A Harm Reduction Approach to the Mental Health System

Noel Hunter, PsyD
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There are an ever-increasing number of professionals and lay people who advocate for reforms within the mental health system. Even the staunchest of biological psychiatrists agree that changes must be made. When I first decided to pursue clinical psychology as a career, I did so with the intention of trying to change the system for the better, or at least to offer a different experience to individuals in distress. Personally, I believe that peer-led alternatives and independent funding are the things that advocates should focus more heavily on, but that does not solve the problem of what to do to decrease the amount of harm that is being done on a daily basis in the present. In this sense, I believe that a “harm-reduction” approach to dealing with the current system is the best way to get what we can until something better exists. In order to reduce harm and create alternatives that do not simply adopt the same harmful dynamics that already exist, we must understand those who are trying to find good in a horrible and broken system.

All mental health professionals, including psychiatrists, are human beings first and foremost. Their reactions and sometimes harmful behaviors are the result of identifiable precursors and psychological and group dynamics that can influence any of us depending on our environment and life experiences. I think it is imperative to recognize and acknowledge this if we are to eventually create alternatives that do not replicate the current problems. Robert Whitaker and Lisa Cosgrove recently published their book, “Psychiatry Under the Influence”, which describes the institutional and financial corruption that underlies many harmful practices, and the cognitive dissonance that prevents change. This was an excellent analysis for anybody who has not yet read it, but it is only a very small piece of a much more complex web. Psychiatrists are only part of the problem; the common human elements that all mental health professionals possess (because, again, they are human) can just as easily be exhibited by peers. These human elements are also the very reasons why I do not believe the system will really ever change and why we must be strategic in our efforts to reduce harm.

History of Family Discord

Just like many who experience extreme emotional distress, mental health professionals often have a history of childhood trauma and attachment disruptions (Farber, Manevich, Metzger, & Saypol, 2005; Fussell & Bonney, 1990; Zerubavel & Wright, 2012). They also tend to come from a higher socioeconomic class then most “patients” (e.g., Cooper, 2009). Aside from overt abuse (which is highly prevalent), it is typical for the chronic “patient” to have played the role of scapegoat and/or to have been the target of a parent-child triangulation (Bowen, 1978) wherein the lack of differentiation literally drives a person crazy.  Triangulation can occur in several different ways: 1) when a parent recruits the child to “take sides” against the other parent; 2) when the child’s “problems” become the focus, allowing the parents to ignore their own relationship issues; and 3) when one parent sides with the child on particular issues against another parent. These dynamics have been shown to create problems in attachment and identity formation and to be common in the family of adolescents experiencing mental health problems (West, Zarski, & Harvill, 1986). Often, such children become rebellious, anti-authoritarian, and non-conformists.

On the other hand those who eventually become professionals tended to be the “helper” of the family (Farber et al., 2005). This role, and the actions of engaging in the triangulation and scapegoating of other family members, is a central part of some clinicians’ identities. Of course, all of these roles may be interchangeable and overlapping, but for purposes of demonstration I am presenting them as dichotomous. The child who is parentified into the “helping” role is often a participant in scapegoating siblings and/or a parent as well, but they cover up the blaming nature of their behaviors by “caring” for said sibling or parent. Further, these children also tend to be very conscientious of pleasing authority figures, have high levels of guilt and so are virtually incapable of taking in criticism, and they avoid conflict at all costs. This is an important dynamic to consider when the adult becomes a professional working with those very individuals he or she once spent an entire childhood siding against. It seems that the familial dynamics in the backgrounds of many professionals and “patients” alike get played out infinitely through the current mental health system (Hamman, 2001; Jung, Adler, & Hull, 1946/2014).

In addition to the role one has been reared to take on, the belief system one develops based on their specific environment and status in society also becomes a central aspect of identity (Greenberg, Solomon, & Pyszczynski, 1997). All of us, as we age, develop particular beliefs and worldviews that are part of our sense of self, and these may protect us against overwhelming despair and confusion. Often, the greater the level of despair and turmoil, the more extreme the beliefs become to protect against these intolerable feelings (Maxfield, John, & Pyszczynski, 2014). Sometimes it’s religion, for others it may be politics or materialism. For most, it’s all of these and more.

The various mental health paradigms, from psychoanalysis to neuropsychiatry, are all ideologies that help protect individuals from chaos and an awareness of the unjust nature of the world.  It is important to distinguish science from ideology because addressing and critiquing them entail very different approaches; in science, one may debate the facts and research findings and, usually, scientists seek to constantly challenge perceptions and beliefs in the name of advancement.

With ideology, conformity and faith are demanded, and those who question or bring about contrary evidence are usually punished through ostracization and labelling (think heretics, terrorists, or witches). Psychiatry, and clinical psychology programs specifically, are designed to weed out any person who might demonstrate an unwillingness to conform, who may disobey authority, or who may behave outside of the stoic norms set for such professionals. Consider this when reading to the following studies.

“Evil” Behavior, not “Evil” People

There are 3 classic studies that demonstrate how the power of authority, role expectations, and pressure to conform can cause good people to do evil things. Most have heard of these studies at some point, and many have refuted them for their lack of “proper” methodology or ethics. But I would like to take a moment to highlight them as they relate to the topic at hand because regardless of their controversial nature, they demonstrate fundamental human attributes that cannot so easily be dismissed.

The first study is the sum total of the Asch conformity experiments conducted in the 1950s. Solomon Asch had various different scenarios in which groups of people would verbally (and, later, in writing) answer questions posed by an examiner. He found that people tended to ignore reality, even when the correct answer was unambiguous, and answer the questions wrong in order to conform to the rest of the group. Conversely, when asked to write down their answers, participants gave a correct response 98% of the time. Additionally, the more people in any given group, the more likely one was to conform.

On the other hand, he also found that having social support (at least one other person in the group who agreed with the participant) led to decreased conformity. The conclusion of this project was that human beings tend to conform, especially when group members are considered to be of higher social status or more knowledgeable, and this happens for fear of ridicule and a belief that other people are better informed. Yet, when people are supported in their views they are more likely to be confident and express these views despite the larger group’s consensus.

