A Conversation about Having Conversations about Psychiatry

Amber Gum, PhDMariaelena Bartesaghi, PhD
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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.

151 COMMENTS

  1. This is an interesting discussion; while reading it I was reflecting on how rarely I see psychiatrists speak with this degree of openness and awareness of nuance and complexity. Those who are able to look at these conflicting issues together tend to more often be psychologists, psychotherapists, professors in related disciplines, and others whose status and income is less dependent on adhering closely to the biological-defect model. It often strikes me how brittle and vulnerable psychiatrists must feel as they attempt to maintain their house of cards which is increasingly coming under assault as more and more people realize how fraudulent the lies about diagnoses, drugs, and biological-genetic causation of social problems are. No wonder they use the most developmentally primitive defenses – i.e. denial, projection, and avoidance – to such a degree, remaining prisoners of the corporations and institutions that pay their rich salaries.

    While it is nice to think that biological psychiatrists could become more open-minded, I do not think that the most important changes need to come from within the system. Rather, the most important voices are not professionals and experts but the people – members of the public, especially those suffering emotional distress (with “lived experience”) and their families. Change needs to come forcibly from outside the system, from people demanding change and refusing to continually accept the lies about diagnoses and drugs.

    In this age of the internet and fast communication, the common people can be enabled to more effectively speak their truth and to demand change of the status quo, and to live the change they want. Most experts, most of all biological psychiatrists and researchers, are not interested in fundamentally changing the status quo – why would they be; they profit so much from the system of fake diagnoses (e.g. “schizophrenia”) and from barely helpful, often harmful neuroleptics and other poisons.

    We need articulate, clear, forceful speakers from among psychiatric survivors and other interested members of the public, who can speak their truth and expose the depth of the scam that mainstream psychiatrists and their allies are perpretrating. I intend to be one of those people, and many potential or present others are here at MIA, in ISEPP and ISPS, Mindfreedom, or working on their own. Let us have faith that what we are doing will result in transformations, in openings of the eyes of many more people to the realities of human suffering and how best to alleviate it.

    • I agree with the authors that the narratives of psychiatry vs. antipsychiatry get very binary, and falsely position psychiatry as central and more important than other approaches. In reality psychiatry is only central because it is such a profitable scam, not because its ideas have merit or produce good outcomes.

      I suspect that many people would think I am very antipsychiatry – and yes I do have a virulent hatred for biological psychiatry’s core ideas – but I do not even think of myself primarily as antipsychiatry. I want to be pro-what-works best for ameliorating severe distress, which seem to be things like Open Dialogue approaches, psychoanalytic psychotherapy approaches, Formulation/No-Label approaches, approaches emphasizing social and psychological factors, low-and-no drug approaches which respect the individual’s ability to choose, etc. Most of the research posted on MIA seems to be showing that these approaches usually lead to better outcomes and more hope than using diagnoses and primarily drugs.

      To undermine psychiatry and make it obsolete we need better alternatives available; that is what the first focus should be in my opinion, with the arguments around psychiatry itself being secondary. Psychiatry is threatened more by people abandoning it and moving toward what works for them… continuing to focus most attention on psychiatry may paradoxically help psychiatrists stay in power.

      Our nation’s political discourse over the last several years shows that attacking the other side without ever offering an alternative does not inspire people, promote progress, or build unity. We need the courage to be for things that are better than psychiatry.

      • “Distress” is a modified version of “mental disorder” “defect” or fundamental flaw. While the criminal justice system is built upon presumption of innocence, the mental health system, sanctioned by law, is built upon presumption of “sickness”. Keyword here, presumption. This keyword leads to the next problem, and that is that of due process, something that is lacking in the “mental health” world.

        One synonym for madness, to my way of thinking, would be unruly. The powers that be feel they must suppress unruliness. I, however, see unruliness as a positive thing. Ceasar may be able to seize the mind with a neuroleptic, however he remains unable to seize the soul. There is something there that, even in shackles, refuses to be constrained and contained.

        The good little poster-board mental patient has a big future now. You can kiss-ass your way into a decent living at advocating for “the voiceless and vulnerable” if you play your cards right, and if that is your aim in life. People are making yuppie-type careers out of those alternatives you mention, but it is still a matter of invalidated nation (i.e. people relieved of “voices” and described as “most vulnerable”). These careers are a matter of prisoner becoming warder, and slave become overseer. Myself, I see a lot more virtue in the abolition of the institution of slavery, and this goes for the institution of psychiatric slavery as well.

        If it weren’t for mental health law, you wouldn’t need alternatives to forced treatment because forced treatment would be a crime, and treatment would no longer involve force. Mental health law is a way around the law. Okay. So people are not going to vote forced psychiatry into the trash bin. What we do have is the CRPD, international law, a stealth bomber of sorts when it comes to attaining those ends (i.e an end to harmful non-consensual coercive psychiatry.)

        • I do not think distress is synonymous with defect or flaw. It is a more subjective, experiential, human word. Here is the Oxford dictionary definition of distress:

          “extreme anxiety, sorrow, or pain”

          I agree that psychiatric institutions ought to be abolished, but do not agree that approaches to human pain like Open Dialogue or psychoanalytic psychotherapy are about “kissing-ass your way into a decent living” based on “invalidated notions.” You might want to read more about the approaches in question before you judge them…

          • Well, if a ‘knight in shining armor’ is the answer for a ‘maiden in distress’, I’m not sure what would be required to relieve the distress of people in general. Regarding the “maiden” mentioned above it is usually a relationship of one sort or another that said “knight” might relieve her of. Frankly, my idea of a “warrioress”, to reverse the gender, is not a social welfare or “mental health” profession bureaucrat. They tend to be of the sort that gets one tied to the railroads tracks in the path of an oncoming train.

            Psychiatry plus (i.e. the psycho-pharmaceutical industry aka the “mental illness” industry) is very, very big business. It is also a growing business. I tend to see in “mental health” workers more a sort of Dickensian villain than a hero of any substance. The alternatives that are most alternative often have the most difficult time surviving, and can tend towards extinction. People do, though, make a killing in “mental health”, many killings in fact. I think it could use a lot of shrinking, and I don’t want to contribute any more than I have to to the problem, that is, the entire complex of the “illness” business.

          • I was undergoing psychotherapy at one time that evolved into ‘group therapy’. I can’t say that I have much good to say about it. I was seeing a psychoanalyst because that’s what families have their more troubled members, as they see them, do. I was glad to leave it behind me. The talk therapy versus drug therapy debate doesn’t interest me so much. Drugs are harmful, but talk therapy can be a royal waste of time. I think some people are channeled by the system onto what could be called a failure track, and psychotherapy is not necessarily going to deal with the social issues involved, that is, psychotherapy is not likely to put them on a success track. There is also the matter of what we regard success in today’s society. Some people are in institutions of higher education because they think success is solely a matter of working for a multinational corporation in some fashion.

          • I was not talking to you, MariaElena. If you read the statement in context you can see it is a response to Frank’s (another commenter’s) statements likening depth psychotherapy to “kissing-ass” based on “invalidated notions.” From reading the essay I am confident you would not think this way.

