In spite of constantly increasing opportunities to tell different stories to the canonical story of bio-psychiatry, it can be risky for academics to voice a different perspective than the mainstream model of mental illness. In this conversation, a communication professor and a psychology professor discuss their challenges and personal experiences with going against the grain, such as what it means to be labeled “anti-psychiatry” by colleagues and responding to students upset to learn their medications may not be all they thought they were.
Mariaelena:
Amber, how lovely to get the chance to have this conversation with you. A couple of years ago, after our lives and careers had, as often happens in academia, caused us to lose touch, your revelation that I had somehow changed your life (and not necessarily in a positive way) truly amazed me.
Amber:
It has been a positive change, although not always pleasant. I think it’s important to distinguish between the two. It is very unpleasant to realize one has been wrong. In spite of the unpleasantness, I am very grateful that you introduced me to different areas of research and ways of conceptualizing mental health. This ongoing journey of learning and considering different perspectives is helping me to grow and, hopefully, contribute to the mental health field in a more valuable way.
Mariaelena:
I struggle too, you know? I used to be so angry, write angry, teach angry. Now rather than right or wrong I try to think of it in pragmatic terms, as a social construction, as what would happen if we could go down this road or another? There are, after all, many cracks for the light to shine through, especially abroad – the creation of a village built around people with dementia in Hogeway, Holland comes to mind, as does the Italian initiative of inviting those diagnosed with a mental illness as guests at family meals.
I know that a large part of why we decided to have this conversation was to discuss our trepidation to bring in alternative versions to the canonical version offered by psychiatry. Well, it’s not so much trepidation for me. Since graduate school, I have been interested in counter-narratives to psychiatry. I read Szasz’ “The Myth of Mental Illness,” and of course Foucault, Laing, British critical psychiatry, Erving Goffman’s “Asylums,” and work in social construction. This interdisciplinary framework is derived from Berger and Luckmann’s “The Social Construction of Reality” (1966) and interrogates knowledge of the inner world, nosological categories, the therapeutic relationship, and diagnostic measurement. The role of the psy-complex, which social theorist Nikolas Rose (1989) identifies as the set of professions dealing with the psyche: psychology, psychiatry, psychoanalysis, psychotherapy, psychiatric nursing, and psychiatric social work, is to regulate family life, sexuality, mind, and rationality. In the world of psychotherapy, the fact that “mental illness” is not a matter of brain but communication dynamics has been taken for granted since Bateson’s Palo Alto group and various schools of family therapy, as well as narrative therapy. So in my world, there is very little unfamiliar about what I am reading now. I am just happy that Whitaker has been so successful! The problem is perhaps different, and it is one of communication between two incommensurate discourses, or a conversation that probably cannot happen. If it were to happen, psychiatry as is (or as I see it being) would cease to exist as a medical discipline.
Amber:
You mentioned that this is a conversation that probably cannot happen because it is such a threat to the discipline of psychiatry. This is a major reason I feel such trepidation expressing a different viewpoint. I don’t like conflict, and I suspect many other academics don’t like conflict either. I respect and empathize with my colleagues in psychiatry, psychology, and other areas of mental health who have dedicated their careers to helping people who are suffering. So it becomes uncomfortable to say that I disagree with their approaches to conceptualizing mental health conditions from a biological framework and relying on medications to treat them. They don’t want to consider that their approach might not be the best way, and yet they may not want to have a disagreement with me.
I recently met another academic for the first time at a conference. We were expecting to meet each other and had each reviewed the other’s web page before our meeting. This person commented on my “anti-psychiatry” stance. I was taken aback by the label and immediately felt the need to defend myself. I said that I thought that characterization of my position was “harsh” and tried to explain that I believe the research demonstrates that current psychiatric medications are less effective and more harmful than most believe and that my primary purpose in writing that article was to encourage open-minded discussions on the matter. I was not able to continue the conversation due to an interruption. I have had similar experiences since my paper (see coverage of this article on MIA) was published – of people commenting on me being anti-psychiatry or anti-medication, trying to briefly explain myself, and then the other person disengaging in some way (e.g., changing the subject, speaking to someone else).