The next study is Milgram’s research on obedience to authority. Stanley Milgram conducted his studies shortly after the start of the World War II criminal trials, in an effort to understand how an entire society could come to support the actions of the Nazis and engage in such brutal torment of innocent people. Here I offer a quote from him that exemplifies his findings:

“The social psychology of this century reveals a major lesson: often it is not so much the kind of person a man is as the kind of situation in which he finds himself that determines how he will act.” –Stanley Milgram, 1974

Basically, his study showed that most average, every-day citizens would shock a person (who could be heard screaming for their life in another room) to the point of death just because they were told to do so by someone who exemplified an authority figure (an unknown person in a white coat). Many stated that they trusted that the authority figure knew what he was doing and had everyone’s best interests at heart. Approximately 65% of participants delivered the highest shock possible, which was labelled “death.” Many exhibited anger, frustration, and anguish, some pleaded with the “authority figure” to stop, yet they still went on to deliver the final shock. This study has been replicated several times with the same findings: people tend to do what they are told to do (e.g., Burger, 2009). Milgram concludes:

“Ordinary people, simply doing their jobs, and without any particular hostility on their part, can become agents in a terrible destructive process. Moreover, even when the destructive effects of their work become patently clear, and they are asked to carry out actions incompatible with fundamental standards of morality, relatively few people have the resources needed to resist authority.”

We all tend to commit what’s called a “fundamental attribution error,” where we understand our own negative behaviors as a result of circumstances while we attribute others’ negative behaviors to internal, moral deficits. Milgram showed that this is, indeed, most often an error. This idea is further reinforced when looking at another famous study from 1971: The Stanford prison experiment. This study has become so famous that it was recently turned into a movie. Philip Zimbardo set out to answer what happens when you put good people in an evil place – Does humanity win over evil, or does evil triumph? He planned a 2-week investigation of college kids playing the part of prisoners and prison guards in a make-shift “prison” set up in the basement of his Stanford lab. He had to end the study after only 6 days. As he states, “In only a few days, our guards became sadistic and our prisoners became depressed and showed signs of extreme stress.”  At least one “guard” reported that he engaged in sadistic behaviors because he believed that this would “please” Zimbardo.

Assuming there is even an ounce of truth in these studies, then, what do you think happens when even the most genuine person determined to change the system begins training to become a powerful, authoritative, expert doctor? These studies show that few will be able to withstand the pressure to conform, obey authority, or defy their role expectations, and will engage in harmful practices even when they go against one’s moral and ethical threshold.

Human Response to Accusations of Harm

There has been much research into the social psychological phenomena of racism and discrimination. Why do people, seemingly otherwise good people, continue to support racist and discriminatory systems and laws? And how does that relate to mental health professionals?

When a person is confronted with suggestions that his or her actions may cause harm, it is common to respond with assertions of one’s own hardships while justifying said behaviors in an effort to maintain self-identity (Phillips & Lowery, 2015). Exposing a person to his or her privilege is an inherently aversive experience, and people will automatically respond with self-protective reactions (Lowery et al., 2007; Rosette & Tost, 2013). In other words, when confronted with the hardships of “patients”, professionals are likely to respond by asserting their own hardships and will position themselves as victims (often as victims of the patients themselves). This is far more complicated than cognitive dissonance, even if this does play a role. How often have you said to a professional “These practices have hurt me” only to receive a response of “Well, what about me, I’ve been hurt too?”

Another response quite common to confrontation of harmful behaviors is denial of personal responsibility. Many professionals agree and acknowledge that stigma is a problem and that harmful and ineffective practices exist, but such practices are never engaged in by “me.” They deny any role they may have. The role of trauma, both as an etiological factor in emotional distress and as a direct result of standard practices, is also often denied because it challenges one’s beliefs in a “just world.” It is also denied because it threatens the privileged status of professionals (or “normal” people). The prevailing view often is that the professional is not privileged because he or she also has experienced hardship, and if a “patient” describes something so horrendous that it cannot be comprehended, then it is probably made up to get attention anyways.

Further, people will justify their privileged status by claims that they have “earned” it or “deserve” it somehow (Tyler & Smith, 1998). This tends to occur when privilege cannot be denied, or when one’s identity is intertwined with said privilege (i.e., “I am an expert”). How many doctors have you heard make some claim that “I went to school for X amount of years, so therefore I know more than you” in response to challenges to their practices? Granted, they may know more than you or I about certain things, but how relevant that is to healing wounds and understanding humanity is debatable.

Since so many people have at least heard of Jeffrey Lieberman’s response to the Tanya Luhrmann article in the New York Times (and if you haven’t, I urge you to do so as it is quite entertaining), I will use it to exemplify some of things I am speaking about here. On February 18, 2015, Lieberman wrote a letter to the editor that was only published on Medscape, entitled: “What does the New York Times have against psychiatry?” He states:

“Psychiatry has the dubious distinction of being the only medical specialty with an anti-movement. There is an anti-psychiatry movement. You have never heard of an anti-cardiology movement, an anti-dermatology movement, or an anti-orthopedics movement.”

Rather than consider the lack of an “anti-“ movement in other areas of medicine as a possible sign that something is wrong with psychiatry, he begins to present his (and psychiatry’s) hardships, putting psychiatrists into the role of victim. He goes on to do so by flawlessly equating the woes of psychiatry with those of psychiatric “patients”…

It is very disturbing that we still live in an age when the stigma of mental illness and the lack of interest in trying to present medical science as it deserves and needs to be to an informed public is still preyed upon by this kind of journalistic opportunism.

He continues to deny any personal or professional responsibility for the criticisms levied against his field, and diminishes his privilege by personally identifying as a victim and then asserting his deserved and earned importance…

“I tried to write a serious, responsible, and constructive letter to the editor, which I submitted within 24 hours. Seventy-two hours have elapsed since the article’s publication. I haven’t heard from the Times about their interest in publishing my response, so I assume they won’t publish it. The name that I publish under is my own. My credential is the Chairman of Psychiatry, Columbia University College of Physicians and Surgeons, one of the leading departments of psychiatry in the country, past president of the American Psychiatric Association, and the author of the forthcoming book for the lay public called Shrinks: The Untold Story of Psychiatry.”

