOR: And the once-revered Socarides was heckled for his positions that a new generation saw as outdated and discriminatory.

Dr. Socarides, the American Psychiatric Association, when it was founded in the vicinity of middle 1850s, considered Blackness to be a sign of genetic illness-- is this not correct?

I'm not familiar with that, but perhaps you're right.

- I am.

(audience laughter and applause) Now, of course, we don't believe any of that today.

Judgments have changed.

Isn't it possible that in 50 years, it will be considered just as ludicrous when we hear all the comments that you have made about homosexuality, with... (applause) BAYER: It's easy to look back at that moment and say, "How could people have been so blind "to how the... uses of diagnosis was oppressing people and punishing people?"

And I think when we do that, sometimes, we forget the fact that these psychiatrists very often really thought of themselves as saviors.

They saw themselves as saving someone from a tragic future.

(elevator chimes) ELECTRONIC VOICE: Going up.

NARRATOR: When the A.P.A.

removed homosexuality from the DSM in 1973, Mia had finished her tour in Vietnam and was working as a lawyer.

Although the psychiatric profession finally accepted homosexuality was not a disease, what did it offer those who questioned their gender?

YAMAMOTO: Back in those days, if you asked me if I was gay, I would say no.

I've always loved women, I was enthusiastically straight.

But I go to bed at night, I had the same feeling, like, why am I in this body?

Why am I here, why am I still living like this?

This has to be either 1973 or 1974.

The length of my hair actually is an expression of my gender identity at that point.

I was in therapy for very many years once I could afford it.

At first, I went to a guy who worked with homosexual people.

A gender therapist didn't exist in those days.

So I went to this fella and I said, "I feel like I'm a woman, feel like I've got this body, "and I feel like I don't belong in this body.

"And, and I like to cross-dress.

"Actually, it helps me to feel whole, it makes me feel complete."

He had so few answers for what was going on with me.

He says, "It's really odd that you like women."

He said, "That's, like, really...

queer."

He says, "I..." You know, "I'm a, I'm a therapist for homosexual people," he says, "And they're queer people."

He says, "But you are the queerest of the queer."

NARRATOR: The delisting of homosexuality had exposed the fluid, even arbitrary nature of diagnosis.

And Mia's therapist was not alone in his confusion.

In the 1970s, a young Michael Walrond was struggling with mysterious health issues.

A doctor labeled him with a psychiatric disorder, hypochondria.

WALROND: I heard that word often growing up, because no one could pinpoint what was wrong with me.

I have a rare disease, common variable immunodeficiency, although I was misdiagnosed for 36 years.

As I grew, something was always wrong-- hospitalized, emergency rooms.

I remember some people thought I was trying to get out of school, but I wasn't feeling well.

And then because no one necessarily had answers, but I knew what I was feeling, it puts you in a space where there were days you don't really want to get out of bed.

There are days you don't really, you don't really want to engage people.

I was experiencing these what I would now call depressive moments.

And at the heart of it was my physical challenges.

And to seek out help almost affirms that maybe I am crazy.

NARRATOR: The fear of being labeled with a mental disorder was well-founded.

♪ ♪ For decades, with subjective diagnoses, hundreds of thousands were confined to mental institutions, often against their will.

By the early '70s, many had had enough.

DAVID ROSENHAN: Psychiatric hospitals are storehouses for people in society whom you really don't want, whom you really don't understand, and for whom you've lost a great deal of sympathy.

♪ ♪ NARRATOR: Americans wanted to know-- after decades of trying, could psychiatry even separate the sane from the insane?

CAHALAN: You had a huge backlash against psychiatry.

MAN (in film): I'm a therapist in a day treatment program.

We have an anti-psychiatry model.

We've gotten rid of the normal, normalcy/abnormal dichotomy.

CAHALAN: All this groundswell of fear, and loathing, really, for the psychiatric establishment raises questions about the daily indignities that people face when they are labeled with a psychiatric condition.