Mariaelena:
Interesting, this term, “anti-psychiatry,” because it works on multiple levels. First, it connects those so defined to a particular historical time when institutionalization, use of shock therapy and other treatments for punitive purposes came under attack fueled by the work of R. D. Laing, Thomas Szasz, Rosenhan’s experiment, and novels like Kesey’s “One Flew Over the Cuckoo’s Nest.” Second, it creates a semantic conundrum with psychiatry at the center and presumes those characterized by the term as having to position themselves accordingly, pro or con, black or white, no middle ground. By the same token, it is the one who is “accused” who is accountable for their putative views about psychiatry, as pro is the default, and psychiatry does not need to account. A pro and a con where you are in relation. Lastly, the term “anti-psychiatry” reifies a notion of psychiatry as one monolithic movement, with a center, in effect smoothing over any potential tensions and schisms within it.
Amber:
I suspect that people mean different things when they call someone “anti-psychiatry.” I interpreted being called “anti-psychiatry” as meaning that I am against the entire discipline of psychiatry and want it to disappear. This is not my opinion, but I certainly think psychiatry and the broader mental health field must make drastic changes. There are many ways in which human behavior is shaped by and shapes biological functioning (such as the release of cortisol when we perceive fear or stress), and I believe these relationships are valid areas of study for psychiatry, psychology, and neuroscience. To me, the problem with the dominant biological hypothesis in mainstream psychiatry is its reductionist, narrow focus on biology, and refusal to consider empirical evidence that counters this hypothesis as well as evidence regarding the equally (or more?) important roles of psychological and social influences.
This discussion about the definition of “anti-psychiatry” illustrates to me that there is more than one counter-narrative – I don’t see myself as “anti-psychiatry,” whereas there are others who want to abolish the entire discipline and mental health system and then others somewhere in between. And in fact, there are differences of opinion within psychiatry itself.
Mariaelena:
See, I balk at terms like “behavior” already, for “behavior” presumes an observer who can define actions in such terms, a vocabulary and a metric for these observations, and scales of evaluation that abstract actions from social settings and dynamics of interaction – hence we have “abnormal” behaviors, and so on. To me, the language of behaviorism and cognitivism gets us back to square one. The fact is that, as a communication scholar, I am not “in between,” for I do not believe in a biological hypothesis for mind/brain at all when it comes to what I see as the medicalization of the human condition. Now, brain lesions, brain injuries are the realm of neurology. To me, neurosyphilis (also a neurological condition) was, in fact, the last condition that psychiatry could claim as “brain” and not “mind.”
Amber:
So here is something we disagree about. There, that wasn’t so bad!
I just suggested that there are several counter-narratives, and you and I seem to have different views from each other about biology. We also have different views about behavior, which I contend that we can measure (to some extent at least). Even so, we also agree about many things.
Earlier you mentioned two incommensurate discourses. Can you expound on those – what are the two incommensurate discourses as you see them? And why would discussing them lead to psychiatry’s demise?
Mariaelena:
The discourse of suffering as illness, for one. As neuroanthropologist Tanya Luhrmann writes, there is a difference between non-essential pain, which is what the biological hypothesis tells us is something removable from us and fixable by medication, and essential pain, which is suffering that is a part of us, that does not go away, that some of us will have as part of life, and that we will find hard to accept in loved ones and other people. Essential pain requires complex empathy, that we love someone in spite of their suffering, that we accept that they will “fail” medication and that this will not mean that they have “bad” brains. It just means that they are human.
Amber:
You seem pessimistic that a conversation can happen between adherents to the mainstream mental health narrative and those who propose counter-narratives. I remain hopeful and wrack my brain trying to figure out the best ways to engage others in a genuine dialogue – in which we inquire about the other person’s perspective, consider its merits, and weigh the empirical evidence and logic together. Looking back on the recent encounter when I was called “anti-psychiatry,” I later realized that I felt defensive and responded accordingly. I suppose I should have been better prepared. The next approach I will try is to build empathy and understanding. If I were to have that conversation over, I would begin by asking questions – “What do you mean by ‘anti-psychiatry?’ What do you think about psychiatric diagnoses? Medications? Why do you think that?” If I want someone to open-mindedly ask me questions and consider my perspective, then I will try to begin by doing the same.
Mariaelena:
Actually, not pessimistic completely. I have a colleague practicing systemic therapy in Italy who works with pediatric neurology in cases of autism. Both reject psychiatric methods, though, and see autism as metaphor, in a humanistic context. Their treatments, which are not behavioral and therefore not “mainstream” and do not include medication, are decidedly sought out. But Europe is not the US.