Many laughed and dismissed this letter as the ramblings of a bitter and arrogant psychiatrist who is losing his ground. This is a mistake. He has responded in a very typical manner to accusations of privilege, discrimination, and harmful practice, and his very recent role as president of the APA shows how representative he really is of many others in this field (not just psychiatry). For instance, some have asserted that psychiatry is “an endangered species” and psychiatrists are “convenient scapegoats” who are “under attack” (positioning themselves as victims; Lieh-Mak, F., 2010). The suggested response is to characterize their deserved privilege by demonstrating an “ownership of a specialized body of skills and knowledge,” “accepting or excluding members,” and “being accorded a high status in society” (defending the deserved privilege). In this sense, privilege = exclusion, and so all those who do not conform or obey are ostracized as a display of their importance. It is even asserted that to question current practices or listen to criticism is, itself, unethical.

I can tell you that this is an extremely pervasive message that I have heard from every single type of professional (from orderlies to clinical directors). To laugh it off as the ridiculous rantings of evil psychiatrists would be to ignore the greater picture.  Further, to equate these responses and actions with morally defective professionals is to be vulnerable to recreating these same problems in peer alternatives or new paradigmatic systems.

Why I Fear the System Won’t Change

Thus far I’ve touched on the ways in which otherwise decent people may engage in “evil” behaviors through conformity, obedience, role expectation, justification of privilege, and denial of harm. The aspects of the system that are corrupt and influenced by money and power are more obvious, but because of their obvious nature are also easier to alter. But decreasing this overt corruption will not change the fundamental problem inherent in the overarching system.

The very human aspects that underlie the pervasive oppression, discrimination, and aggression inherent within most practices of mental health professionals are the very things that need to be addressed but are extremely difficult to get people to see and acknowledge. It is possible to offer social support (alleviating the strong tendency for conformity), change the authoritarian structure (making obedience a less dangerous endeavor), de-emphasize the power differentials and expert status of helping professionals (changing the role expectations), and increase awareness of the harms while also honoring the moral standing of those who may be engaging in such harm (difficult, but not impossible), which all may result in lasting change.

On the other hand, the system itself is representative of a powerful ideology and those involved in the system have built an identity that is undifferentiated from the external environment. There is no distinction between the system and one’s action within it and the personal character of the individual. To insinuate that the system is harmful is to insinuate that the individual is “bad.” Direct accusations regarding one’s character (i.e., all psychiatrists are evil) further reinforces this diffusion and makes their cohesion stronger. The group of “psychiatrists” or “mental health professionals” or “psychologists” only becomes stronger and their need to assert their own victim-stance and deny the existence of problems becomes resistant to any infiltration. And so, no amount of ego-boosting strategies can circumvent this diffusion of identity. But, then, why should those who have been harmed have to stroke the fragile egos of their oppressors anyways?

The denial and inability to allow any acceptance of individual association with harm is especially strong when there is no overt abuse or corruption. The subtle nuance of the psychological harm that is created by messages of illness and helplessness, the stripping away of civil rights for “one’s own good,” the half-truths that underlie categorizations and separation of people with messages that something is innately wrong, and the slow deterioration of one’s brain through drugs euphemistically called medications are often more harmful than the physical abuses that cannot be so easily denied. Yet, these harms are also the easiest to justify.

It does not help matters that many involved in the system as patients also benefit from their own victim status (a victim of bad genes), their identification with disease and having something wrong (continuing their role as scapegoat and owning the familial problems), and the denial of trauma that is too difficult to face. There is a collusion that clings to the illness paradigm that is too strong for simple logic to break.

There is also a cultural norm that encourages the current mental health paradigm. We accept that unemotional, intellectual, stoic, white, upper-class mannerisms and behaviors are “normal,” and everything otherwise is somehow “sick.” We accept that our goals in life should be the accumulation of wealth and material goods at the cost of nature and physical well-being. We drug ourselves into becoming “normal” when the problem may be that the norm is not normal at all.

Challenging the status quo is a dangerous endeavor and threatens all who have any stake in the system as it is; system justification is at the root of many social ills, including racism, sexism, and classism (e.g., Jost & Hunyady, 2002). It is accepted that you cannot speak to the truth of inequality and harm at the systemic level without reaping the consequences. You cannot argue with doctors or police or teachers or other revered authority, lest you be labeled based on the stereotype of your race, gender, or age. The mental health system now provides handy medical labels to further justify ostracization of those who rebel, particularly if they are rebelling against the mental health system! If you speak up too loud or insist too much or argue, you are reinforcing whatever label du jour they have bestowed upon you in the first place, also justifying why you need their help. It is an impossible cycle that has been developed. Any discussion of the problems in the mental health system must first and foremost be focused on protecting the ego and status of the mental health professional. This is why such conversations can never get us anywhere.

So, What do we Do?

I believe that the system as we know it will continue to thrive for a very long time. The best we can do is to work strategically with what we know to lessen the harm that occurs. What if there were none of us within the system attempting such changes? Would there be any hope at all? I must admit that as strongly as I feel about the things I’ve spoken of, and the science that backs it up, I also know that there has to be people within the system so long as it exists who can help to promote less harmful practices. Much as I hate to admit it, people tend to listen to those who have fancy letters after their name. Or, is this just my own self-preservationist justification allowing me to continue pursuing the path that so much time, money, and effort has gone towards?

The British Psychological Society has shown that dedicated professionals can, in fact, make some difference and pave the way for less harmful practices. What do they do that is different? They include people with lived experience in much of their work. Theirs is a different culture, however. America is predicated on power, materialism, and status; we allow “peers” and “experts-by-experience” to play a role as tokens, rather than acknowledging their status as an equal.

