A Harm Reduction Approach to the Mental Health System

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.