What Happened to You?
I believe that it is my responsibility as a practicing social worker to listen to the voices of persons with lived experiences and accept this truth: individuals are the best experts on themselves. People don’t forfeit that personal wisdom when they have distressing experiences in their lives. It is impossible to understand anything meaningful about an individual’s needs or situation by looking only at broad generalizations. It is the person-in-context that matters most. Understanding a person in their context happens only one way: through patient, active listening to that person and the loving invitation to share their personal story.
Through the act of deep listening to personal stories of distress and healing, I have become convinced that even the most well-meaning mental health professionals are persistently asking the wrong questions. We are operating within a system that prizes the stability, conformity, and sedation of persons with experiences too unusual or too “disruptive” to social norms. It is a system that asks the question, “What is wrong with you?” and it is a system that defines “fixing” the problem as managing symptoms so that people aren’t a bother (financially, logistically, and socially) to other people.
The disease model promotes a backward notion that the experience of extreme emotional states begins from a biological root independent of social context, and then causes social and relational turmoil in a person’s life. I have no problem believing that there is a biological component to human lived experiences of extreme distress. That seems to be basic common sense. It’s not magic; obviously biological things are happening when we feel or experience anything.
But while there is little supporting evidence for the disease model hypothesis, there is ample supporting evidence for a social/trauma perspective which suggest that tough stuff happens to us in our life and sometimes our mind and body struggles to cope. The tougher the stuff, the more extreme the compensation / coping efforts of the mind and body. Really tough stuff can sometimes set a person down a road to a very isolated place full of internal confusion and complicated and distressing thoughts and feelings. These coping may alter biological activity so that our brain does “look” or act different when engaged in these high-intensity trauma coping endeavors. But I believe that such biological changes are most frequently effects of unresolved traumatic lived experiences, not the causes of the “symptoms” themselves.
The question we should be asking is, “What happened to you?” Our primary task as a humble servant of fellow human beings should be to become a meaningful partner in a healing, restorative journey as defined by the individual seeking support. Our aim should be at providing love and encouragement and love to a person undertaking a meaning-making journey. We must not be afraid of intense lived experiences and we must humbly offer the possibility of compassionate partnership as individuals work to reconcile these experiences with their deepest selves. Doing this requires accepting all the ways in which unresolved trauma impact lives, and creates tension and distress. I believe that the appropriate attitude of a social worker toward such experiences is one of tenderness and patience.
Selective, Evidence-Informed Prescribing
Psychiatric medications can, in some instances, be a helpful tool to provide relief from acute distress. When they are prescribed selectively for a limited duration, they may be one part of a larger healing process. When the minimal benefits are not overstated and the substantial risks are not minimized, medications may be understood by the individual as useful in temporarily alleviating acute distress. When prescribing choices are made in collaboration with the individual and when the individual is free to choose the approach that feels right for them (including the legitimate choice to take no medications,) then the relationship between individual and prescriber can be fruitful.
As a social worker, I believe it is my ethical obligation to question prescribing practices that ignore scientific evidence or justify prescribing decisions based on flawed “common wisdom.” Research has consistently told the same story for years: while psychiatric medications can sometimes be helpful when used briefly and selectively, they are consistently more harmful than helpful over the long term in the majority of cases. I believe it is the duty of every mental health worker, whatever their area of expertise, to be fully and accurately informed about the risks and benefits of medications. I believe we have an obligation to protect the people we serve from reckless, thoughtless, or dogmatic prescribing practices.
While working within the public mental health system, I have experienced a tremendous amount of pushback by asking for evidence-supported rationale for prescribing decisions that impact the people I work with. That’s because more often than not mental health “professionals” cannot logically or rationally justify their decisions with a sound and articulate rationale that is consistent with available evidence. Many if not most prescribing and mental health “treatment” decisions are made based on illicit appeals to authority, “common wisdom,” unexamined biases and emotional reactions, or blanket statements repeated over and over again without any factual base.
I don’t accept that certain “professionals” are above the requirement to justify their decision making and demonstrate clear and accurate rationale for the choices they make. Every human being is capable of being informed about the evidence (or lack of evidence) available concerning the uses and efficacy of psychiatric medications. And every person making prescribing choices has an obligation to clearly explain their decision making and demonstrate that those decisions are consistent with evidence. And any person has the right to ask for such justification from a prescriber or any other “professional.”
