What does it mean to me to be a social worker working within the public mental health system in the United States? This question is important to me because I never intended to be doing direct “clinical” work within this system. For six years after I graduated from college I worked in the corporate world, working my way up to the esteemed middle-management position within a major corporation. For those six years I consistently struggled with the feeling that my work did not matter. I carry a deep sense of obligation to be about service to other human beings, something I inherited from my protestant father and from the culture of my upbringing. I could not reconcile that sense of duty with my work, which was supervising people making widgets that didn’t matter to sell to rich people that didn’t need them.
After six years of feeling lost and out of place, my entire team and I were unceremoniously laid off. At the same time, my own history and trauma experiences led to extreme emotional distress that left my life in shambles. For me, one part of my path toward healing included the connection I made with a therapist. She responded to a desperate phone call I left with her when I was looking through the phone book trying to find someone who might be able to help me find my way through the nightmare I felt I was living.
Reckless and irresponsible choices meant I had no money left to show for all the years I had worked at a high paying job, and she volunteered to see me for free after her workday was over. She met with me once a week for six months, sometimes for nearly two hours at a time, against all “best practice” advice about professional boundaries and the limits of interaction. And during that time she simply listened to me and became a partner on the meaning-making journey I was undertaking. She gave me patience, she gave me a compassionate listening ear, and she gave me a select few pieces of wisdom at just the right moments without ever taking over my journey of healing.
I will never be able to thank her enough for her partnership in that journey. With the help of that relationship, I came to a place of vitality and reconnection to myself. Emerging from that painful period in my life changed me forever. It solidified my commitment to give back to other hurting people the way my therapist gave to me. I entered graduate school and received my master of social work degree, and for the past four years I have worked for various programs and agencies that offer services to persons on Medicaid and/or social security disability insurance (SSDI). This means that I work as part of the public mental health system of the United States. I have worked in an acute psychiatric crisis respite program, a secure inpatient psychiatric facility and most recently, as part of an Assertive Community Treatment or ACT team.
I have to be honest and say that the experience of working within the public mental health system has been painful and difficult. Many months ago I wrote a guest piece on Mad In America entitled, “Corrections Officers, Not Clinicians.” And since that time I have walked away from that job because of the irreconcilable conflicts between its mission and my own heart. I have become convinced that, as an institution, the public mental health system of the United States is a disaster. There are always individuals within any system who are doing noble, beautiful things. But that doesn’t absolve us of the responsibility to confront institutional norms that are oppressive and dehumanizing.
I feel like it is important that I have a clear sense of what my professional values are if I am to continue to work within a system that is so deeply flawed. Clearly defined core values help me keep my sense of direction and sense of professional identity within a vast system of structural injustices. So over the last several months I made it my task to make a list of ten core points that reflect my values and beliefs when it comes to serving other human beings with lived experiences of emotional distress. Here is the result:
ONE: “Mental Illness” is a metaphorical label for the experience of extreme cognitive and emotional distress; labels are tools of differentiation, estrangement and disempowerment.
TWO: The most significant cause of extreme cognitive and emotional distress is frequently unresolved traumatic experiences
THREE: Any “normal” person, given the right set of circumstances, can and will experience extreme cognitive and emotional distress as a normal part of the human range of responses to traumatic internal and external stimuli
FOUR: People can and do fully recover from even the most extreme cognitive and emotional distress
FIVE: Human experiences of extreme states hold meaning and wisdom to be understood by the individual living them.
SIX: Persons experiencing extreme cognitive and emotional distress surrender none of their rights as equal human beings, including the right to make decisions (including “bad” decisions) for themselves, the right to full and informed consent in every dimension of service provision, the right to privacy, the right to freedom of movement and decision making, the right to identify and live by their own chosen values, etc.
SEVEN: Psychotropic medications have limited usefulness and significant risks
EIGHT: Paternalism and pathologizing are the enemies of healing relational partnership.
NINE: Collaborative service provision is an ethical obligation of all practitioners
TEN: The foundation for supportive, healing partnership is a non-coercive non-hierarchical relationship of unconditional positive regard and genuine empathy.
