Sánchez’s (2017) main protagonist, Julia, is a 15-year-old Mexican-American learning to navigate two cultures. Sánchez covers many of the topics one might expect in the YA category: first romance and sexual experience, transitioning to college, getting into trouble, problems with parents, and the death of a loved one. The book’s greatest strength is its intersectionality; as Sánchez notes: “She’s a snarky brown girl, just as I was” (Ladish, 2018). By and large, Julia is depicted as a unique individual who happens to be dealing with severe depression and anxiety. However, Sánchez makes a token effort to introduce several additional characters dealing with mental health issues that reduces the quality of her work. What follows is the most important excerpts from the analysis organized by criterion, as well as a discussion of themes not fully encapsulated by the guidelines.
Stereotypes
People living with a mental illness are often depicted negatively as dangerous, violent, even criminal (Coverdale et al., 2002; Klin & Lemish, 2008; Wahl, 2003; Wilson et al., 2000). Julia is consistently labelled by her family, especially her mother, as a troublemaker. Although some of the actions that lead to this label can be directly traced to Julia’s mood, far more of her family’s frustration comes from Julia’s inability to conform to cultural expectations of womanhood. Had Julia been the only character living with a mental illness depicted in the book, I would have considered the book fairly free of stereotype. However, Sánchez introduces several additional characters (for a single chapter depicting Julia’s experience in group therapy) and many of these characters are depicted with stereotypical features. For example, Luis has a “demented look in his eyes” and “laughs like a maniac” (2017, p. 223). Or Josh, with acne so extreme that it “looks as if someone set fire to his face” (2017, p. 224). At one point, Sánchez describes the whiteheads on his face splitting and bleeding. Not only does Sánchez use loaded words to describe her characters, but her physical descriptions are also monstrous. Traditionally, characters with disabilities have been cast as monsters and villains (Beauchamp, Chung, & Mogilner, 2010); it is disappointing to see Sánchez introduce characters with such negative physical features when it has no additional bearing on the plot.
Tokenism
Sánchez (2017) creates a unique and multidimensional character in Julia. She is smart, ambitious, and a bit mean. She wants nothing more than to leave home for college and become a writer. From a feminist perspective, there is much to like about Julia. Her mental health is a large part of the story, but it is not necessarily her defining feature. Sánchez spends a substantial amount of time emphasizing Julia’s struggle to define her view of what it means to be a woman (i.e., “I am not your perfect Mexican daughter”). It is for this reason that I would agree the book depicts people living with mental illness as genuine individuals. However, Sánchez’s depiction of the therapy group feels very much like a token effort. The characters are defined almost exclusively by their mental illness and have no bearing on the remainder of the plot. The entire chapter appears to be an effort in teaching the reader about therapy, but the story could have been effectively told without the addition. Once again, these supporting characters are a detriment to Sánchez’s overall depiction of mental illness.
Agency
Sánchez’s (2017) book begins with the death of Julia’s sister Olga. The plot contains a mystery element in which Julia finds some of Olga’s hidden belongings. These items (sexy lingerie, a hotel key) contradict Julia’s understanding of Olga as a bicultural woman. This story arc allows Julia to actively search and problem-solve, but it is by no means the only evidence of Julia’s agency. Julia goes to school, completes college applications, dates a boy, and writes. Julia has an extreme desire for independence; this is not stifled by her mental health but by cultural expectations.
Standards for Success
Nasatir and Horne (2003) voice concerns that character’s depicting disability must develop extraordinary skills to gain acceptance from their peers. Much of Sánchez’s (2017) work focuses on Julia’s struggle to gain her family’s acceptance, but the focus is unrelated to her mental health. Julia is accepted despite her different goals and beliefs about femininity and requires no exceptional skills to compensate for her mental health.
Problem-Solving
Julia is portrayed as a good problem solver. Not only does she work consistently to solve the mystery of Olga’s hidden life, but she also works to develop the coping skills her therapist offers her to maintain optimal mental health (e.g., regular exercise, mental distortion journal).