      • You are absolutely right. In an excellent ethnographic study “Making It Crazy” Sue Estroff who lives for a long period of time in a transitional community with people with a schizophrenia diagnosis notes that the ONLY way to get well is for the members of PACT (the name of the community) to LEAVE psychiatry completely: the other members, any affiliation with the medical community, the notion of brain, medication, and the community of “insiders.” This is not a provocation, but what she concludes by seeing the few who make it out, into reintegration. It is stunning.

      • narratives of psychiatry vs. antipsychiatry get very binary, and falsely position psychiatry as central and more important than other approaches

        No, it is not the “narrative” which puts psychiatry in the center, it’s the effect of laws which have allowed and encouraged psychiatry to become embedded into the fabric of society and the institutions which run it.

      • Our nation’s political discourse over the last several years shows that attacking the other side without ever offering an alternative does not inspire people, promote progress, or build unity.

        This is a self-defeating line, as well as incorrect in its assumptions.

        First, as Szasz pointed out, the alternative to concentration camps is no concentration camps, for starters. The alternative to genocide is no genocide. It is not the duty of the oppressed to provide the oppressor with an acceptable “alternative” as a precondition for his taking his boot off your neck.

        Second, alternatives to psychiatry have long existed; they are human connectedness, love, compassion, empathy and courage, among others. We have become alienated from these innate capacities over the course of centuries of capitalist/corporate rule, which holds these human qualities in subservience to the quest of the rulers for personal wealth. The answer will not come in the form of “programs,” with or without trademarks, but through liberating the planet from the shackles of corporate slavery and allowing our humanity to reemerge. This of course is an inconvenient truth for those who wish to capitalize on helping others through their misery.

  2. Incarceration, castration, sterilization, mutilating brains through surgery, artificially produced comas, electricity induced seizures, mass murder, brain damaging health destroying drugs, etc. These are treatments that psychiatry came up with. Is it any wonder that I’m not putting my anti-psychiatry in quotation marks?

    There is a very easy way to improve treatment outcomes, and that is by not drugging people. 1. You are talking about people who are only figuratively and not literally “sick”. (There’s my quotation marks.) 2. This, I imagine, automatically explains the success of a program like Open Dialogue in Finland. Those brain damaging health destroying drugs mentioned above only come at the end of many other atrocities.

    Conventional psychiatry now-a-days accuses its critics of anti-psychiatry. Most of those critics are anything but anti-psychiatry in point of fact. There are people who would render anti-psychiatry (opposition to incarcerating the innocent under medical pretenses, brain damaging health destroying drugs, and a whole system of dealing with people in general) a thing of the past. I can’t do that because I know where power asserts itself there will be resistance, and where that resistance has been quashed, it will only rise again. You can kill people. You can’t kill an idea.

    I could get cynical here, but then I don’t see what point that would serve. If 75 % of the population isn’t “in recovery”, there’s anti-psychiatry sans quotation marks for you. Psychiatry is the selling of bogus diseases, and the treatments, mostly drugs, that go with those bogus diseases. Some people haven’t bought a disease yet, or if they have, maybe they’ve managed to, heaven forbid, ‘get over it’. Maybe they’ve managed, like yours truly, to lose their “mental disorder”.

    Once upon a time one common “delusion” a person might have had was that of being Napoleon Bonaparte. Today it’s more typically Jesus Christ, the slave king. For some women, it’s the queen of England. Unless it happens to be the author of Harry Potter who I hear now surpasses her in wealth. Napoleon once claimed that his life was worth more than thousands of men, and thousands of men went to their grave under his command. Bill Gates and Steve Jobs might have competition somewhere from the loony-bin back wards. Quasimodo is still the Prince of Fools. The line between fantasy and reality is paper thin and many miles wide. Karl Marx got a few things right there.

    I imagine that the problem is not so much the person who thinks he is Napoleon as the person who happened to be Napoleon. If you don’t know your place, well, that’s the why, as far as I’m concerned, of psychiatry. I think people are better off not knowing their places. I call that ‘not knowing’ anti-psychiatry. Another word for it is the plural of revolting, revolution. When the revolution comes, I’d like to see all those stuffy and arrogant academics and professionals brought down to the level of your average denizen of tent-city. It is then that you would see that multinational corporate intrigue isn’t everything. As is, the Hilary/Trumponomic ‘trickle down theory’ of the oligarchs has much to be desired.

    • I am with you. Enough apologia for our views. When I teach the undergraduate class Communication, Language and Mental Illness I tell my students that it is not my job to tell the story of psychiatry, for they are doing quite a fabulous job of it already. First, I study psychiatry as a DISCOURSE, that is, as a way of how it has always existed as a construction in language, and language makes it so, it ratifies and justifies things as “treatment” vs. “torture”. Then, I tell them that this is a class in appreciating how we create the world we live in, and if we choose to abide by institutions that are undesirable and oppressive, and communicate within their discourse, then we are in a sense allowing them to exist and continue.

      • I’d say that’s very commendable on your part. Here in Gainesville we’ve got UF, but I don’t know of any discourses along the lines of that you are taking part in taking place here. I’d definitely like to see it. UF has got a big pharmacology department and so forth, but an understanding of the potential harm of psycho-tropics hasn’t arrived so much. I’d like to see the kind of discourse that was aware of Open Dialogue and the studies included in Robert Whitaker’s books but, alas, we’re still a long way away from that kind of thing. I don’t see how schools can ignore so completely those studies regarding the high mortality rates of people in treatment for the most serious of “mental disorders”. I would like to see college debate groups, and departments, take up the matter sometime. The power of the pharmaceutical companies, in other words, shouldn’t be able to manage a complete blackout when it comes to the damage done to people by psychiatry, even if disseminating such information is not in their commercial interest.

    • Conventional psychiatry now-a-days accuses its critics of anti-psychiatry. Most of those critics are anything but anti-psychiatry in point of fact. There are people who would render anti-psychiatry (opposition to incarcerating the innocent under medical pretenses, brain damaging health destroying drugs, and a whole system of dealing with people in general) a thing of the past.

      Yeah, and the psychiatric establishment labeling reformist shrinks as “anti-psychiatry” serves both to stigmatize them in the eyes of their profession and confuse everyone else as to what anti-psychiatry really means. Two birds with one stone.

  3. Thanks for your discussion. I think there is a third way beyond psychiatry and anti-psychiatry which you alluded to in your discussion. I, also, think that the NIMH is receptive to it, as evidenced by the fact that the NIMH has embraced the Research Domain Criteria and abandoned the DSM. People in mainstream psychiatry have considered and perhaps even embraced the notion that inflammation can manifest as depressive behaviors. For psychosis, at least at Emory psychiatry, hypofunction of NMDA receptors are viewed as the culprit and inflammation leads to NMDA receptor hypofunction. (My book, Neuroscience for Psychologists and Other Mental Health Professionals, and my website, littrellsneuroscienceofwellbeing.org, cover these stories). There are many studies attesting to the amelioration of inflammation with diet, exercise, yoga, meditation, and social support. Additionally, there are many studies linking psychological stress with inflammation. Thus, one can fully embrace physical explanations for behavioral changes without believing that medications are a good idea. Moreover, with the Affordable Care Act, behavioral health is supposed to be integrated into primary care. In my book, I argue that we should be screening for an absence of happiness in primary care and just skip the self-fulfilling prophecy psychiatric labels. Then behavioral health people can engage individuals in salubrious life-style changes: anti-inflammatory diet, exercise, and support groups. All of these changes are quite consistent with preventing cancer, heart disease, and diabetes. It’s a win all round.