People who have experienced their own severe emotional distress and been harmed by the system must take back power, fight the messages of brokenness and helplessness, and stop justifying a system that is broken through to its core. People who “have been there” need to stop being afraid and rise up to the challenge of taking back their humanity. People who have struggled are sometimes the most able to help similar others and work together to build community and safety. Human beings need human beings, not experts, not doctors, not internalized messages of secondary status. We need compassion, love, forgiveness, and confidence to pursue our innate talents. Can we do this for each other? Is there really any “expert” on these things? Can school and degrees and fancy letters really provide someone with “techniques” to provide this for others?  Maybe, maybe not.

At the same time, people suffer in such extreme ways that they do need someone and someplace to turn to. And, therapy can actually be extremely helpful for many people! Having a relationship in which to work on and through painful experiences and emotions is extraordinarily valuable. That is why I suggest a “harm-reduction” approach to the mental health system. If we cannot abstain, then at least we must try to reduce harm. Until something better exists, we must do our best to use the system to our advantage while working to create something different. Whatever we may build in the future, however, must keep in mind that we are all vulnerable to the effects of power, role expectations, pride, ego, self-preservation, and pressures to conform.

* * * * *

This blog is the text of a presentation given by
Noel Hunter at this yea’s NARPA conference on August 21, 2015

References:

Bowen, M. (1978). Family therapy in clinical practice. New York: Basic Books.

Burger, J. M. (2009). Replicating Milgram: Would people still obey today? American Psychologist, 64, 1-11.

Cooper, L. A. (2009). A 41-year-old African American man with poorly controlled hypertension: Review of patient and physician factors related to hypertension treatment adherence. JAMA, 301, 1260-1272.

Farber, B. A., Manevich, I., Metzger, J., & Saypol, E. (2005). Choosing psychotherapy as a career: Why did we cross that road? Journal of Clinical Psychology/ In Session, 61, 1009-1031.

Fussell, F. W., & Bonney, W. C. (1990). A comparative study of childhood experiences of psychotherapists and physicists: Implications for clinical practice. Psychotherapy, 27(4), 505-512.

Greenberg, J., Solomon, S., & Pyszczynski, T. (1997). Terror management theory of self-esteem and cultural worldviews: Empirical assessments and conceptual refinements. Advances in Experimental Social Psychology, 29, 61-139.

Hamman, J. J. (2001). The search to be real: Why psychotherapists become therapists. Journal of Religion & Health, 40(3), 343-357.

Jost, J. T., & Hunyady, O. (2002). The psychology of system justification and the palliative function of ideology. European Review of Social Psychology, 13, 111-153.

Jung, C., Adler, G., & Hull, R. F. (1946/2014). Alchemical Studies. Collected Works of C. G. Jung. Princeton: Princeton University Press.

Lieh-Mak, F. (2010). Psychiatrists shall prevail. World Psychiatry, 9(1), 38-39.

Lowery, B. S., Knowles, E. D., & Unzueta, M. M. (2007). Framing inequity safely: The motivated denial of White privilege. Personality and Social Psychology Bulletin, 33, 1237-1250.

Maxfield, M., John, S., & Pyszczynski, T. (2014). A terror management perspective on the role of death-related anxiety in psychological dysfunction. The Humanistic Psychologist, 42, 35-53.

Phillips, L. T., & Lowery, B. S. (2015). The hard-knock life? Whites claim hardships in response to racial inequity. Journal of Experimental Social Psychology, 61, 12-18.

Rosette, A. S., & Tost, L. P. (2013). Perceiving social inequity when subordinate-group positioning on one dimension of social hierarchy enhances privilege recognition on another. Psychological Science, 24, 1420-1427.

Tyler, T. R., & Smith, H. (1998). Social justice and social movements. In D. Gilbert, S. Fiske, G. Lindzey (Eds.), Handbook of Social Psychology (Fourth Edition). New York: McGraw-Hill

West, J.D., Zarski, J.J., and Harvill, R. (1986). The influence of the family triangle on intimacy. American Mental Health Counselors Association Journal, 8, 166-174.

Zerubavel, N., & Wright, M. (2012). The dilemma of the wounded healer. Psychotherapy, 49(4), 482-491.

28 COMMENTS

  1. I think it is honorable for decent people to work within the system and try to be as helpful as they can. Even the writer here, though, makes clear that won’t do much to change the overall system.

    There is nothing really mysterious about the “mental health” system, though it certainly has succeeded, so far, in promoting that perception. At bottom, though, we are looking at a social institution dedicated to maintaining the power and privilege of a few people against the many, just like much of the rest of our society. And it does this by violating the human rights of its “patients.”

    Other groups whose human rights have been grossly violated like this have made some progress by just banding together and insisting that they won’t take these abuses any longer. There are millions of people who have been locked in psych wards here in the US. There are many more who have been drugged and shocked without having been incarcerated, plus many friends and family members of such people who have understood the destructive nature of psychiatry without having been victimized themselves.

    Millions of people ready to be organized…We can’t give up.

    Over and over, we post articles on Facebook saying how terrible everything is. We talk and talk and talk, but somehow do nothing.

    The potential is out there for a powerful and effective movement, but somehow we do nothing. I won’t try to answer the question “Why?,” because I think a lot of people know why.

    But we shouldn’t give up. We can’t give up.

  2. I think this sums up the underlying problem nicely, “We accept that our goals in life should be the accumulation of wealth and material goods at the cost of nature and physical well-being. We drug ourselves into becoming “normal” when the problem may be that the norm is not normal at all”.
    That being said, as a soon to be nutritionist and health researcher, there are many who are speaking up about our failed orthodox medical model. When I refer to those speaking up, I mean numerous doctors, scientists, nutritionists, researchers, and ex-patients.
    Not to put a “new-age” spin on this, but our awareness to these issues is first and foremost. It matters (a lot), and websites like this are helping, as is the author of this article (Thank you both, or all).
    There is and continues to be more and more people (professionals included) within all disciplines trying to make a difference. Wholesale change as discussed above will happen, it is inevitable. Once one has “woken-up” it seems like too slow a process to real change, but that is how nature (in its literal sense) works. 10 years ago I would have had no idea what I am thinking and doing today, and would have thought I am today crazy 🙂

  3. Good article.

    I think it cannot be emphasized enough how overfocused American culture is on money, power, materialism, and individual achievement. This culture combined with the the sheer amount of profit and status that is available for psychiatrists and drug companies who opportunistically take advantage of those in extreme states… these two factors create a perfect storm where the psychiatric system of diagnosing and drugging has gained a stranglehold over American culture far more than in any other country.