FRANCES: People said, "You don't know what you're doing "when you diagnose people "and you don't know what you're doing "when you treat people.

Why is this a medical specialty?"

NARRATOR: The American Psychiatric Association diagnosed the problem: Freud.

LIEBERMAN: In the 1970s, public opinion had shifted from, "Freud's brilliant, this theory is great," to, "The emperor has no clothes, there's no evidence for this."

The leadership of the profession got together and said, "We've got to fix our diagnostic system."

What we need is a diagnostic system that reliably produces a predictable result.

NARRATOR: To oversee this herculean task, they appointed Robert Spitzer of Columbia University.

CAHALAN: Robert Spitzer is a very mathematically-minded, very objective, fact-oriented psychiatrist who had always had an interest in numbers.

So, Spitzer established algorithms.

For each diagnosis, we're going to establish certain items that are required for the diagnosis, and how many of those items have to be present before making the diagnosis, and then how many weeks must we have this.

NARRATOR: But without any biological tests, Spitzer's team could only describe symptoms, so they still shaped diagnoses in a highly subjective way.

FRANCES: I started working on DSM in 1978.

It was very arbitrary.

Wasn't as if these were meant to be graven in stone.

But diagnostic reliability went way up.

Well, you can't do diagnosis without having an agreed-upon system.

It's better to have a consensus subjectivity, than each person inventing his own way of doing diagnosis.

NARRATOR: The A.P.A.

published DSM-III in 1980.

It split vague and broad types of neuroses into new, more specific disorders.

At the time, the manual met society's demand for a more scientific-seeming approach.

But psychiatrists keep rewriting it to describe an ever wider range of experiences as they grapple with the same questions raised by Freud: is there such a thing as normal?

Or does everyone live on a spectrum?

The current DSM has 265 mental disorders, nearly three times the original.

One describes the feeling of having the wrong gender assignment, called "gender dysphoria."

But because of social judgment, like all diagnoses, it's a double-edged sword.

NEWS ANCHOR: Tonight, the FBI is digging deeper into the murder of a transgender... NEWS ANCHOR: A transgender teen has taken her own life.

YAMAMOTO: Gender dysphoria, as a category, it places people in a position of, if not mental illness, some sort of mental deviance.

But apart from the way we view our gender identity, we are in all other ways normal.

It just doesn't look that way to a world who is used to seeing things in terms of a binary.

KIM: This was the day we got married, this was in Millie's chambers.

YAMAMOTO: On the other hand, there is a whole movement that is succeeding, actually, in getting insurance companies to cover therapy and even gender surgery.

So to have no name for it at all I don't believe would be helpful.

MAINS: You still doing your sunset?

NARRATOR: The authors of DSM-III established the diagnosis of post-traumatic stress disorder to finally recognize the enduring effects of trauma, but it's not easy to overcome the legacy of stigma.

MAINS: I'd always been an advocate of, you know, end the stigma, everything, you know, it's okay to not be okay, et cetera, until it was happening to me.

Are you done with that one?

NARRATOR: Like all mental disorders in the DSM, PTSD is defined by symptoms, not biology.

♪ ♪ In the hopes of someday changing that, scientists are searching for trauma's biological fingerprints.

YEHUDA: When I started my post-doctoral fellowship, I had never heard of post-traumatic stress disorder.

Many people didn't believe that this diagnosis was real, and certainly very little was known about it.

So I joined a lab that was the first group that began examining the biology of PTSD in hopes of understanding what it was.

We've had to create a whole language for this.

We've had to create a whole science for this.

The tools that we needed haven't even been available for that long.

NARRATOR: Over 30 years of research, Rachel Yehuda has helped unravel some of the biology of PTSD.

YEHUDA: We really understand from brain imaging studies right now that experience does produce physical changes in us.

NARRATOR: Yehuda's work shows that trauma can damage crucial connections between the memory and emotional processing centers of the brain.

These connections are made of tissue called white matter.