Role
Nasatir and Horne (2003) argue that an appropriate representation of disability is one in which the story could be told in the same way if the main character was able-bodied. The second half of Sánchez’s (2017) story depends to a large degree on Julia’s suicide attempt, diagnosis, and treatment. The story arc created in the first half of the book could have been completed without the addition of a mental illness. Sanchez’s desire to write a story in which “young people of color” can be “seen by the book” is not contingent on Julia having a mental illness (Ladish, 2018).
Lifestyle
Ideally, depictions of mental illness offer the reader authentic insight into the daily of someone living with a mental illness (Nasatir & Horne, 2003). In many ways, Sánchez (2017) delivers. Julia is seen going to therapy and establishing the coping skills necessary to maintain her mental health (e.g., regular exercise). Meanwhile, she continues to navigate the rest of her life by making decisions about college and boys and improving her familial relationships. However, I question Sánchez’s decision to mix grief and depression in a single book. Grief can certainly trigger or intensify a major depressive episode (Zachar, First, Kendler, 2017), but in this case, it also masked Sánchez’s intentions for half the novel. A first reading of the book was insufficient for me to recognize Sánchez’s intention to depict an increase in depression following a major stressor. I interpreted Julia’s struggles as bereavement. As a result, Julia’s suicide attempt and diagnosis felt sudden and jarring to the existing plot. Other reviewers have also felt Sánchez may have included too many elements in a fairly short novel (for example see SLJ’s review).
Relationships
The disabled protagonist is a fairly new phenomenon (Beauchamp et al., 2010); therefore, it remains important to ensure that character’s living with a mental illness function in leadership roles (Nasatir & Horne, 2003). Because Julia is the protagonist, we see her struggle to come of age and develop the independence and leadership over her destiny that she so desperately craves (Sánchez, 2017).
Self-Image
Nasatir and Horne (2003) argue that characters living with disabilities should be positive and constructive role models for readers. Because Julia’s depression is exacerbated by grief, the depiction may be ideal for some readers but problematic for others. Because depression is uniquely expressed in the individual (Tolentino & Schmidt, 2018), I expect many readers can benefit from at least some aspects of Julia’s story. In particular, Sánchez (2017) has done a fine job of depicting a useful therapeutic relationship in which Julia is challenged to consider her suicide attempt, her relationships, and the events that led to her depressive episode. Furthermore, Julia is shown to learn and incorporate healthy coping strategies to maintain her mental health.
Empathy
Blaska (20031) argues that depictions of disability should promote empathy, not pity; however, she did not define either construct. According to Gerdes (2011), empathy involves recognizing and sharing in another’s emotion while pity is negatively construed as feeling sorry for someone who may be perceived as having certain character flaws (e.g., self-destructive). Sánchez (2017) has created a storyline sufficient for readers to empathize with Julia’s desperation to reach independence. I certainly empathized with Julia’s grief over the loss of her sister. However, because it was possible to misinterpret Julia’s depression for grief, I am left uncertain that the book specifically promotes empathy for people living with mental illness. That said, Julia is depicted as an intelligent and capable young woman and there is certainly no reason to pity her. Therefore, I would conclude that Sánchez promotes empathy, but readers may misattribute their empathy.
Acceptance
Blaska (2003) believed depictions of disability should include acceptance, not ridicule. Sánchez (2017) shows Julia being supported and accepted by her friends, family, and teachers both before and after her diagnosis. I particularly enjoyed a scene in which Julia’s best friends show up outside the hospital in the Chicago winter to dance on the sidewalk and wave at Julia from a distance. When considering the brief introduction of characters attending group therapy, Sánchez does not incorporate the characters well enough to depict acceptance. One might argue that Sánchez promotes pity when Julia feels sorry for a fellow therapy attendee who has severe acne.
Success
Blaska (2003) advocates for a balanced depiction of success and failure for characters depicting disability. Although Julia certainly suffers and attempts suicide, Sánchez (2017) also incorporates many successes for Julia: college acceptance, long-term romance, improved family relations, and the adoption of a healthier lifestyle.