    • “Behavioral health” might be an even more Orwellian term than “mental illness.”

      I argue that we should be screening for an absence of happiness in primary care and just skip the self-fulfilling prophecy psychiatric labels. Then behavioral health people can engage individuals in salubrious life-style changes: anti-inflammatory diet, exercise, and support groups.

      And the above is easily the most terrifying and totalitarian statement I’ve heard today.

      • Exactly! Because there is absolutely nothing wrong with being unhappy. The prevalent attitude is that we’re supposed to be happy 24/7, no matter what and we all know this is not humanly possible nor desirable. I too cringed when I read that statement. As Mariaelena asked, is unhappiness some kind of dysfunctional state?

        • I read an article on XoJane. The anonymous writer was glad she had a label of “depressive disorder.” Why? She felt she needed an excuse for being terribly unhappy (!)

          By the end of the article I pitied the woman, but thought her line of reasoning bizarre. Does she honestly think she needs a note from her doctor to show to everyone saying, “Please excuse Janie for being unhappy much of the time. She can’t help it. She really has a sick, defective brain,” ?

    • Screening for an absence of happiness does sound like the beginning of an Orwellian totalitarian state… people should be encouraged to be less than happy sometimes… and see it as a possible signal informing them of problematic areas of their lives… most people also don’t need or want a “professional” to “screen” them for “absence of happiness”.

      Being worried, afraid, ambivalent, sad etc are not evidence of illness or dysfunction needing “treatment”…

      • Sounds like Huxley’s dystopia to me. Nothing soma and orgies can’t cure!

        I also think of Erewhon by Samuel Butler. In Erewhon people are fined, imprisoned and even executed for things like sickness, financial loss, or losing a loved one. By suffering these things the unfortunate people cause distress and discomfort to the other Erewhonians. Hence they are punished for these “offenses.”

  4. The problem with this approach is that there are no mega-bucks to be made by industry, so that the true biological practitioner, who isn’t your average pill wheeler dealer, has to endure guff from the Pills ‘r Us DSM crowd AND the socially oriented MIA crowd.

  5. Thanks for writing this article. It resonated with me deeply.

    I recently received a doctorate in Clinical Psychology and work as an unlicensed practicioner, studying for licensure. Prior to beginning my graduate studies, my scholastic interests were in anthropology and religion.

    I didn’t realize that mainstream psychiatric practice was as narrowly focused on specific doctrines and was as guild oriented as it is until I was financially tied to the field, having not been a consumer prior to graduate education.

    While I have been consistently offered very positive feedback by my supervisors, teachers, and clients about my work, and have been awarded highly sought after positions through externship, internship and post doc, I have virtually no idea how to begin my career if I take my beliefs, values, and the way i think about my work into consideration (aside from a life of quiet subversion or something else as inauthentic.)

    Both of the writers are accomplished in the field and I was wondering if they, or others, have any advice or direction to offer early professionals who need to make a living in psychotherapeutic practice whose positions would be labeled “anti-psychiatry” or social constructionist in regards to the field.

    • Hi,
      The “label” of social construction in therapy is quite a good one…are you familiar with the work of Lynn Hoffman, Harlene Anderson, David White, Tom Andersen, The Milan School of Family Therapy? Again, labels are misleading, and the best therapist, I find is eclectic and NOT a slave to their beliefs…by this a mean not only trained in ONE way of doing things, you know? Like CBT or attachment modalities…but with a rich toolbox. It seems that you are doing fine, and that your interests will serve you well!

        • Another method to look into is Choice Theory/Reality Therapy. If this resonates with you, you might want to get certified in Choice Theory therapy at the William Glassner Institute.

          While I appreciate Robert Whitaker’s writings against psychiatric abuse, my first introduction to anti-psychiatry came from Dr. Glassner’s book Warning: Psychiatry Can be Hazardous for your Mental Health!

      • The good therapist is the one who has a “rich toolbox”. I really like this and it makes sense. What so many therapists today do not realize is that they themselves, in touch with who they are and what their own issues are, the therapist who is not afraid to use their own humanity as their most valuable tool and technique, is the therapist who will walk with people on their path to true healing. The therapist who works as the “wounded healer” is the one who probably has the touch and gift of real healing for people. Too many psychiatrist’s tool boxes are filled only with hammers since every problem that they see is a nail to be pounded down with the neuroleptics. For many people this is not a path that will lead to healing and well-being, for a few it will be but probably not for the majority.

    • Just chiming in, I know your remarks were directed to the authors but I thought I’d put in a good word for the life of quiet subversion. Also consider that the “anti-psychiatry” tag could be something of value in the future if you live long enough; you will be able to point out that you were ahead of your time. Though I must admit that doesn’t pay very well in the meantime…

  6. I am anti-psychiatry because mental distress is a social welfare problem of naturally painful emotional distress (from distressful experiences) rather than a medical problem of a brain (or “mental”) disorder. Psychiatry is a medical science based on the philosophy of mental distress as a medical problem; this erroneous perspective causes great harm to the community.

    Best wishes, Steve

  7. This is among the better pieces I’ve seen on MIA. I have some academic background in communication and have been on the receiving end of mental health services since the womb it seems. My concern for folks struggling the most (whatever the cause of the struggle, or whatever one cares to argue the cause) is who is approaching me, what is their motive and what is their method? I’m well at the moment, and I imagine I will stay somewhere on that end of the continuum, but when I was under the impression that the CIA was after me, I’m not sure I would have been receptive to a discussion of yoga, no matter how helpful it is (it is part of my life now, but it became so later, once I was more in the category of “worried well” rather than three outbursts from incarceration of the criminal sort, not civil.) Not to say drugging me into a stupor was a better alternative, as it had it’s own consequences. But I was marginally dangerous, which is not the case of all.

      • Much agreed. I don’t think protective factors should be misunderstood to be curative. The things described as alternatives absolutely help me stay well, once I got to where I wanted to be and I was glad to learn about them as I went along. But they had no help in getting me there.

  8. Very creative approach, I appreciate this dialogue model and highlighting all the forks in the road where we could always do better in terms of bringing clarity. We do learn as we go, if we are listening to ourselves without judgment and are ok with not being “perfect” all the time. We are works in progress.

    To me, that’s the goal in such dialogues, to achieve universal clarity. Personalities, beliefs, and opinions are as diverse as personal experience and individual process, and indeed I agree it’s vital to be 100% inclusive here. After all, we’re talking about the whole of humanity, so how is it possible to leave anyone out of that group? Everyone who is alive belongs to it.

    Needing to be ‘right,’ however, is a dubious inclusion, imo. There is no right or wrong here, as I believe it is the energy of dialogues such as this which creates the next level of reality, at least to my mind that is the case. Respect, curiosity, and authenticity can lead to all sorts of good things, certainly better than what we have going on now, in a society which sorely lacks these qualities for the most part, from what I’ve witnessed in any event.