Amber:
This is encouraging to learn about different methods that are working and being sought out. These kinds of examples may help people to be less afraid of changing their practice or research if they can see other ways to maintain a career and livelihood. Fears of harming one’s career and livelihood are an additional source of trepidation. For example, I would like to have a consistent salary all year and eventually get promoted to Full Professor. I have research ideas I would like to test out. To achieve these goals in my current organization, I need to seek federal grant funding, and the National Institute of Mental Health is the primary funding source I have been trained and encouraged to seek. NIMH funding is highly contingent upon reviews by 3-4 anonymous people, and I am not sure what they will think if they see the paper I wrote and how it might affect their reviews of my applications.
The financial risks are even direr for some colleagues, who wholly depend on salary generated from working within the mainstream system as practitioners or researchers. I think it could be very valuable to collect case examples of psychiatrists and other mental health providers who are helping and making a living providing alternative types of interventions, to illustrate that we can achieve meaningful goals (helping people in suffering, making a living) through other kinds of interventions.
Mariaelena :
Absolutely, and I think Mad in America is playing a big role in doing just that.
Amber:
I agree, although unfortunately, I’m not sure how many mainstream mental health professionals are aware of Mad in America as a resource. I think Breggin’s “Psychiatric Drug Withdrawal” also presents useful information for psychiatrists who would like to shift their practice.
Another challenge is discussing divergent viewpoints regarding psychiatry and psychiatric medications in the classroom and with students. I have begun teaching students about this and assigning readings, but I am concerned about seeming biased or trying to push a particular perspective, especially with people over whom I have power (e.g., to assign grades, write letters of recommendation). I believe they must feel free to disagree with me, although I challenge them to base their opinion on science and logic, not simply mainstream assumptions.
I also am fully aware that some of my students take psychotropic medications, and they discuss their mental health issues (or those of friends and family) with me at times. They occasionally ask my advice. I present them with different resources (like those I listed in my paper) and tell them they must make their own informed decisions. I do caution them that, if they are already taking medication, it can be dangerous to make changes, so they need to educate themselves about how to make changes safely.
Mariaelena:
Amber, though I am not a licensed mental health professional like you, I encounter the same issue. And perhaps my situation is more fraught, and certainly more dangerous. I walk a thin line in my classes. When I show students that psychiatry exists in communication, that it is a discourse — that it rests on claims, contingent on sociopolitical circumstances and historical beliefs — students often feel that they have been misled, cheated. They feel alone. They do not know where to turn. But discomfort, and being able to tolerate it, has to be the starting point.
Amber:
It seems we walk a thin line in many of the conversations we try to have about these topics. So where do we go from here?
My primary goal is to encourage people to have these difficult conversations instead of continuing our separate, incompatible discourses. I am not sure how to foster conversations when we are afraid of being wrong, afraid of losing our livelihoods, and afraid of conflict. As I wrote before, I believe we must try to empathize with each other, and ask questions. Also, we are not going to agree about everything, so we need to be able to tolerate differences of opinion.
Mariaelena:
I think there is more than tolerance at stake. Psychiatry has admitted wrongdoings all along, and simply couched them in terms of progress, “now we know better.” I do not believe this should be the way anymore. Medicine and holistic medicine and alternative medicine are all surviving alongside each other…and medical practitioners are experimenting or considering different ways of doing things! So, let the cracks happen and the light shine through.
Amber:
I agree. Tolerance is the starting point, not the end. I think we begin by tolerating many things: uncertainty, ambivalence, changing our minds, speaking up, conflict, different opinions, our own and others’ pain and suffering, the wide range of psychological experiences people have. As we tolerate, then we can inquire, ask more questions, seek more information from divergent perspectives. Our conversation has shown me that we need to define our terms very carefully because these terms we throw around so easily (e.g., psychiatry, anti-psychiatry, biological hypothesis, behavior, suffering) mean something different to each of us. Then perhaps we can move toward consensus, or at least, greater awareness and freedom to choose among alternative approaches for understanding and addressing human suffering.
Mariaelena, thank you – for presenting me with the opportunity to take this road instead of another, and for engaging in this conversation. I look forward to many more.