I was recently surfing the internet and came across an Etsy ad selling a lobotomy tool set – hammer and orbitoclast. I was tempted to make the purchase and indulge my penchant for this historical “apparatus” especially given its rise as heroic1 therapeutic intervention for three decades. It was a mere $168.00. Let me refresh your memory – lobotomies emerged as a treatment from 1936 until 1967. It was a psychiatric procedure that involved rendering a patient unconscious usually via electroshock then strategically drilling holes into the patient’s skull to access and cut nerves of the brain thought to be the areas that would cure the symptoms of psychiatric disorder.
Although I didn’t buy the historical torture device, that ad left me with one penetrating realization: psychiatry is here to stay. While psychiatry no longer performs lobotomies, and psychiatric practices have changed, the actual profession and discipline forges on despite its troubled past and my hunch is that it will continue to do so. In close constellation with other affiliated professions, (for example, social workers, occupational therapists, dieticians, psychologists, nurses, pharmacists, lawyers and now peer support workers) the field is not at all phased by the current onslaught of modern critique. The New York Times recently published an essay entitled, “Psychiatry’s Identity Crisis,”2 and in April of this year, the current editor-in-chief of the Lancet (one of the most well respected peer-reviewed medical journals), Richard Horton, proclaimed that a lot of published research is unreliable if not completely false.3
There are continued disputes about industry bias over clinical trials and the print media is often writing about problems of over prescribing medications for “people whose problems are close to normal.”4 Nevertheless, I suspect that the next ten years new PR efforts will be launched in order to socially market mental health treatments to citizens and continued attempts to encourage medical students into a psychiatric career will grow. Psychiatry will not be slowed down by all the sordid scandal. Western psychiatry is expanding into the global south, into the military, schools and rural communities. Technological interventions such as e-health only to serve to facilitate more access to mental health discourse, monitoring and treatments. Recently, Thomas Insel stepped down from his role as Director of the U.S. National Institute of Mental Health to join Google Life Sciences (one of the subsidiaries of the big conglomerate Alphabet Inc.) In his blog of August 2015, Insel wrote:
“As genomics, imaging, and large health care studies generate terabytes of data daily, companies that know how to extract knowledge from data have become essential partners for progress towards new diagnostics and therapeutics.”5
Today you can now download a variety of mental health apps onto your smart phone. More than that, biology is a much less isolated, siloed and is increasingly merged with disciplines such as sociology and law, for example, via new discussions about the role and the importance of social interaction in brain development and further in the study of epigenetics or with law in the development of “neurolaw” aiming to makes sense of the brain’s role in crime and delinquency. Biology is social.6
So, given psychiatry is here to stay, I beckon the question: Should consumer/survivors assist psychiatrists become better psychiatrists? What of the potential implications and pitfalls of such dangerous engagements? What dangers exist in not stepping in to participate in discussions and policy change? Given that the entire history of inpatient treatment has precisely changed because survivors spoke up to reform the practices, it makes it difficult to argue for abolition particularly since there is very little in terms of an implementable “Plan B” ready to be executed that speaks to the very complex issues in the lives of extremely marginalised people.
Presently, in Toronto (Canada) there are approximately 37 new students each year entering the residency program (called psychiatric residents)7 at the University of Toronto which takes us to about 190 new psychiatrists after five years and upon graduation. According to the Canadian Psychiatric Association, there are a total of 4770 psychiatrists in Canada.8 Given that consumers/survivors have historically argued and fought for inclusion, participation and a desired “seat at the table” in order to influence and inform processes, I offer below an example of one such attempt in Toronto, Ontario, Canada to modify the current practice of psychiatry. While attempts at psychiatric reform are nothing new, I want to query how peers/consumers/psychiatric survivors etc. in this latest exercise understand or imagine such change might be defined, let alone envisioned and rolled out.
“Patients as Teachers”
In the province of Ontario, Canada, a fairly recent initiative where consumer/psychiatric survivors are “advisors” to psychiatry residents in their fourth year of study is getting a lot of praise and attention both by psychiatric institutions and a bit of media. The program entitled, “From Surviving to Advising” or more delightfully, “Patients as Teachers” is meant to provide opportunities for residents to interact “intentionally” with “people who have recovered and, are recovering successfully from mental health and addiction issues.”9 It’s also meant to foster opportunities for residents to learn about “lived experience” in an atmosphere that is “free from the constraints imposed by the doctor-patient relationship.”10 In this initiative residents are permitted to bring forward clinical dilemmas they are experiencing with hospital in-patients (anonymously to protect privacy). These dilemmas and other topics can be discussed one on one with patient teachers in order to get feedback or advice. This initiative which began as a research project is currently evolving towards potentially becoming an embedded piece of training for all residents. The “how” and “what” of this inclusion is still embryonic.
Through this project, the residents work with former service users who are in “advanced stages of recovery” (a requirement for participating as an advisor or teacher). I am perplexed about the meaning and assumptions laden in that statement. Does it mean that only service users who are “well” and no longer experiencing struggles or distress can teach, speak or be taken seriously? How recovered must you be? What if you are too “recovered” and asking questions that move well beyond the recovery paradigm and begin to poke around into the colossal structural challenges for mental health clients both in and outside of psychiatry? What is the nature and boundary of this “voice” of an advanced stage of recovery? Is “recovery” being used as a term to replace conversations about “skills”? If one only singularly speaks about “improving on one’s recovery” as opposed to “improving skills,” then how does a patient ever hope to move away from the tautology that is the recovery self-narrative?