    Although the one thing I find glaringly missing in this dialogue is passion. I think it’s ok to get angry and embody our emotions–not demeaning to others or digging in heals, but really so that we can feel comfortable embodying our emotional truth, I believe that is healthy and healing because it is, in fact, truthful.

    So many of us have been so extraordinarily negatively impacted by psychiatry and the mental health system, that I believe that being passionately indignant about these practices is not only real and authentic, it is also valuable information, perhaps even pivotal. Many of us have been really, really pissed off about all of this for a good long while, and for a variety of very good and overwhelmingly evidential reasons.

    And mostly, because it is NOT being rectified! And I see that it’s because clarity cannot seem to be achieved, despite all of these valiant efforts at ‘civil dialogue,’ which to me begs the question: WHY NOT? After all, aside from medication, ‘therapeutic dialogue’ is the other major practice we’re talking about.

    I believe this should be factored in, if you want a comprehensive big picture.

    • Just occurred to me that I have an example of what I’m saying, I have this 10 minute clip from a film I made a few years ago, exactly about this topic of psychiatry, mental health system, psych drugs, stigma, and discrimination, and we talk about our experiences amongst ourselves, while also sharing in public presentations, we were all part of a speaker bureau, although we’ve long moved past this since then.

      This clip is largely our discussion, with a few other clips in between to support what we are saying in conversation. But I think it adds up to a lot of what you’re saying, here, about these particular conversations, and as you’ll see, it is with plenty of passion. We are all survivors.

      https://www.youtube.com/watch?v=LN0-m6nhUIE

      There is more of this conversation in the film, which is posted in its entirely on YouTube, I posted it as a public service. If you’re interested i seeing it, please search “Voices That Heal.” (Since I’m posting the clip, I’m not comfortable posting the entire film also).

      We are not of one mind, we each have our own perspective. Two of us totally disagreed, but no one was disrespected yet we were truthful and direct with each other, and all voices were heard. We all grew and healed a lot from having made this film.

      I hope you find this relevant, meaningful, and supportive to your goals.

      • Ah, I’m glad to hear that. I agree many ways to express it, I think that’s our human beauty. I picked up the civility in the above discussion but the passion eluded me, but of course, I’m reading on my screen, which can be limiting.

        And I PASSIONATELY agree with you that ‘anger is not welcome in academia.’ I have close associations with this, and nothing can be truer, and more toxic, to my mind. I have deep grievances about this because I don’t think that is sound at all and causes a great deal of problems that undermine the credibility of academia, to my mind, and of course, the mental health field is academic.

        I’m an energy healer, we work with nuts and bolts of the person and their energy. Nothing academic about it, it’s grounded in natural reality, which means the totality of our being, light and shadow and all emotions included.

        Which leads me to your question, re ‘therapeutic dialogue.’ What I mean by this is that the core of psychotherapy is ‘dialogue,’ and so often the quality of this dialogue can be extremely problematic. Some people love therapy and their therapists, so this does not apply to them. I had one a long time ago who was wonderful, I saw her early in my life, and for a while, that was extremely productive and healing.

        But starting in the late 90’s, I came in contact with a slew of therapists, first, in graduate school where I got degreed in counseling psychology, and then, I happened to go into the system right after, to come off a lot of psych drugs which were breaking me down internally and suddenly disabling me quickly, after 20 years of taking them. I saw a lot of psychiatrists, therapists and social workers at that time, from the other side of the fence, as they had been my colleagues, partners, and supervisors before this.

        What struck me being on the client side was how dialogue was often seriously weird, in that it was slanted, controlled, tons of innuendo, not straightforward but more ambiguously suggestive, and if questioned or criticized–which I think is totally fair and natural–it could easily become quite demeaning and crazy-making. It’s enough to make anyone feel enraged from powerlessness, because the grievance process is futile, people tend to band together in the system, it’s not neutral. It’s about alliances, which I believe is more regressive than progressive.

        That’s what I found over and over again as I made my way through all of this, which was really, really hard, even included a law suit, because dialogue with anyone in the system, including the managers and CEO of a social service agency, was IMPOSSIBLE! I am not exaggerating, they forced my hand.

        This gave me the best glimpse ever into the avoidance of clarity which permeates the mental health world, for whatever reason, and it was most evident in the one-sided conversations which only led to chronic power struggling. This is what people are trying to get AWAY from in order to heal.

        In short, my question is: if psychiatrists and clients have trouble dialoguing effectively in sessions–which, at least from my experience and a plethora of testimonials I’ve read on MIA and elsewhere seems to be the case–then I’m wondering how to ascend this very blatant communication gap that exists between the two groups. There seem to be conditions on being acknowledged respectfully and eye to eye in the conversation, and one of them appears to be not disagreeing and thinking independently. To me, that is a blatant paradox to healing.

        That’s why I was happy to see this addressed in your dialogue above. We often get triggered when disagreed with, but that’s one’s trigger to deal with, not to project it onto another. I think dialogue in psychotherapy can often fall short of this. We talk quite a bit about clinicians not taking responsibility for their own stuff, which is how it gets projected onto clients, and I think this happens readily, and causes a great deal of harm. That’s the stigma, the clinician’s shadow. It can be tortuously traumatic for a client, even long term, if they are not aware of what they are taking on from a therapist.

        Long answer, didn’t mean to ramble, but this is what came to me when I saw your question. Thank you for prompting me, I appreciate the question.

        And many thanks for your interest in the film clip, I hope you find it valuable!

        • Alex!
          Yes! Therapy is a helping asymmetry, and thus depends (relationally) on the patient’s agreement to be “helpless” (Seligman has done some interesting work on learned helplessness.
          Maybe you might be interested in reading some of my work? I would love to hear what you think? I study therapeutic authority…which is the assumption of dialogue, but not dialogue at all.
          This one is available on academia.edu 🙂
          https://www.academia.edu/1271106/How_the_therapist_does_authority_six_strategies_for_substituting_client_accounts_in_the_session

          • Love this, Mariaelena, thank you so much for posting your paper. I took a glance at it just now and indeed, I’m extremely interested in what you have to say here.

            I’m closing up shop for the evening, so I will give this a thorough read within the next few days and I’ll be happy to give you my impressions.

            Very exciting work you are doing, I think this is so central to the core problem/solution, these relationships and communication/non-communication. I’m quite tuned into the quality and energy of communication, been my focus for a long time, also. There are multiple layers of energy there, we communicate in so many ways, subtle and overt.

            I really appreciate all of this, and your blog. To be continued…

        • “What struck me being on the client side was how dialogue was often seriously weird, in that it was slanted, controlled, tons of innuendo, not straightforward but more ambiguously suggestive, and if questioned or criticized–which I think is totally fair and natural–it could easily become quite demeaning and crazy-making. It’s enough to make anyone feel enraged from powerlessness, because the grievance process is futile, people tend to band together in the system, it’s not neutral. It’s about alliances, which I believe is more regressive than progressive.”

          Amen, Alex! How weird is this aspect of psychotherapeutic culture!? I spent a long time trying to figure out how to “submit” effectively to the authority of clinicians when in the coercive ritual of “training analysis”, (really to avoid the gaslighting and crazy making you described so well) and afterword trying to “heal” from it with another therapist.