The Mental Disease Myth
Despite over half a century of effort and billions of dollars spent in search of a biological root cause for what is labeled “mental illness” there remains not one single medical test available to identify or predict so called illnesses of the mind. Not one biomarker can be identified. There is no consistent pattern of difference in brain imaging between a “normal” and “mentally ill” person, once the brain-altering effects of psychotropic medications are taken into account. The oft-perpetuated claim that “mental illnesses” are the result of chemical-imbalances in the brain has been long discredited by scientific research, and as of this moment there is zero supporting evidence that “mental illness” has a biological root origin, or is an illness at all. The term “mental illness” is, at best, a metaphor.
The term is a metaphor for the wide array of extreme cognitive and emotional states which can sometimes cause suffering for the persons experiencing them. Such extreme states can seem unusual and frightening. They can, on rare occasion, lead to risk of harm to the individual or to others. Society is intolerant of things which do not assimilate into the pattern of accepted norms. It is unaccommodating in its rigid sense of “normal,” and thus out of fear and discomfort it forces persons with experiences deemed “abnormal” to the fringe.
The less privilege a person has the greater the severity of the marginalization. It is much better to be a wealthy, white, heterosexual man experiencing serious emotional distress than it is to be a poor, black, lesbian woman experiencing the same. The former person is quite likely to end up in designer private therapy with a ample resources and relational supports. The later person is quite likely to end up in the state hospital, civilly committed and forced onto medications against her will. The social lesson for persons with lived experiences is this: if you’re rich you’re eccentric. If you’re poor you’re a problem. The disease model offers the justification for labeling the problem and taking action that primarily serves the interests of the system rather than the individual.
[Poor] Persons with “abnormal” experiences can run afoul of police, end up in emergency rooms and psychiatric hospitals primarily for the crime of being “unusual” and burdensome to civil society. It becomes an easy transition for society to shift from the label “abnormal” to the label “sick.” If a person is sick, then a whole range of actions which would otherwise seem abhorrent can be rationalized as “treatment,” and the unspoken goal of treatment becomes adjustment to social expectations of normal, rather than the fullness and richness of life for the individual as defined by the individual.
Challenging Bigotry, Paternalism and Pathologizing
One of the most insidious effects of broad professional acceptance of the evidence-absent disease model of “mental illness” is the legitimizing of bigotry toward persons with lived experiences of severe emotional distress. Bigotry is a heavy word, but I believe it is the correct word. Bigotry is defined as someone who, as a result of their beliefs and biases, treats other people with fear or intolerance and legitimizes dehumanizing attitudes and actions. The disease model has encouraged a system in which persons with severe emotional distress are “Other.”
It goes like this: those other people are sick. Those other people cannot make decisions for themselves. The experiences of those other people are nonsense to be chemically and/or behaviorally suppressed and ignored. We professionals have the right to dictate how those other people live, define what those other people’s problems are, and what those other people should do. If those other people resist our decrees, it is because those other people are ignorant and sick, and thus we have every right to treat them as sub-human. We must coerce those other people into submission to our authority. Because we know best. As I reflect on our social history, this all sounds eerily familiar.
I can appreciate that many of my colleagues reading this may be offended by my stark language. But I do not believe it is hyperbole. I believe that mental health “professionals” (particularly those operating within the public system of mental health) have found all sorts of Orwellian language to sugar-coat the truth in sweet sounding terminology and political rhetoric. In the mental health system up is down, black is white, and we have always been at war with Eurasia. It is a system that has coopted the word “recovery” and transformed it into something that means anything but that. Phrases like “person-centered,” and “trauma-informed’ are hallmarks of rhetoric. But the conditions on the ground tell a much different story: bigotry toward persons with lived experiences is the cornerstone of the public mental health systems in the United States. Just ask a psychiatric survivor.