    I remember reading that around 45% of the people worldwide who take psych drugs are American, which if close to the truth would be an incredible statistic (given that American has 4.3% of global population).

    Also think the article might more clearly emphasize that, despite human nature, many of its considerations apply especially, and sometimes only to American people and culture. In some northern European and South American countries, the stranglehold of psychiatrists and drug companies is not nearly as strong as in America, and it is easier to be responded to outside the system or even to find help within the system.

    I was only able to get better myself when I extricated myself from taking drugs and seeing psychiatrists and was able to see an outpatient therapist and leave the system. Unfortunately this remains the only hope for many suffering people and for many it is not practically achieveable due to lack of funding, awareness or other resources.

  5. Excellent article Noel,

    I think that we can understand that people who have suffered from emotional traumas should have access to caring, well trained professionals who have studied hard to understand how to best help those in need. It is a tragedy that so many mental health professionals are causing harm rather than helping people, and that often peer groups can offer better support.
    A very interesting book that adds some other perspectives to the problems and issues in psychiatry training is “Of Two Minds: An Anthropologist Looks at American Psychiatry” by T.M. Luhrmann. Luhrmann describes the distortion and emotional politics that occurs in psychiatry with people being pulled to believe more in narrow points of view than in actually understanding and helping people.

  6. Noelle

    You have made a penetrating analysis of the way the “system” works and retains its power, and also how conformity is maintained within in it and tends to block possibilities for revolutionary change.

    I do take issue with some of your implied conclusions, especially regarding the possibilities for revolutionary change and your related presentation of the inevitable dichotomy between “science” and “ideology.”

    Your many enlightening blogs here at MIA, and my own personal conversations with you, lead me to believe you are indeed very much a firm advocate for revolutionary change and you struggle mightily with the contradictions of working inside the current mental health system. I know some of those contradictions well; I have been there for the past 24 years. But I firmly believe we must resist (with all our might) the powerful gravity pulling us on “the path of least resistance” that constantly tries to persuade us to “settle in” and lowers our expectations for revolutionary change.

    Yes, it is quite possible that the current mental health system and the overall political and economic system that has given rise to it, may not change for a long time. However, there is ALSO the possibility for major upheavals to occur in the world that can develop rapidly (sometimes when we least expect them and from places we could not foresee) that will shake every institution within the status quo to its very foundations. These events can open up opportunities for change that we currently cannot image could presently happen. I believe one past revolutionary used the phrase “hastening while awaiting” to describe the orientation we need to have in order to be ready to “seize the time” when these opportunities present themselves. This orientation is one way we can fight the tendency to “settle in” and expect less.

    Throughout your blog, when you would describe all the ways the system and typical human responses reinforce the status quo and resist change, you would always acknowledge that a few people are able (or were able) to break free from these conservative tendencies.

    It is these individuals (with their leadership abilities) who were historically able to see beyond and resist the powerful weight of the status quo in order to make breakthroughs in transforming the world. The oppressed will always seek out an ideology of liberation to counter the ideology that justifies and enforces the institutions that oppresses them.

    Science must not somehow be seen as separate or divorced from ideology; this is a false dichotomy. It is when an ideology (in a scientific way) most closely approximates the conditions within the material world, that big changes are able to occur. In other words, the ideology that guides future liberation struggles must include the very best that science can provide us at the time.

    Part of any future liberating ideology must be the inherent inclusion of the necessity for people to constantly challenge the status quo and further develop and even transform conventional thinking, thus leaving open the possibility for continuous “revolutions within the revolutions.” So ideology is not a barrier to change, but rather it is unscientific, dogmatic and rigid presentations of those ideologies that stifle or even reverse revolutionary changes.

    Many people currently working in the mental health system will become transformed in the course of future upheavals and can be won over to revolutionary change. I have always advocated for a strategy that “unites all who can be united”, this even includes dissident psychiatrists. I believe that people, at certain historical moments, can see beyond their narrow self interests; this may include seeing their own profession going out of existence or becoming something unrecognizable.

    We do not need to somehow develop lofty justifications for working inside the system, we just need to learn to live with the very intense contradictions and daily battles this environment will throw our way. To remain sane and truly ethical in this process we must seek out a liberating ideology and have intimate connections to those working for change on the outside, and most importantly, intimate connections with the more conscious survivors who have battled to overcome the damage inflicted by this oppressive system. This will help keep us honest and prevent us from “settling in” and becoming pessimistic about revolutionary change.

    Comradely, Richard

    • Hmmm, I have failed indeed if I have given the impression of “settling”. Such a thought does not “settle” well with me at all, for I am the last person to suggest such things! My suggestion is that I do not believe the system can be reformed…I am a full-blown abolitionist at this point. At the same time, I believe that any system, peer or otherwise, that replaces what we have now best note these human tendencies because good intentions are not enough. And, while I fully believe that those who have been there must take back their power and revolutionize, my other point is that we must take a “harm reduction approach” in the mean time (and that is stolen from addiction work). What are the least-worst options and how do we at least decrease the overall harm being done until something better is in place? Just saying “no” to any services won’t work either because some people do need help. This is my point.

      And, as for the dichotomy, I agree that science and ideology cannot be so easily separated. But, for purposes of strategically fighting for change and revolution, one must know what they are fighting against. We can speak up about the science til we’re blue in the face (and many of us are that blue), but until we realize that we are fighting ideology then we will lose. We are fighting the church of psychiatry, not science. It’s like trying to argue creationism versus evolution with some religious believers. There’s just no point in trying to argue using science in this regard. Ideologists will not listen, they have shown us that too often. And, my article is trying to demonstrate why that is. But, I perhaps created a false dichotomy in doing so.

      In any case, thank you for your well-thought out response. And, for the love of cookies, let’s never settle.