          I think what I’ve learned is that you don’t have to play into this crazy making aspect of the game. You only feel crazy if you buy into their covert techniques by trying to confront them or figure them out. The power imbalance between patient and therapist is immense, so you can’t really challenge them without great risk to yourself. Don’t challenge, just ignore and don’t react directly…eventually they’ll give up.

          If they don’t want to have a real dialogue with you, you should just leave or say whatever you want and don’t over value their feedback and assessment because it’s too indirect to be meaningful anyway.

          Also there’s this awesome, but pretty analytically heady book called “Gaslighting, the double Whammy, Interrogation and other Methods of of Covert Control in Psychotherapy and Analysis” by this Analyst Theo Dorpat. It is brilliant and can basically help you make yourself immune to the crazy making techniques you’re talking about in therapy, as well as in non therapeutic interactions.

          • Rooster, you know exactly what I’m talking about, don’t you? I’m going to check out that book, it sounds very interesting. I’ve talked a lot about gaslighting in this context. Thanks for posting this. I’ve seen some videos on YouTube lately which say, “Don’t argue with an extreme narcissist, just walk away.” We’re onto them.

    • Hi Mariaelena,
      I hope you and the class found the clip/film meaningful and that it generated good discussion. These threads have become long and a bit tedious to navigate, so if you’d like to give me feedback on the clip–and the film if you watched the entire thing–you can write me directly at [email protected]. I’d be very appreciative to get your perspective on my work here.
      Thanks,
      Alex.

  9. I only have two words for the medical model crowd,

    Prove It.

    It’s kind of fun around the alcoholism addiction crowd when they start talking about how its genetic and all that.

    It is ? Where is the DNA test ? It runs in families ? Voting for a particular political party and being a fan certain sports teams also runs in families is that genetic too ?

    It’s like shooting fish in a barrel but they usually think they got you when the go to the smart phone looking for proof they “know” is out there and its not.

      • No one in the groups I goto believes that bullcrap anymore.

        Like I already said it shooting fish in a barrel, its so easy to tell everyone the truth about psychiatry kind of covertly in a 90 second share.

        “Before I came to AA I was in this treatment center and they were telling everyone they had broken brains and chemical imbalances so I asked them if there was any scientific evidence to support this…. Seems to me if your going to take drugs for a chemical imbalance it would be wise to get a test to confirm the existence of an imbalance… What if its just life ?… They wanted to give me more pills but didn’t Einstein say doing the same thing over and over again expecting different results is insane ? I refused to let those people zombify me and call it better again….”

        When you deprogram people, you get them to think…but keep them off balance and this get them to begin questioning, to open their minds. When the mind gets to a certain point, they can see through all the lies that they’ve been programmed to believe. They realize that they’ve been duped and they come out of it. Their minds start working again.

        I find the meetings fun and is part of the fun is debunking the medical model. The rigid thinking “you have a disease” people can’t stand me and that’s fun too.

  10. 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.

    The monolithic concept unifying psychiatry is the contention and belief that it is a branch of medicine. To work or identify as a psychiatrist treating “mental illnesses” is either to implicitly accept the medical model or ignore the fact that one’s profession is based on a contradiction. To be anti-psychiatry is simply to reject the medical model when it comes down to it, but also to recognize and deal with the fact that you cannot “reform” something when its very basis is fraudulent; you can only toss that theory out and start over again, hopefully learning from past mistakes..

  11. 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.

    One thing here I can wholeheartedly agree with.

    We can start by recognizing that the medical model and biological psychiatry are two completely different things and are not interchangeable terms. Any school of thought or practice using terms such as “mental health” or “mental illness” is employing the medical model. Biological psychiatry is an extreme form of the medical model, just as fascism is an extreme form of capitalism; it takes the existing confusion over the terms “brain” and “mind” to its logical conclusion, linking (with no scientifically or logically sound basis) metaphorical “diseases” to actual brain anatomy.

    • Yes, we need to be using our terminology consistently. Your post surprised me in that I’ve always considered the terms medical model and biological psychiatry to be synonymous. To me, the word medical implies biology. I choose the term disorder over disease but obviously some are offended by the word disorder too.

      • I’ve heard Seth Farber make this same distinction between terms but otherwise it seems that more and more they are (incorrectly) used interchangeably. Psychiatry by virtue of professing itself to be a branch of medicine has always been the prime manifestation of the medical model.

        Szasz’s The Myth of Mental Illness, which first challenged the medical model, was written in the early 60’s, well before the advent of what is now referred to as biological psychiatry. At that time, while using medical lingo and drugs, psychiatry was still largely grounded in psychoanalysis rather than flirting with neurology and biochemical explanations of thought and behavior.

          • Take the example of someone who believes that “schizophrenia” can be “cured” by psychotherapy alone. “Schizophrenia,” as is any “mental illness,” is a medical model term, even though the “cure” would not be pharmacological, or rooted in biology, but in environment and personal experience,

            For the record I personally don’t think that the separation of so-called biological psychiatry from the rest of the field is particularly helpful, as it’s all a variation of the same basic mentality.

          • But psychotherapy is outside the medical model. In your view, is just using the word schizophrenia enough to have you labelled a medical model adherent? Am I a medical model adherent because I use the term mental disorder?

          • Oldhead, I don’t need any “wiggle room.” When I say mental disorder, that’s exactly what I mean. I don’t conceptualize mental disorders as illnesses so I don’t use the term mental illness.

          • The word “Schizophrenia” usually, not always, implies the user of the term is thinking in a reductionistic medicalized way. There is no schizophrenia, as Jim Van Os and John Read’s research shows, and so we should abandon this word… it almost always is used to refer to the notion that someone has a brain disease that is partly or wholly caused by unknown genetic or biological factors… which is just bullshit since we don’t have that knowledge.

            The Van Os and Read research strongly suggest that along the psychotic continuum there is no way of reliably cutting off certain people as “schizophrenic” and others as “non-schizophrenic”… and that up to 10% of people experience varying degrees of psychotic “symptoms” at some point in their life. “Schizophrenic” processes do in fact become present to varying degrees in so-called healthy or normal people when under severe stress, and in many people held in prolonged isolation, hostage situations, or warzones for long periods.

        • Actually R. D. Laing came up with the term “medical model” to differentiate what he did from “biological psychiatry”. I don’t think Thomas Szasz was friendly to the term because I don’t think Szasz would be friendly towards anything Laing happened to come up with. Thomas Szasz spoke of “the disease model” by which he meant that the model that psychiatrists followed when looking at “mental disorders” was that of syphilis where biological organs are definitely effected.

          • Whether Laing or numerous people simultaneously first used the actual term “medical model” I’m not sure; “disease model” is fine with me too. What I’m trying to explain to Circa is that all psychiatry is based on such a model, not just so-called biological psychiatry. If you believe in mental “diseases” you’re using a medical model, by definition, whether or not you believe that the “cure” lies in talk “therapy” or drugs.

          • That’s incorrect, Oldhead. Not all psychiatry is based on the medical model. Szasz himself was a psychiatrist, don’t forget. Whether or not you subscribe to the medical model has to do with how you conceptualize mental disorder and the approach you take with it, not what terminology you use. Mental illness is a metaphor; however, the phenomenon it describes still exists. Szasz was quite clear on this.