The most heart-wrenching part of working within the public mental health system is listening to appalling statements about persons we supposedly serve get made casually without anyone batting an eye. In its worst form, it takes the form of genuine bigotry that speaks about other human beings as though they were less than human. In its slightly more sophisticated form, it becomes paternalism – the attitude that persons are so debilitated and disabled that they really have no more autonomy or insight than a young child, and that we the “professionals” have the right to dictate how those people live, move, and breathe.
The National Association of Social Workers (NASW) Code of Ethics states that it is the ethical obligation of practicing social workers to challenge oppression and align with persons who have been marginalized by society or by its institutions. I have become convinced that the public mental health system in the United States operates with the goal of minimizing the social inconvenience of poor people who are experiencing severe distress. I believe this is accomplished by promoting “interventions” (even the term is insulting) aimed at symptom maintenance, by promoting long term chemical sedation, and by encouraging a submissive, “treatment compliant” group of people who don’t bother anyone and don’t cost the system a lot of money. I believe that once you strip away the smokescreen of professional lingo and euphemisms, that is the practical function of the public mental health system today.
I believe that function is morally wrong. And I believe the only reason that agenda is acceptable is because the persons “served” by the public mental health system are desperately poor and disempowered, and because the disease model justifies bigoted attitudes and dehumanization. I believe that as a social worker it is my responsibility to challenge the structure of this system, and to confront bigotry, paternalism and over-pathologizing wherever I can.
As someone who has had my own lived experiences of extreme emotional distress, been placed on psychiatric medications that were more harmful than helpful, and gone through the difficult trial and error process of coming off medications, I seek to stand in solidarity with my human brothers and sisters who have similar experiences. We are not sick. We are not diseased or broken. And to my colleagues in the field of mental health I say this: we know more about our own experience and needs for healing than you do. What we need are loving, relational partners in our journey; Not dogma.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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This is great! I think your 10 points are spot on.
Two statements, in particular got my attention:
1) “One of the most insidious effects of broad professional acceptance of the evidence-absent disease model of “mental illness” is the legitimizing of bigotry toward persons with lived experiences of severe emotional distress.”
This is the issue which stands out to me the most as problematic, especially in how to address and shift this. For me, it’s the most significant issue: the stigma, oppression, and discrimination that are based on distortions and mythology that is inherent in the mental health diagnostic culture. “Insidious” is the exact right word for it. Mind-boggling.
2) “The most heart-wrenching part of working within the public mental health system is listening to appalling statements about persons we supposedly serve get made casually without anyone batting an eye.”
When I was on voc rehab staff or consulting for various advocacy agencies, after having been through the system as a client, this is all I encountered, utter callousness. And it added up to what I had been feeling as a client, without quite being able to pinpoint it—as you say, it can be subtle, but ever-present and palpable.
Once I was behind the curtain, it all made sense, and I got why those environments made me feel the way they did–that is, marginalized and dehumanized. At age 40, that was new to me.
I discovered that it turned out that my personal issues, which is what I thought I was addressing during this time, really had no bearing on anything whatsoever, and that nothing much was expected of me, when my goal was to heal. It was suddenly ‘my place in society’ which seemed to matter the most, and of which I was continuously reminded. It was hard work to not take that on and internalize it, but it caused me a great deal of grief on a practical level. These never-ending projections completely blocked me from working.
I took an agency to legal mediation over all of this, and they were shameless, everyone could see it. It was a sweet and validating victory for me, but I don’t think it made a dent in how this agency perceives its clients. They were back to business as usual.
What really confounded me is that these folks thought of themselves—or at least they tried to sell themselves—as the true advocates. Of course, when it comes to funding, one has to use both faces to survive. That’s the belief, in any event. Good for you for following your heart.
Thanks for the very hardy and insightful reflection about the system. Makes perfect sense to me.
If only most MH professionals were like this. I especially appreciate the word “bigotry” instead of “stigma.” “Stigma” sounds as if we have some kind of disease.
This is one of the best articles I’ve read in a long time. Thank you.