There are of course other questions and challenges such as how payment for this labour should be privileged and for whom. Since the focus is on the recovered self, the piece about skill set is not articulated and why would it be – the discussion could inevitably open a can of worms about employment equity and standards. In the long term, how should these patient teachers be situated – are they part of faculty? Do they have to go to school to become “patient teachers” or, are they patient teachers by virtue of having had mental health issues? What kind of mental health issues qualify? Are we to assume that just because someone has “lived experience” they are a good “teacher?” What values and principles and teaching styles will be moved forward and which ones will be left behind in the name of creating “safe comfortable spaces” for resident learning?
Mad in America blogger Sera Davidow and others have begun to pose important questions about the tensions and quandaries that arise from essentialist assumptions about service users or “peers” in the system.11 I have at various points also flagged the ethical snags with not only the depoliticised peer model as it is evolving, but also the way patients are leveraged through the use of their personal mental health narratives as a device for eliciting interest, attention and empathy from professionals.12 When I have tried to offer critiques about peer co-optation I am often relegated into a trepanation hole of no return. My criticisms are not at all targeted towards any specific “patient teacher” but instead at the underlying assumptions built into this initiative and ones like it that continue to obfuscate the overall larger challenges and meta narratives operating within psychiatry.
First, the assumption that power is somehow equalized in these exchanges that are deemed to be outside of the more formalized clinical spaces is, in my view, delusional. Yes, when not at the mercy of the rules, texts, policies, and the rigid regulations of a psychiatric unit, there is less pressure to fall into the “patient-doctor” role as we have historically understood it. However, this project is still driven and controlled primarily by (well meaning) psychiatrists and not any consumer/survivor organisation with an accountability structure and identity. Thus far, it does not seem to address the status or standpoint each individual brings to the table (such as privilege, race, disability etc.) and whether this project caters to anything outside of individualized dialogical exchange as opposed to a collective politicised one. There is perhaps not enough attention paid to the new kind of dynamic reproduced in this work: one of the residents compelled to interact with a patient teacher, and try as they might, consumer/survivors in this context can never disentangle themselves from identity inferences of former patienthood. Thus, the old binary of doctor and patient is not gone – it’s been merely turned into doctor and “recovered patient”. Which leads me to my final point.
My primary reservation has to do with the ways in which these individualized encounters prevent collective organizing and political solidarity between the consumer/survivors and ultimately, including the residents themselves. When I hear about efforts to make system change via that swag-less cliché, “hearts and minds” – skepticism creeps up into my frontal lobe. You see, it’s all a bit too…. convivial. Friendly attachments, minimal discomforts and what Sarah Ahmed has called the development of “happy objects”13 whereby all altruistic feelings can be driven into the assumption that everyone is aligned and equal. Past wrongs can be overlooked amongst these new “friends.” When and where there is in-depth acknowledgement of the serious problems within the field is a mystery and I would reckon it’s an important point given this initiative is essentially meant to be a remedy for the failures of the current mental health system despite self-promoting campaigns claiming the inverse. So failures, disappointments, current indignities of psychiatry remain all but sequestered; there appears to be no evidence or frame for how to teach residents to “unlearn” their power and privilege. And there most definitely appears to be no commitment to build capacity and independence for consumer/survivor organisations to build a business or a facility of their own.
For those few psychiatrists I have met and who constantly reflect on these tensions, I am grateful and for those consumer/survivors trying to earn a living – yes of course, I get it. I do not mean to diminish the complexity of system change or, of madness itself and recognise that solutions must mean more than platitudinous attacks. But, if there is one thing we have all learned from the past and from the wild optimism that can be conjured for new interventions, whether lobotomies or, “patient as teachers”… is that sometimes what appears revolutionary is not so much.
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- Pressman, J. (2002). Last Resort: psychosurgery and the limits of medicine. Cambridge: Cambridge University Press.
- Friedman, R. (July 17, 2015) Psychiatry’s Identity Crisis. The New York Times.
- Horton, R. (2015). Offline: What is medicine’s 5 sigma? Lancet Vol. 385, No. 9976, p1380.
- Kirkey, S, (May 13 2015). Antidepressants and other mood-altering drugs dangerous with very little benefit, expert argues. National Post.
- T. Insel. (August 31, 2015). Director’s Blog: Look who is getting into mental health research (Blog).
- Rose N. & Joelle M. Abi-Rached (2013). Neuro: The New Brain Sciences and the Management of the Mind. New Jersey: Princeton University Press.
- For more information on the psychiatric residency program please visit http://www.psychiatry.utoronto.ca/education/postgraduate-program/prospective-residents
- Canadian Psychiatric Association: http://www.cpa-apc.org/browse/documents/19
- For more info please see: From Surviving to Advising. Centre for Addiction and Mental Health.
- For more info please see: From Surviving to Advising. Centre for Addiction and Mental Health.
- Davidow, S. (July 4, 2013) Cheers for Peers (blog) in Mad in America. Retrieved from:
- Costa, L., et al. (2012). Recovering our stories: A small act of resistance. Studies in Social Justice, 6(1), 85-101.
- Ahmed, S. (2010) The Promise of Happiness . Durham: Duke University Press