Positive Image
Blaska (2003) asks us to consider whether the book promotes a positive image of people living with mental illness. In this regard, I believe Sánchez (2017) has done a good job by creating Julia as an intelligent and capable young woman who also happens to live with depression and anxiety.
Accuracy
Sánchez’s (2017) depiction of depression is fairly consistent with the DSM-5’s criteria for diagnosis. A major depressive episode requires five or more symptoms in two weeks (Tolentino & Schmidt, 2018). One of the symptoms must be depressed mood or anhedonia (loss of pleasure). In addition to repeated episodes of sudden-onset sadness, Julia describes many of the alternative symptoms of depression: loss of energy, concentration troubles, worthlessness, guilt, and suicidality. The only thing that was difficult to determine was the presence of simultaneous symptoms within a two-week timespan. I am not intending to diagnose a literary character, but I believe an alignment with current diagnostic criteria speaks to Sánchez’s accuracy. Sánchez also describes some of the potential side effects of taking antidepressant medications: decreased appetite, weight changes, and decreased sexual appetite.
Although Julia is diagnosed with depression and anxiety, Sánchez (2017) appears to conflate several different anxiety-related disorders based on Julia’s symptoms. Julia mentions panic attacks twice and alludes to avoidance behaviour around public bathrooms and crowds akin to a specific phobic. Generalized anxiety disorder is conceptualized as distinct from panic disorder and phobias (Glasofer, 2020); therefore, I have trouble categorizing Sánchez’s depiction of anxiety as accurate. Despite excessive anxiety or worry being the hallmark symptom of generalized anxiety disorder (Glasofer, 2020), I found only a single mention of ruminating worry in the book: “I keep thinking and thinking of all the worst-case scenarios until I feel like a tornado of worry and consider going back to bed” (Sánchez, 2017, p. 92). In contrast, Julia repeatedly mentions and ruminates on her sadness, hurt, and aching throughout the book. It does not help that many of the alternative symptoms for generalized anxiety disorder are identical to those for major depressive episodes: fatigue, concentration difficulties, and sleep issues (Glasofer, 2020). The result is that Sánchez’s depiction of depression overshadows her attempts to portray comorbid anxiety.
One aspect of Julia’s behaviour that is neither discussed nor diagnosed in the book is binge eating. I found seven examples of Julia using food as a coping skill, eating when she is not hungry, overeating until she feels sick, and loss of control of her eating behaviour. These are all diagnostic criteria for diagnosing binge-eating disorder in the DSM-5 (Berkman et al., 2015). This behaviour occurs before and after Julia’s suicide attempt and the resulting therapy. I find it concerning that Sánchez (2017) includes some fairly convincing evidence that Julia is suffering from an eating disorder, but that it never gets mentioned in her therapy or highlighted as a problem in any of Julia’s conversations with family or friends. One diagnostic criterion that is missing is distress from Julia over her eating behaviour. As the author, I can only assume that Sánchez does not find this behaviour distressing, and as such, it does not get highlighted as a mental illness in the book.
Respect
Blaska (2003) argues that depictions of disability should demonstrate respect for people living with the disability. Although Julia feels her mother completely disregards her feelings and wishes, this has more to do with her actions as a woman and cultural expectation than it has to do with her mental health. I believe Sánchez (2017) demonstrates respect for people living with mental illnesses. Julia is treated well by her therapist, and at no point do her parents or friends question her diagnosis, despite a mental illness being an invisible disability. Even when considering the poorly depicted peers in Julia’s group therapy, none of the group members’ feelings are disputed during sessions; thus, even here Sánchez maintains a tone of respect.
Othering
Blaska (2003) suggests we assess the book for othering of people living with a mental illness (i.e., ‘one of us’ vs. ‘one of them’). After her diagnosis, Julia’s friends continue to support her, and her relationships with her mother and father improve. I found no evidence of othering in Sánchez’s (2017) work.