          • Szasz often used the phrase “problems in living” where I use the phrase “mental disorder.” There is no contradiction there, just differing terminology.

      • Disorder is an inappropriate word for multiple reasons, Circa…. including that life problems occur on spectrms or continuums without clear boundaries… and that most life problems the manifestations of which get labeled “disorders”… are not inappropriate or abnormal responses to stress (as the word “disorder seems to imply”… but rather entirely understandable and “normal” responses to abnormal or overwhelming conditions of stress, poverty, neglect, abuse, trauma, and other “bad” things.

        • A distraught middle-aged woman emptying salt and pepper shakers at a pub for no reason is exhibiting some degree of mental disorder. In the absence of any evidence of “overwhelming conditions of stress, poverty ….,” they can’t be assumed. The fact there exists a continuum doesn’t negate this; it just means that this particular example is on the lower end of the spectrum. I will stick with the term disorder.

          • Yes, my position is that “mental disorders” don’t exist. I can’t make the same claim though about folly, and folly can be an affliction that no amount of treatment is going to “cure”.

          • Circa, there are always causes and reasons, even if they are invisible to us at a particular time. Adverse psychosocial experiences are the cause of many or most emotional and functional problems (what you call “disorders”) as shown in the ACE Study. It’s also possible that innate constitutional vulnerability to stress, or a lack of support of various kinds, can result in a person evidencing these problems. But such responses are never inappropriate or abnormal if one considers the deeper causes… they always make sense from a certain perspective. Also, they are not primarily medical problems. That is why I think the word disorder is inappropriate.

            Oh and…

            People don’t empty salt and pepper shakers for no reason at all 🙂

        • Ah, I think this is the source of our disagreement! You say “are not inappropriate or abnormal responses to stress (as the word “disorder” seems to imply).” You see, I don’t feel that’s implied at all. I see a disorder as possibly arising from just about any cause, sometimes entirely appropriately.

          • I don’t think people have “disorders” anyway. This sort of goes back to that leaning on the western civ idea, the Greco-Roman/Christian thing. Given cold war politics, Maxwell Smart, in other words, facing off against Chaos.

            Thomas Szasz has pointed to “disorder” as a weasel word. Psychiatrists use it to imply “disease” without saying “disease”. The authorities can arrest a person for “disorderly conduct”, and they can lock a person up for having a “mental disorder”. If “mental disorders” were actually “mental orders”, little difference, the doctor prefers his “order” to yours, which he has been given the authority to pathologize.

          • My position is that “mental disorder” is a figure of speech. In itself it means little, but as a type of shorthand, well, the DSM would catalog unwanted behaviors under that ruse. Whatever anybody is talking about, troubles, problems, stress, circumstances, misfortune, alienation, misbehavior, etc., it cannot be encompassed, nor encapsulated, merely by joining the two words “mental” with “disorder”.

          • Right, it’s reasonable and not pathological… being afraid of dogs is therefore not a “disorder” or “pathological” (meaning bizarre/inappropriate/out of context)… it makes sense!

            The semantics of this is what is difficult. What many of us here would like is to be able to talk about life problems without assuming defect or inappropriate medicalized responses in the person who is doing some behavior. Being scared of dogs because they bit you just is what it is, an entirely understandable response to scary dogs. It’s not an evidence of some discrete “condition” one has…

          • Circa, it is a problem that you think, apparently, that one has to label or crystallize or concretize emotional-thinking-behavioral problems as discrete reified entities with the word “disorder”… one can describe problems as logical understandable responses to stressors and deficits without employing the words “disorder”, “illness” etc, which are inappropriately medicalized and assume knowledge we do not have.

            I agree that there are no mental disorders, in the sense that human life problems do not divide discretely into separable categories that are valid (or very reliable). I encourage you to check out the Formulation narrative approach to life problems (written about on this site by Lucy Johnstone) and the developmental relational approach to emotional suffering (written about by Lawrence Hedges and available for free in his book Relational Interventions at http://www.freepsychotherapybooks.org)… there are other, arguably better approaches, apart from conceptualizing our behavioral problems as”disorders”. This doesn’t at all mean that the problems people have are not very distressing and maladaptive for their circumstances… but that is different from their being a medical “disorder” or from being abnormal in the sense of not being an understandable response to stressors at a particular time in the past.

    • I don’t think “medical model” and “biological psychiatry” are two completely different things. I think they are one and the same thing. Psychiatry needs for “mental” ill “health” to have a biological basis, otherwise why all those years in medical school. If “mental illness” is a myth. There is no reason for a physician, and all psychiatrists are trained physicians. Psychiatry is propped up by this illusion that you have a “biological” problem, and thus need a physician. The thing is, if there were no “disease” in the first place, and the treatment (iatrogenic injury) is the problem. well, that’s what you need to treat, the presumption. The treatment is far worse than the disease, if ever a disease there was, which is not the case. Let people be, and all the maladies caused by psychiatric intervention, will take care of themselves.

        • Perhaps you are misunderstanding him. I dunno. I can only take him at face value.

          One can say “biological psychiatry” is at the extreme end of the “medical model”, but even then, you don’t have two entities, you have a continuum that goes from one extreme to the other. As there is no “medicine” without “biology”, I don’t see it. At the other end of the continuum are social and environmental forces, and such as are not, and cannot be, without resorting to metaphor, touched by “sickness”.

          • But if biological psychiatry is at the extreme end, then what is at the other end of the medical model? As you say, social/environmental/etc. factors are outside the realm of medicine.

          • I’m guessing that oldhead meant that all psychiatry is of the medical model because all psychiatrists are medical doctors. “Biological psychiatrists” are a subset of these.

          • We’re pretty much trying to say the same sort of thing Frank, at least I think. I agree totally about the continuum and that biopsychiatry is the extreme end, and that actually all psychiatry is biopsychiatry because of the medical degree.

      • All psychiatry, “biological” or otherwise, is a manifestation of the medical model, which is simply conceptualizing the many problems people end up experiencing in life as medical ones, rather than social/political/environmental ones. I don’t know how it can be put more simply. Some people speak of “the medical model of mental illness,” which is tautological, as “mental illness” itself is the prototype medical model term.

  12. Thanks, Uprising. I don’t think that’s what he meant by medical model, though, because not all psychiatry is the medical model. There are plenty of psychiatrists that, although they there are medical doctors, don’t approach mental disorders from that angle. But I can’t think of a single proponent of the medical model who doesn’t preach biological psychiatry.

    • I’m aware that the phrase “medical model” is commonly used as a synonym for “biological psychiatry” (i.e., “brain disease” based approaches to severe human distress), but psychiatrists who happen to emphasize humanistic approaches rather than reductionist “brain disease” based approaches are still medical doctors, so how can we say they are not part of a medical model?

      Similarly, despite the common usage of the phrase “biological psychiatry,” all psychiatrists are in fact biological psychiatrists, because all psychiatrists are physicians.

          • There’s that weasel word again.

            If you don’t have a pathology, you don’t have an “illness”, you don’t have a “disorder”, “mental” or otherwise, you don’t have “symptoms”. “Symptoms” presume pathology.