      • Noel

        Perhaps I was not clear about the way I used “settling in.” I view you as one of the most articulate critics at MIA of Biological Psychiatry and the current mental health system. The “settling in ” term was not meant in any way to characterize your analysis or current role in the system.

        I believe there is a danger for “settling in” to occur (over time) if people lower their expectations for change and are not ready for those historical moments when the conditions are ripe for qualitative leaps.

        For that reason I would suggest that “Harm Reduction” should be viewed more as a short term TACTIC in certain situations and struggles, and NOT as an overall STRATEGY for how we view working within the system or how we view trying to make major systemic change.

        If “Harm Reduction” were to become our over riding approach within the movement it would eventually lead to lowering our sights for possible revolutionary change and could easily lead to more accommodation and co-optation.

        Noel, I know you are clearly against any form of accommodation or co-optation. I am only raising some comradely critique regarding the prescriptions for the way forward and the use of certain terminology to describe our strategic orientation.

        Respectfully, Richard

        • Very good point, Richard. Harm is the prerequisite for harm reduction. The problem with harm reduction as a long term strategy is because it presupposes harm. Remove the harm, and the reason for harm reduction also vanishes.

          As a tactic, in the here and now, it makes sense. People are being harmed, and we’d like to see less of it. As a goal, you’d be giving too much to futility, or perhaps, that most common of shortcomings in the mental health system, cynicism. Harm reduction, after all, is far from harm eradication.

      • Noel,

        I also interpreted the article as a little defeatist. Toward the end I noticed that you expressed some hope about making some degree of change within the current system. But your view of human nature seemed unduly pessimistic.

        I also think there is reason for more optimism. I don’t have the links to them, but know that there are several studies showing that people often overestimate what change can be achieved in the short term and greatly underetsimate what changes can be achieved in very long timeframes. It can be good to keep this in mind.

        Also as Lewis implied above, when making gradual changes to a difficult or stuck system, one with a lot of inertia, for a long time nothing can appear to be happening. This is similar to some natural systems… for example, it takes many decades for pressure between continental plates to build, before suddenly in seconds or minutes an earthquake happens in which all the potential energy stored is released suddenly.

        I once saw something similar in a sand castle on a beach which was having a trickle of sand very slowly poured onto one edge of it by a child out of a bucket. For a few minutes nothing happened and one edge of the sand castle slowly got bigger and bigger. Then suddenly, the whole system shifted with most of the sand castle collapsing and the whole pile reaching a new equilibrium. There is a writer called Charles Hugh Smith who writes about these processes in his blog, Of Two Mindz, and in his book, An Unconventional Guide to Investing in Troubled Times.

        Another reason for optimism is the internet and a freer exchange of information between people in and outside the system. Up until the late 1990s, much less information was shared because the velocity at which that information could be shared via printed words and in person meetings was relatively slow. But now with the internet and other forms of electronic communicating, more and more people are enabled to see that psychiatric diagnoses and overuse of drugs really are houses of cards. The lack of validity behind diagnoses and the ineffectiveness of psych drugs really are two massive weaknesses, and they can’t be fixed or run away from, only hidden for as long as possible. These two issues are really massive Achilles’ heels that can be targeted over and over by antipsychiatrists, and they will be.

        At some point there may be a tipping point at which pressure on the system becomes overwhelming resulting in accelerating changes. Charles Hugh Smith writes about this in his ideas based on the Pareto Principle, the idea that if around 20% of the population becomes aware and informed about an issue, they can often heavily influence the other 80%. This 20%-80% idea applies to many other areas of life, roughly… that the highest paid 20% of basketball players in the NBA score the large majority of the points, that the top 20% of earners in a field tend to earn about 80% of the income, etc.

        Another interesting and potentially daunting thing to consider is that within several decades, fossil fuels might become so expensive, and renewables such an inadequate replacement for them, that large parts of modern society, like the large-scale production of psych drugs, or the maintenance and operation of universities that train psychiatrists, might become economically difficult.

        This scenario involves a regression of society away from the technological development starting with the Industrial Revolution that eventually produced psych drugs. It may not happen but is interesting to consider what would happen to psychiatry if it did. Most likely much of modern psychiatry would not survive. We should remember psychiatry in its modern form has only existed about 150 years, a blink of time in the 10,000-15,000 year existence of human civilizations and a much smaller blink in the history of life and earth.

        I would say the chances that psychiatry in its current form of mass diagnosing and drugging will survive 150 more years are actually rather poor… in either direction, continued technological development (in which case the internet/increasing awareness will continually expose psychiatry), or regression of society to a more primitive state due to energy generating problems (in which case training of psychiatrists, travel to see them, and production of pills becomes problematic)… in either direction there are Scyllas and Charybdises waiting to deliver fatal wounds to psychiatry.

        • I don’t know the approach other authors here take, but, for me, I find writing on MIA to be such an excellent opportunity to receive feedback and learn to better articulate my thoughts. On that note, I thank you both, Richard and BPDtransformation, for challenging me and pointing out processes that perhaps I wasn’t even aware of.

          Yes, I agree, this piece is pessimistic, and it is because that is how I feel. I once was naive and believed that the system could change because it was full of “good” people and if they only knew the evidence then they would want to do right by it. There are definitely people within the system, many of them on this site, who are trying to swim against stream, but I have completely lost all faith that the system can change. My belief is that it must be replaced by a completely different system, preferably headed up by people with lived experience, but that such a system may also fall prey to corruption and authoritarianism if not protected against.

          In no way, however, does this mean that we should resign ourselves to defeat or lose sight of the bigger picture…just the opposite! Within the system, let’s try to do less harm. At the same time, let’s use our energy, resources, and voice to create change outside of the system. Let’s change the minds of the general public and start ignoring the ideologues in the system. Let’s change the minds of lawmakers who are not funded by pharma or NRA. Let’s change the minds of our peers so that they believe in themselves and believe that their voice is more than giving lip-service to “illness” and “meds”. We spend so much time and energy trying to fight the voices within this system and I do not believe for one second that it will do us any good outside of the choir. So few are willing to hear anything, especially if it invokes any feeling of guilt or helplessness in the professional. It is demoralizing and sucks the energy out of people like a leech on a bloody rag. BUT, we all are prone to be this way too and we should always keep this in mind.