YEHUDA: White matter refers to a part of the brain where the neurons can carry information from one neuron to the next.

So, in a sense, you can think about there being highways in between structures in the brain, and then the question is, how good is the highway?

And what you see in somebody with PTSD is, you know what, it may not be running that great.

Which really accounts for things like over-responding to triggers or feeling that things are dangerous in the environment when they're not actually dangerous in reality.

NARRATOR: But the strength, or "integrity," of these neural highways often improves when patients confront problems using a distant descendant of Freud's psychoanalytic approach called cognitive behavioral therapy.

YEHUDA: There is an idea that the reason you can't talk about the trauma is because you're afraid that if you talk about the trauma, you'll become really distressed.

But if you do this in a safe environment with a therapist, the therapist can tell you that your distress doesn't mean that this is happening all over again.

And continuing to tell the story over and over again may reduce the distress.

And this can make changes in your brain circuitry.

In somebody who has successfully responded to therapy, we start to see that white matter integrity building up.

We can see it improve.

So we're not exactly where we need to be, but we've come a long way from where we started.

DAVID FERENCIAK: We're going to be moving toward the fear/trauma memories.

NARRATOR: Since his counselor at the fire department declared him unfit for duty, Ryan turned to a type of cognitive behavioral therapy called exposure therapy.

- But what would be maybe as close to 100 in intensity?

One of the, one of the traumatic calls that we went on at work.

NARRATOR: For him, this involves the retelling of trauma narratives and revisiting the scarring experiences that ended his career.

So, I want you to close your eyes, and when you're ready, you can start describing the narrative.

- I don't remember exactly what time it was.

It was dark, we had toned out for a hit-and-run, a child that was struck by a vehicle.

We were the first ones on the scene.

I see a child laying on the ground.

Family says that, that the vehicle that hit him didn't stop.

I jumped in the ambulance.

As we pulled up to the E.R., the E.R.

staff was waiting for us outside.

♪ ♪ (voice trembles): Uh... - Give me a level.

- 75.

Um... That was about the time that the family started to arrive.

I hear the screams... ♪ ♪ From the family, um, when, uh, the E.R.

staff told them that they, they were, they were stopping, that there was nothing, nothing else that they could do.

I... felt really angry.

I was, I was furious.

I think I even threw some things, I was so angry.

- We're just gonna take a moment right now.

Before we go back into it, I really want you to do your best to speak through the memory, as if it was happening right now.

- Okay.

- Okay?

So what we're going to do is, we're gonna rewind right back to the beginning.

One of the misconceptions I had about PTSD was that I would go to treatment and it would be cured, and I never had to deal with it again.

I hear the reaction from the family, I hear the screams.

I have a better understanding now in that it's never going to go away.

It will always be there.

- Give me a level.

- (crying): 85.

- (whispers softly) And emotionally, how did that feel?

- Gut-wrenching.

My reaction to it has changed, and I think that has been the most powerful, uh, thing for me.

- Can you feel any physical sensation right now as you're recounting this?

- Yeah, yeah, I've got that uneasy feeling in my stomach.

My PTSD doesn't own me as much if I can control my reaction to it.

I don't know how it's going to go over the next ten years.

I just try and handle each moment as it comes.

- You did a great job.

It's commendable the amount of courage that you show in being willing to open this wound up again.

We're going to be revisiting this event as many times as we need to, in order to clean out that wound, so that it can heal effectively.

♪ ♪ MAINS: Thanks for coming out, guys.

NARRATOR: Ryan's last day at the fire department was nearly a year ago.

(indistinct chatter) MAINS: This is my pension beard.

So until I get the, get that settled, we're just gonna let it go.

(chuckling) NARRATOR: Today, he'll run one kilometer for every firefighter-paramedic who's died by suicide in the past year.

He's raising money so others living with PTSD can get treatment.

It's gonna be brutiful.

When I initially told people that 130 firefighter-paramedics died by suicide last year, they were shocked.

WOMAN: Here we go, guys!