I really enjoyed reading this, and I relate to many of your concerns. I love how you identified your top ten professional values, and I agree with all of them. My professional label is “Clinical Mental Health Counselor,” but all of my professional energy right now is being channeled into changing the system in whatever ways I can. This means that my life experience – primarily as someone who was in and out of the psychiatric system as a patient for over a decade (not to mention as a client in therapy for nearly two decades) – is the guiding force in my journey. Additionally, the five years I spent as a NAMI volunteer, and the year I spent as a peer counselor in a community mental health facility opened my eyes to a reality I simply will not deny regarding the mental health system. It is my passion right now to do anything I can to change it – even if it is one conversation at a time . . . although I do have quite a few other ideas. They are just now beginning to materialize.
Thank you for the comments. Mary Anne, I love hearing from other people still actively engaged in the mental health system who are also committed to speaking out and being an advocate for justice.
I can’t say I will work in the public mental health system for the rest of my life, or even for how much longer. But I will say that we should all (I think) be very grateful that there are some people with similar passions who are working in mental health. Because it really doesn’t matter how broken the system is, or how little hope for “change from within there is.” The fact of the matter is, persons are still funneled into this system every single day, and more than anything these human beings will need advocates and partners who stand with them when the resist systemic abuses. So thanks for your dedication and commitment.
This was a great socio-political analysis of the current conditions in community mental health in this country since Biological Psychiatry took control over the last 20 years. I have worked that many years in one clinic and have been a witness to all that you describe.
Most importantly, it is a devastating critique of the social role these clinics now play in managing and controlling the more oppressed and volatile sections of the populations.
In the 60’s when I became politically alive many people from the “under classes” were quite active and militant, and played a key role in advancing the movement at the that time.
Today, many young people from that strata, who otherwise might be springing to political activism, are now being labeled and drugged into oblivion.
The social role that Biological Psychiatry plays is quite useful to the ruling classes by turning people’s attention away from our “diseased” institutions and to, instead, focus people on “genetic theories of original sin” and individual struggles for survival.
Everyday is a battle working in community mental health; it is filled with tiny victories and major moral dilemmas that can explode at any moment in to a situation where we are defending people from harm and, at the same time, fighting to preserve our job. We all have much work to in this struggle.
Thank you so much, Andrew Yoder, for sharing your profoundly insightful wisdom here. I wholeheartedly agree with Alex’s comment above that your 10 points on serving others in emotional turbulence are spot on! I will try to pass them along and share widely. And thanks for exposing and highlighting the cause and effect connection between the disease model of “mental illness” and its resulting in bigotry toward suffering humans. Brilliant. As you are probably well aware, one of the most blatant proponents of bigotry is the Treatment Advocacy Center. They recently posted this article on their website and Facebook timeline, claiming that 40 to 50 percent of people with “bipolar” and “schizophrenia” are too impaired to have any say in their “treatment!”
And then TAC goes on to describe the “mentally ill” as sitting around naked, smearing themselves with feces and pulling out their own eyeballs. How is this anything but HATE SPEECH!?
Anyway thank you again, Andrew, for sharing your considerable wisdom. I especially appreciated your observation that if a wealthy person is diagnosable as mentally “ill,” then that person is considered “eccentric,” but a poor person in the same condition is a problem, “sick,” and in need of “treatment.” Well said!
BTW, from a Beachy to a Yoder, are you too often asked if you’re Amish?
Powerful and riveting article, Andrew, thank you for passing onto me. I feel fortunate to work alongside you at the agency and fully align with the integrity and spirit you bring to the clients.
Your article expressed the tactic we have been falling back on as a society, where we so easily confuse treatment with sedation. We leave our critical thinking caps at the door when it comes to people with significant acute symptoms, and fall into the trap of seeing folks at one-dimensional.
I believe that mental health treatment needs to offer interventions that help to restore life processes. Products don’t do this (though meds can help in the short run in certain situations), but thoughtful work carried out be vested, in-touch counselors, community members, etc, etc do. i am excited for how your piece will contribute the a future direction less weighed down with societal interests, for one instead that contains heart and soul.
As a long-time reader of MIA, I would have to say it is one of the best pieces I’ve read on this site.
You addressed each of the points clearly and speak to the concerns many of us share.