          And, of course, there absolutely are people who are different, who will listen, and change can happen! But, I do not believe it will happen in the system. So, on that point, I disagree with you Richard. Yes, a harm reduction strategy should be short term…in the hopes that the system will cease to exist.

          • Noel

            Thanks for the clarification and the openness to critical feedback.

            On the point of where will system change primarily emanate from? I have NEVER said that I thought meaningful change would come from within the system.

            I believe people on the inside have a role to play, but it will most likely be outside events (such as economic crises, war, climate change, pandemics etc.) combined with various forms of social rebellion and upheaval that will create favorable conditions for “mental health” institutions to be dismantled.

            Most of my blogs have always posited the current mental health system within an overall oppressive profit based economic and political system. In my blog titled: “What is Biological Psychiatry – Anatomy of Power and Control” I made the following statement:

            “Today’s Biological Psychiatry has become such an essential part of the economic and political fabric holding together our present day society, including its ability and need to maintain control over the more volatile sections of the population, that its future existence may be totally interdependent on the rise and fall of the entire system itself.”

            This system is literally trying to drug away and/or incarcerate the next generation of creative agents of change. And they have had significant success with this strategy, either consciously or just as a natural oppressive outgrowth of their system.

            I think we have to do our best to avoid accepting or being influenced by the “system’s” narrative about the essence of human nature. It is their capitalist system and ideology that teaches and reinforces the belief that human beings are selfish, that is, always looking out for number one and stabbing people in the back to get ahead. For this is exactly the ethics of survival in capitalism – to accumulate and expand capital by any means necessary.

            In primitive communal societies cooperation was an essential feature of human nature out of necessity for survival. Yes, of course there was still violence against other humans on the outside of the tribes. Today, we live in the age of “freedom” where we can (and need to) choose to cooperate not just because of necessity but because it is moral and ethical, and makes the most sense for humanity as a whole.

            Today we have social production of the goods necessary to survive and mostly social living arrangements in cities and towns BUT we have private appropriation (by the one percent) of property and the goods produced collectively.

            This is a HUGE contradiction that is the source of major conflict in the world and permeates, in a negative way, every aspect of how medical care, science, and care of those psychologically distressed is handled in our society.

            These factors are all woven together and we can’t deal with any one issue without confronting the overall system that dominates every aspect of our lives.

            This will be a Long March, but it is our vision of a different world while nurturing the very best of our humanity, that will help get us where we need to go.

            Richard

        • Noel, and bpdt,

          The point about over estimating possible short term change and under estimating possible long term change is very relevant, both in terms of looking at the help people receive and in possibly feeling optimistic about changes in the system.
          Part of the corruption in psychiatry has been due to the pressure to prove short term change is possible with the subsequent promotion of medication and simplistic therapies. Clearly this model is to the financial benefit of drug companies, psychiatrists and insurers, but is disastrous for people in need. We should also be focusing on long-term change for the system, even if immediate change is necessary. The foundation of modern psychiatry is being eroded by advocates for change as well as significant research.
          I don’t feel that a complete tearing down is necessary or will likely happen. In the past, there were some good training centres in psychiatry that taught psychotherapy based humanistic treatments. There are many people who want to return to a more humanistic model of training, with a greater emphasis then ever on people’s real experience. I think that we should take some of the building blocks that have existed, throw out the corrupt blocks, add in non-dismissive real life experiences, and build a new structure. There can be hope. We need to identify what is valuable and what has to be discarded. Many people have had excellent experiences with good therapists. There is a growing body of research to indicate what makes a good therapist. This information, and approaches that allow good psychotherapists to be created and valued needs to be promoted. Let’s work on what is possible to achieve by continuing to fight against abuse and corruption, but value what may deserve to be saved.

  7. Modern AMA medicine and Big Pharma have set a deadly precedent that many people are unaware of or are afraid to articulate .They have proven they can make pseudo science for profit fly . Plus make profitable mistakes fly as well. Some glaring examples are the bogus germ theory , vaccinations , chemo therapy, and radiation, and the prescribing of numerous “medicinecocktails” ” that don’t work. Besides marginalizing and stigmatizing other first do no harm healing systems that in numerous instances work far better. The ADA as well with its mercury loaded amalgams , dangerous root canals , and cavitations .
    Psychiatry’s upper echelon strategists surely believe Psychiatry can get away with an even higher level of profitable deception especially now that they are forming closer alliances with AMA primary care physicians. Besides the extraordinary support from government all around . This and what you speak of in your excellent article and I’m sure additional factors including unseen backers of this control system and other compatible cartels like Monsanto for 1 example, control of mainstream media , make up the expanding packman on steroids Therapeutic State .
    As long as we still can access clean water even if we have to filter it ourselves , grow clean real food , have access to medicinal wildcrafted herbs , and natural healing systems best practitioners. We can still out think and surely put into effect better options with the help of many psych survivors seared by the tortures of psychiatry who will not sell out to the lies and coercion of psychiatry knowing there are better first do no harm solutions to life problems that don’t require psychiatry to exist but do require Health Freedom as part of the list of human rights we will fight for till our last breath for ourselves and all who see how badly its needed .

  8. There are many therapists like myself who are educated and trained outside of the “diagnostic model” Our mission is to “begin where the individual is” the person’s feelings, interpretations, dreams and wishes are always our starting and end point. Of course I was educated long before the Prozac era and before medications became a first line treatment. I know many therapists who follow this golden rule. We are older and wiser?

    • In the state hospital where I was once held and in which I now work there are clinical staff who’ve been here for 35 years.