            If we have unwanted behaviors, a number of questions arise. Who doesn’t want the behaviors? Is it the person exhibiting those behaviors or somebody/bodies else?

            As for “disorder”/”illness”, there you’ve got only presumption. A person may have complaints, even physical complaints, but that doesn’t mean such a person has any sort of physical problem whatsoever. If you say somebody has “mental disorder”/”mental illness”. I say, “Prove it!”

            Of all the sciences that purport to medical, psychiatry seems to me to be the one constructed mostly upon sand. All you need is a big wave, and everybody is back at square one.

          • When you look at it from the viewpoint and experience of the person labeled as having a “disorder” most of the time their behavior makes all the sense in the world and there is nothing disordered about it. I wouldn’t use the word “disorder” simply because the DSM is filled with all kinds of normal behaviors that are pathologized and labeled as “disordered”. I’m not going to use anything that comes out of the DSM.

    • I wouldn’t say that, but I would say that the basis for medical school, and for psychiatry as a profession, is thrown into question when the source of the problem is not seen as biological. Psychiatrists know this, and therefore you see mainstream biological psychiatry trying to cast all criticism as anti-psychiatry.

  13. Szasz was a rebel psychiatrist who deconstructed the myth of “mental illness” upon which the profession is based. I believe he originally became a psychiatrist because at that time it was a prerequisite to becoming a psychoanalyst. In his own counseling he abandoned all notions that he was treating “mental diseases.”

      • Even if his practice consisted entirely of “talk therapy,” wasn’t his career based on his credentials as a psychiatrist (i.e., a medical doctor)? In light of his writings, that seems a contradiction, as it reinforces the notion that extreme human distress is a medical problem. In this sense, I think Circa’s logic is correct.

        • In some remote sense, yes. He needed the psych credentials to qualify as a psychoanalyst. (This is no longer a prerequisite, btw.) Sort of like registering as a Democrat or Republican to get a civil service job in your locale. But his legacy was built on his refutation of the foundations of psychiatry, and in practice I believe he considered himself to be a psychoanalyst helping people with problems in living, which is not a medical pursuit. While it may be that his credibility with the public hinged on his official status as a psychiatrist, I don’t think he can be blamed for that; in fact I think he would have been remiss not to have taken advantage of it.

          Earlier I said, “To work or identify as a psychiatrist treating ‘mental illnesses’ is either to [a] implicitly accept the medical model or [b] ignore the fact that one’s profession is based on a contradiction.

          While some may argue that Szasz’s status as a psychiatrist would qualify him as [a], in his case I might posit a third condition, i.e. aware that one’s profession is based on a contradiction and actively working to expose it.

          In any case I think this all is leading us away from the original issue I was raising, which is that a) the medical model comprises any school of thought which holds that thoughts, emotions and problems in living are medical issues; and b) psychiatry of any sort is the flagship of medical model thinking, so-called biological psychiatry being just one permutation of such.

    • Since this all fits within the category of sharpening our definitions, hence relevant to matters expressed in the article, I pulled up this quote from Seth Farber:

      “[E]ven non-biological medical models like the psychoanalytical medical model (which Szasz debunked again and again) are mystifying and harmful. Today people think that biology psychiatry is the only medical model. But as soon as one talks about a mental disorder or illness one is using a medical model–the root metaphor is ‘illness.’ ”
      https://www.madinamerica.com/2015/12/70079/#comment-79660

      I emailed Seth to invite him here to help sort this all out but I don’t know if he’ll respond. Maybe the above will convey something in a way I’ve failed to do so far.

        • That’s because it’s describing something which is a contradiction in terms.

          I’m pretty sure he means what I was referring to earlier, when a problem is attributed to “mental illness” and addressed with some form of psychoanalysis-based “talk therapy.”

          • I think that’s the source of the misunderstanding between us. I consider talk therapy to be quite outside of the medical model even though it’s used to treat mental disorders. The word medical to me means a system rooted in biology and that’s why I can’t discern a difference between the medical model and biological psychiatry. The phrase psychoanalytical medical model doesn’t really make sense to me.

            If you mean that what makes an approach medical is conceptualizing the problem as an illness, then I agree with you. That doesn’t address some people’s resistance to my using the word disorder though. Psychologists treat mental disorders; they’re not operating within the medical model.

            This is all just my opinion, of course. We may just have to agree to disagree.

          • Though you may consider it presumptuous, I’m not arguing over a difference of opinion but trying to explain a definition or concept that you apparently haven’t wrestled with prior to this. Maybe someone else can do this better, but it seems that what you’re really reacting to is people pointing out that simply to rename a “mental illness” a “mental disorder” does nothing to change the implied medical nature of the phenomenon — especially when in the same breath you talk about “symptoms.”

          • Completely disagree. There is a profound distinction between the concepts of disorder and illness. Didn’t take much wrestling for me to come to that conclusion. However, I agree that the word symptom was ill advised and will endeavour to use the word indicator in the future.

          • Doesn’t matter, “indication” is comparable to “symptom.” Even if you watch your language you’re still talking about patterns of behavior as categories in and of themselves, independently of their context. Although this is getting beyond the semantics of the medical model and into a whole other (though related) subject.

            Maybe the night crew will have something to add.

  14. Mariaelena, I was up early this morning so I took a gander at your paper. Again, thanks so much for offering this.

    Overall, I find this to be a very explicit account of how psychotherapy can be such a disservice to clients, and draining, due to its dismissiveness/invalidation of the client’s perspective. To me, it describes how we lose ownership of our stories and allow others to meddle in them, which I feel is fertile ground for projection and stigma, not to mention trauma or at least rekindling of trauma—e.g., “”the disclaiming of a client’s everyday talk as ‘communication,’” and as you say, “…how the therapeutic exchange works as substitution, where client talk is replaced by therapist talk.”

    Just reading this makes my stomach churn, from the sheer arrogance and presumptuousness of such a practice, as it suits the needs of the clinician while disregarding the client’s truth. Given that the client is paying for this, I’d call this 100% ‘vampiristic.’

    “But for clients to authorize therapy’s construction of ‘communication’ is to agree to its prescriptive version of pathology and responsibility, that is, to see a causal link between their own talk and someone’s mental illness.”

    I’m wondering here if you are talking about Munchausen by proxy, which is how it reads to me, that simply with language, we can draw an ill-making picture of someone; whereas more thoughtful language would actually neutralize the situation, because language influences perspective and perception. I believe MbP is quite common, and criminally abusive.

    “As part of the helping relationship, therapists are pre-authorized by clients to teach them about a new way of seeing and ‘hearing’ things, and new ways of talking.”

    When I went into psychology, what attracted me about psychotherapy was the idea of putting together a puzzle to help a client figure out where they are feeling undermined or made anxious, and then work together to help a client make desired changes. Otherwise, why are they there?

    That’s how my early psychotherapy went, and I loved it. It was not a substitute for a relationship, nor was I looking to be ‘taught how to live.’ That’s what came later, as I plunged into the world of counseling psychology—suddenly, it was up to the therapist to teach others how to be, how to talk, how to live, etc. I believe this is way beyond the scope of practice for what I consider to be sound ‘psychotherapy.’ That’s more like some kind of ‘possessiveness,’ which I don’t feel is healthy at all, and this would not foster anything at all healthy for the client, and especially not in the long run.