(applause and cheers, noisemakers clanging) Love you!

♪ ♪ MAINS: There are so many mental health issues that we haven't done a good job of, as a society to this point, talking about.

(people cheering) WOMAN: All right, Ryan!

Whoo-hoo!

♪ ♪ MAINS: So I'm hopeful that the more I speak out, the more okay others will be with it and the more normal it becomes.

(indistinct chatter) (cheers, noisemakers clanging) NARRATOR: It's possible that future generations will unravel the mysteries of mental illness and subjective diagnoses will fade away.

In the meantime, many are working to change society and expand the fluid definition of "normal."

WALROND: The first Sunday of the year, we talked about courage, then we talked about anger, then complacency, and then last Sunday, we talked about joy-- joy.

And today we're gonna talk about-- well, it's obvious-- healing.

When I first started talking about depression openly, you know, not too many pastors were going to go on the pulpit and talk about having suicidal ideations.

No, because the first thing is a thought that, "Well, there's countless, "countless people who wrestle with this "and may come to me looking for some resolution.

How do I tell them I'm dealing with the same thing?"

So, that stops so many of us from being transparent.

There have been moments in my life where I've fought depression and darkness and that feeling of a shadow hovering over me, and I felt like I had no one to turn to.

But for me, as I was able to name issues around anxiety and depression, it helped other people see the, the characteristics, the traits, "Maybe this is what's happening with me.

That made my transparency, my vulnerability, necessary-- not just for me, but for other people.

♪ ♪ As we often say in church, "I'm not where I used to be, "and I'm not fully where I'm going to be, but I thank God for progress."

♪ ♪ YAMAMOTO: ♪ Nice work if you can get it ♪ ♪ And you can get it if you try ♪ NARRATOR: Today, Mia lives in L.A. with Kim, her wife of five years.

YAMAMOTO: On my 60th birthday, I started coming out to people.

They really thought I had just absolutely gone crazy.

And I thought, "Okay, you know, maybe I am."

Again, "going crazy," "gone crazy," "am crazy," I've, I've been imbued in that for a lifetime.

♪ ♪ NARRATOR: Over the course of her life, the line between mental health and mental illness has shifted many times.

But society is still deciding who's normal.

YAMAMOTO: When I was going through the actual last gender surgery, I remember the night before thinking, you know, you know, "You're going to be on the table for seven hours tomorrow," you know.

"You're 60-something years old, and you could die tomorrow."

And I remember saying to myself, "Good."

What I meant was, if I can survive this, and survive all the haters... (chuckles) ...and the bigots, then I'm going to be living the life that I've always wanted to live.

The world is going to have to adapt to my identity, to my authenticity.

And that is my fate, that's our fate, my world's fate, as well.

♪ ♪ (cheers and applause) WOMAN: We're coming, we're coming!

(cheers and applause) (cheers and applause) ANNOUNCER: Next, on "Mysteries of Mental Illness"... MAN: The notion of asylum, it was a place to be cured.

WOMAN: The reason he was admitted was worry.

WOMAN: A lot of these people were going to be there for the rest of their lives.

MAN: The practices there were unaccountable.

MAN: Experimental therapies.

MAN: Sterilization without consent.

ANNOUNCER: The first lobotomy.

MAN: The idea was "interrupt the madness."

MAN (archival): There is new hope for all, new drugs.

MAN: The mentally ill were not really de-institutionalized.

ANNOUNCER: Today, there are ten times more people with mental illness in jails and prisons than in hospitals.

- Who's been diagnosed with schizophrenia?

WOMAN: There isn't any one place to make sure that they're cared about once they leave the jail.

ANNOUNCER: To order "Mysteries of Mental Illness" on DVD, visit ShopPBS or call 1-800-PLAY-PBS.

This series is also available on Amazon Prime Video.

♪ ♪ For more about "Mysteries of Mental Illness," visit pbs.org/ mysteriesofmentalillness.

♪ ♪ ♪ ♪