Person-First Language
Blaska (2003) argues for the use of person-first language. Because the book is told from Julia’s perspective, there was very little evidence of person-first language or identity-first language. Julia only formally acknowledges her diagnosis once: “I suffer from severe depression and anxiety” (Sánchez, 2017, p. 219). Although the person comes first in this statement, I am more concerned with Sánchez’s use of the word suffering. The word suffering is loaded with negative connotations and paints depression and anxiety as negative by association. Certainly, Julia experiences suffering in the book, but that is not her only experience. In many ways she also thrives; the importance of recognizing that people can live with a mental illness while flourishing as human beings cannot be overstated.
Realistic
Traditionally, depictions of disability in literature were unrealistic (Shortley, 2018). Disabled characters have been portrayed as gifted, superhuman, and magically cured. They have also been inappropriately depicted as helpless, nonsexual, and nonhuman. Unsurprisingly, Blaska (2003) argued that depictions of disability should be realistic. I found Sánchez’s (2017) portrayal of Julia to be realistic. Julia is not magically cured, even with the assistance of medication. She uses the skills she is taught by her therapist to make slow and steady improvements to her mental health. She is intelligent and capable but not so extraordinary as to suggest that her acceptance as someone with a mental illness hinges on her having an excess of another more appealing characteristic.
Emerging Theme: Intersectionality
One theme that emerged from my content analysis is the importance of understanding Julia’s intersectionality. An accurate and realistic representation of mental illness should consider how Julia’s disability, gender, race, and poverty interact to impact her mental health outcomes.
Sánchez (2017) includes several examples of how Julia’s Mexican-American identity impacts her mental health outcomes. First, Julia’s suicide attempt is consistent with the fact that adolescent Latino females have the highest suicide rates among all adolescent groups (in the United States) (Rothe & Pumariega, 2018). Second, in Mexican culture, mental illness and accessing mental health services is a sign of weakness that can bring disgrace to both an individual and their family (Mendoza, Masuda, & Swartout, 2015; Sánchez, 2017). Studies have found that Latinos underutilize mental health services and are more likely to terminate their treatment prematurely compare with European Americans in the United States (Mendoza et al., 2015). Although Julia is perfectly aware that she is struggling, Sánchez shows her repeatedly tell concerned friends and family that she is okay. Even laying in the hospital after her suicide attempt, Julia tells the therapist that she’s fine. It is distinctly possible that this reluctance to admit that something is wrong is due to cultural conditioning. Additionally, Julia’s mother insists on sending Julia back to her extended family in Mexico immediately after her outgroup treatment is complete. Some scholars suggest that the importance of family in Mexican culture leads to an increased reliance on informal and religious services and can therefore explain the underutilization of health services by Latinos (Dixon De Silva et al., 2020). However, sending Julia back to Mexico to rest may also be easier for an undocumented citizen than safely navigating the United State’s health care system.
Sánchez (2017) also illustrates how Julia’s poverty level impacts her mental health outcomes. In this case, Julia’s low-income status means her state insurance will subsidize her treatment. As a bicultural female, Julia is struggling to navigate between two different worlds. As the book’s title suggests, she feels substantial pressure to conform to the Mexican ideal of womanhood. Although much of this discourse fall outside the scope of this paper, it is clear that Julia feels very misunderstood by her parents. The stress she feels surrounding her relationship with her parents, the lack of honest two-way communication, and the constant need to lie to get around their rules likely exacerbated her depression and anxiety. Even as the book ends, Julia chooses to keep many secrets from her parents. I appreciate Sánchez’s (2017) willingness to leave the book with a somewhat imperfect ending. I feel this is a far more realistic version of what it means to navigate life.
1 Blaska, J. K. (2003). Using children’s literature to learn about disabilities and illness (2nd ed). Troy, NY: Educator’s International Press.
“I haven’t taken a crap in almost four days, but I’m not about to tell Amá in the state she’s in [grieving]. I’ll just let it build until I explode like a piñata.”
Mental Health in YA Literature 