      At one time in the past they did things the way that you describe but now they go right along with the present idea of “treatment” and drug people to the gills with no talking at all about what happened to people to get them to the point of being incarcerated against their will in a state “hospital”. None of them practice as they once did. They don’t seem like terribly bad people, in fact they seem quite nice when I talk with them. But they went right on over to the Dark Side and seemed to have done it without a lot of soul searching. Of course, I can’t see inside their minds and hearts and perhaps some, if not many of them, hate what they’re doing but do in order to bring home that pay check. Who knows? All I know is that they drug people to the gills with the toxic drugs and seem to pat themselves on the back for doing such a good job of “treatment” all done for the good of those receiving said “treatment”.

  9. Exactly! It is cheaper to use meds than to train or hire staff to provide a safe place and time to talk to patients. This was not always the case, as I can attest to, and when this shift took hold I had transferred to the jail. I believe what you say…its going to be hard to reverse this because it is so financially lucrative for hospitals and for the pharma companies. I still know therapists and many psych nurses who spend time with people but the economic and political backlash is pretty fierce.

  10. The feeling that it’s cheaper to use meds rather than good therapy is based on short sightedness and an ignorance of the cost of human suffering. There are studies that indicate that longer term therapy is cost effective, with less cost of medication, fewer costly hospitalizations, better ability to work (and pay taxes) as well as contribute to society. Bad treatment leads to higher costs in every way.

    • Norman,
      I think the key equation operating is not a rationalization of drugs saving money compared to therapy, but rather the fact that meds are making billions in profits for Big Pharma executives and shareholders, as well as allowing psychiatrists to charge $200+ for 15 minute appointments, rather than 45 minute therapy sessions.
      Corporations and most psychiatrists are probably aware on some level that they are failing their clients by overfocusing on pills; they just don’t care… as the bad guy in the movie Taken says, it’s nothing personal, only business.

    • Margie and Norman

      The use of the term “medications” is not being scientific and reinforces the language of an oppressive system. These are “psychiatric drugs” that are just another form of mind altering substance. Mind altering substances have a practical purpose in some situations in this world, but they most certainly are NOT “medicating” something pathological or “diseased.”

      You CANNOT change an oppressive system by continuing to use “THEIR” language.!

      Respectfully, Richard

  11. Really considering the way these toxic synergistic cocktails are secretly developed , approved , and delivered , and forced down our throats or into our bloodstreams then spun by social workers or therapists : your lifelong sick and will be monitored for life, and these “meds” blah blah blah blah blah . Besides you don’t want to lose your minimal disability subsistence cause I can write anything I feel like into your records. Checkmate. Besides if they don’t work for you I can arrange an appointment for you with the psychiatrist who might just recommend another pseudo scientifically figured out cocktail or maybe even the repeated electrical voltage option until you feel better and more compliant for the remaining years of your existence. Oh I see time has run out and I have another client to see but I will arrange an appointment for you . By now.
    Sounds like chemical and electrical warfare to me . BTW they’ve got forced vaccinations in California now . The main eugenic go to state in the first third of the 19 hundreds .

    • If it wasn’t for the brutal “shock and awe”perpetrated on the population by psychiatry( and other medical atrocities), the pharma drug cartel , the bought and paid for government , Troika combined with main stream corporate news spinning and omitting , plus the grinding poverty : The massive human rights demonstrations that would occur would even drive the robber baron families and their think tanks scurrying into the woodwork.

  12. I received a message from Sandy Steingard, MD, whom many here know, after she had some difficulties signing in to MIA. I thought it important to have her point raised here. With her permission, I am sharing our following dialogue….

    Sandy Steingard

    Hi Noel,… While I agree with most of [your blog], I was intrigued by the part where you say something like it is no help that some people find the current system helpful and “deny their trauma.” Isn’t that a slippery slope in which you do to those people – denying their own “truth” a what you feel has been so harmful to others in the system. Isn’t it at least possible that there is great heterogeneity and that indeed trauma plays a variable role in people’s lives (meaning for some there is no discernible major trauma) and that for some the medical model is helpful? ….Take care,Sandy

    Noel Hunter
    10/18, 9:50am
    Noel Hunter

    Hi Sandy, That’s strange that you can’t sign in…would you mind if I copy and paste this dialogue into the comments? I ask because I think you bring up an important point. This is a complex issue that is not done justice in my one flippant sentence.

    I have posted in other blogs my personal reflection on “trauma”. I think that the insistence that there has to be some major event or abuse in someone’s life to justify the distress they may be experiencing as an adult (or else it is, indeed, a “disease”) is harmful and disturbing. When I speak of “trauma”, I am referring to a reaction of the brain and body, the subjective…what is “traumatic” to a 3 year old may be unnoticeable to those around him. I actually have come to loathe the word “trauma” because of it’s political tone and connotations. I should use adversity and dysfunctional family dynamics. That may more precisely reflect my meaning.

    I think that it is our duty and our moral obligation to tell people the truth and not lie to them because it makes them feel more comfortable. We know that DSM diagnoses are not valid and we know that at this time there is no evidence to support the supposition that a disease process is taking place. If people want to believe that, fine. But we should not promote that just because it makes things easier and more comfortable. As a therapist, I do make an effort to get past some people’s entrenched belief that they have a disease because it is virtually impossible to get them to find a sense of agency and a sense of being a whole, valuable human being otherwise. I don’t argue, but i do ask people to entertain the idea that life circumstances may contribute to their distress and let’s discuss it. Otherwise, why be in my office in the first place? Of course, sometimes the only reason some go to a therapist is because it is required in order to continue with the psychiatrist, or because they just want help coping with their “disease”. In these instances, I do the best I can to lightly challenge while also respecting one’s ideological beliefs.

    I have yet to do much digging or searching to uncover childhood adversity and/or dysfunctional family dynamics that very clearly give reason to the particular way a client is suffering. I feel it would be unethical to ignore this and not challenge one’s beliefs about their unrelated “disease”. At the same time, I fully accept that one may need this belief or that it is helpful in some way to them. As with anything (like believing that I am a piece of garbage, for instance), firmly held beliefs must be respected and challenged in a balanced and individualized way.

  13. Some providers/organizations have already transformed their culture to be recovery/wellness oriented. when they do they make more changes in the right direction as they see the benefits. It’s too much to describe in a comment, but the difference is unbelievable.

    Pat Hayes.