Thankfully, I have been blessed to occasionally work with wonderful prescribers. I have sat in the room with a person I was serving and their prescriber and witnessed genuine open collaboration, responsiveness to the needs and wishes of the individual, cautious prescribing choices, selective-use approaches, and general willingness to listen to the individual. But tragically, my experience is that this is presently the extreme exception rather than the rule. This must change, and I believe it is my responsibility as a social worker to be an advocate for these changes.
The “Therapeutic” Stance
The way I see it, the only real difference between me and any person that I might work with is that I get paid to try and be a good person. Lots of other people simply do that for free. What I mean by that is, while its true I have a certain amount of specialized education and training and sometimes that background helps me think about the human condition or social problems in interesting ways, doing my job “well” really comes down to this:
How much love and empathy I can convey to another person
How much patience and flexibility I can offer to another person
How much respect for another person’s humanity and autonomy I can demonstrate
How much hope I can offer and how much faith I can place in another person, and
How willing I am to defend another person from systemic abuses, even when those abuses may come from colleagues or “superiors.”
None of the things I just mentioned require an advanced degree in anything. And yet I believe these things represent the heart of the “therapeutic stance” for counseling or “therapy.” By contrast, the antithesis of the therapeutic stance can be described like this:
Belief that I get to define the problem and prescribe the solution for another human being
Belief that it is helpful or appropriate use coercive tactics to force another person to accept my plans for them
Allowing a sense of personal resentment, frustration or even protective fear to dominate my emotions when another person does not do what I have planned for them
Getting caught up in an emotion-based power struggle in which I seek to “beat” another person, “punish” behavior I deem to be bad, or “win” a power game
Insistence on actions or behaviors from another person that I would never expect from myself.
When I model the therapeutic stance in this way, it seems so obvious. In fact, you could basically label it as the “Don’t Be a Jerk” model of therapeutic interaction. And yet, my experience has shown me that this is not the dominate model persons with lived experiences encounter in many cases. If a person is largely independent, with modest or robust means, and with problems society tends to deem more common or acceptable (some depressed mood, conflicts at work or in relationships, mild grief and loss, etc.) then I think it’s more likely for a person to connect with counselors and professional supports who truly approach their work from the “Don’t Be a Jerk” model.
But the entire landscape changes when it comes to persons labeled by the system with “Severe, Persistent Mental Illness.” Within this system domain, a philosophy of humane partnership seems largely absent. What feels to me like the opposite of an appropriate therapeutic stance frequently practiced and sometimes openly defended when working with those other people. This must change, and as a social worker I believe it is my obligation to be an advocate for such changes.
The Good News
I chose the field of social work because I feel a personal sense of responsibility to try and serve my human and brothers and sisters with a spirit of love. That may sound silly or evoke a little cynicism, but it is true for me. These were the values of my father, who died in my arms at the age of 63 after a nearly lifelong battle with depression. They are the values that helped bring me back from the brink of my own lived experiences of extreme distress. I never expected to work directly within the public mental health system, and some days I question what I am doing within a system that is so deeply, deeply flawed.
And yet, I have recently had the opportunity to begin work with an agency that has given me some renewed hope. The agency I now work for receives payment from the public mental health system, but its roots are in a small community of less than ten thousand persons. It began as a small group of volunteers over twenty years ago, and has held fast to a mission of community based service and its commitment to uphold human dignity and mutual respect in its interactions with people. A person who walks in the front door of the agency and asks for help, is not “Case Number 823491A.” It’s Bob, from down the street, whose having a rough time today and could use a little human support.
That’s not to say things are perfect. I don’t think any agency that intersects with the public mental health system can fully escape the influence of its dogmas or the demands it places on agencies who receive its funds. Attitudes in the agency toward persons the system labels “severely and persistently mentally ill” still reflect a symptom maintenance belief that those people are sick and cannot be expected to do much more than just cope and avoid hospitalization. Those people must take medications, they must be taken without end, and a person should never be supported in stopping them, because that’s too dangerous to them and too costly to the system.
These unpleasant and (I believe) incorrect assumptions still exist. But I also find that within the agency – from my immediate colleagues to agency director – people are having the conversation. I can say to my supervisor, “I don’t believe mental illness is a literal thing and here’s why” and that will turn into an open and positive discussion. I can go to at least one of the prescribers who works for our agency and say, “I really have questions about these medications,” and have a genuine dialog about it without her feeling threated or me feeling insulted.
Things are not perfect. But people are talking. And ultimately, since the social worker’s role is defined as not only direct support of other human beings but also as the duty to challenge institutional injustices and confront social and professional prejudice, a big part of my job is to keep people talking.
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.