    “The idea of clients contesting the therapist’s authority presents a fundamental paradox in a helping asymmetry, for receiving help means authorizing the helper to give it, but what to do if what is given does not feel like help?”

    “Find another therapist,” would be my answer to that question. If one is not happy with services received by someone they hire, we do have choices. If this is in the public system, where choice is limited, and challenges to a therapist’s authority are met with resistance, then that is called ‘oppression,’ which, indeed, is systemic. Not good.

    “Rather, it may be more interesting to see how clients grant authority and, in doing so, co-construct institutionally authorized versions of their own troubles.”

    Were clients to be made aware of what they are walking into, then perhaps they would not so readily trust a stranger with their intimate and personal inner world. With an un-evolved therapist, of which there are plenty, this is a recipe for full on trauma.

    Overall, I believe psychotherapy can be insidiously toxic in the wrong hands. And how do we know whose hands we’re in? We don’t, but we can learn from the personal accounts of so many others, who have been woefully traumatized by an over-controlling and highly presumptuous therapist. That can take a good long while to heal. I’d suggest not even getting started with this, and going another route for healing. There are plenty of healing avenues.

    I don’t really believe in this model (psychotherapy) for healing, although I do know some people benefit greatly. And, I suppose it can be a good adjunct, but I don’t feel core healing is found in psychotherapy, at least not how it is being practiced these days, in general. I appreciate what you outline here, in this close up examination of therapist-client ‘dialogue.’

    I believe that, perhaps, we could have a really powerful and lengthy dialogue regarding what exactly IS the job of a therapist. I have a feeling there would be myriad versions of this, and not all of them copacetic. I bet there would be a lot of personal feelings that would come up in such a discussion that would be quite revealing of why people go into this field. I’m not convinced it is altruistic.

    Thanks again, Mariaelena, for sharing your work. This has been very beneficial to me, and I hope supportive to you, too, in bringing further clarity to these issues. Like anything, it really is a matter of personal perspective, isn’t it? And while always flexible, that comes only from the experience of living.

    • Thank you so much for reading this! So, the idea here is a little like Munchausen by proxy, but it is not a diagnosis 🙂 — I simply show how communication DOES or creates the very circumstances it purports to describe. So, yes, communication makes our world, and through communication we can reconstruct it. The interesting thing is that therapists are taught/trained to use language in a way to bond, so that they can in fact persuade clients to see in the therapeutic way…the irony is that authenticity is therefore a strategy of authority…

      • Hmm, I think I perceive the opposite, that’s it’s NOT about authenticity, in practice, but about manipulation. This ‘bond’ has a price tag on it, so it is not really authentic in the truest sense of the word. If it were, psychotherapy would not be as outrageously costly as it is, for one thing.

        A clinical director where I was doing my MFT internship once said to our training group, “Don’t give your client too much power,” which was pretty much the norm of thinking in the education I received to be a psychotherapist. That was part of my training, learning how to keep the control and power in the sessions.

        I was not comfortable with this and did not feel it was sound supervision (having seen this in practice and finding it very uncomfortable and counter-healing), and I eventually defected the field of psychology in order to pursue other healing and training, with which I’m more copacetic. That would be a combo of energy work and spiritual counseling, based on the principles of Chinese Medicine.

        These are not academic in nature, and so the communication tends to be direct, clear, and no-nonsense, at least in my healing community. It is not about power, but about balance, grounding, and achieving harmony within ourselves. The healer does not intend to make a client see things ‘their way.’ How does that help anyone? We all operate in our own personal realities, that’s natural.

        The healer is there to simply detect where an imbalance is causing anxiety or whatever network of symptoms is the issue, and then prescribe a healing plan to address it, based on natural healing practices which can safely and naturally correct imbalances at the root cause. There is not even nearly the ambiguity that exists in the academic mental health world.

        Clarity is key to healing, and not necessarily intellectual clarity, but simply a knowingness in the heart that one is doing in the right direction for themselves. If there is one thing we want to trust, it is our own process. If not, we suffer with chronic anxiety, which to me signifies something needs to change, internally.

        Language is very important energetically, but most important, I feel, is our intention behind the word, and the meaning we, ourselves, attach to the words as we utter them. I think it’s vital to mean what we say and say what we mean–to speak mindfully and with conscious intention–but that can also be hard to come by, if we are talking strategic communication. I think that’s the exact opposite of authentic.

        When I communicate, it is because I feel the need to express something–my truth–not necessarily to convince anyone of anything, but to feel my truth move through me, that’s one way we flow our energy. Authentic dialogue is organic and present time, not planned, and that makes us vulnerable, which is where we find healing.

        How words and phrases are interpreted is on the hearer, that would be a reflection of THEIR energy, beliefs, and perceived reality. And of course, further discussion might find an intersection here, where a new reality is created.

        It is interesting to see what happens when what is said and what is heard are completely different in meaning and intention, which is quite often these days. I feel that we have a tower of Babel situation going on here. This can be worked out and mutual understanding achieved; however if we are rigid in our beliefs, this will be virtually impossible to resolve, imo. It is our beliefs which dictate our personal reality, so if we are rigid in them, we will not expand to understand respectfully another’s point of view, which is what keeps things either stuck or split.

        I really like the idea of being flexible in our beliefs during dialogue. I find this to be very expansive in terms of understanding a greater breadth of humanity, including our own. When we are self-accepting, we tend to have a more compassionate understanding of others, and I believe this would lead to greater peace.

  15. Amber and Mariaelena

    What came to my mind immediately while reading this conversion was the whole concept of the “market place of ideas.”

    All of these experiences discussed are taking place in the context of a profit based economic and political system. It is so unfortunate that education, science, and medicine are all controlled and influenced in every negative way possible by the bottom line of profit.

    How unfortunate and sad that people are forced to make important decisions about intellectual pursuits and scientific exploration based on the fear of not having (or keeping) a job because their ideas and proposals may challenge the powerful economic and political interests of those propping up the status quo.

    There is a theme and/or emotional undercurrent that permeates this rich discussion related to the fear of reprisal and the basic need to survive in a competitive and harsh world. In this case an academic world that is so reflective of fundamental class conflict in the capitalistic based “market place of ideas.”

    Big Pharma and the elites controlling Psychiatry and “Mental Health” academia are functioning like the “Gestapo” when it comes to how we can think and behave, especially if it might lead to influencing broader numbers of people. This is happening in all areas of academia where the exchange of ideas and related publishing endeavors are heavily influenced by a most fundamental form of class conflict.

    I appreciate your attempts to function in this difficult environment and your willingness to discuss openly some of these personal and political dilemmas.

    Richard

  16. Once science was seen as a viable source of money and power, governments and corporations stepped in and began funding science. Over time both began to dominate that area and determine the sorts of projects they would fund. Gradually academic institutions became subservient to these demands and their proffer of riches. It is not a question of whether psychiatry has a hold on some truth but that it is viewed as a scientific endeavor that is all important. As we should know by now both gov and corporations can be very cruel in their pursuit of various goals. Giving dangerous drugs to unsuspecting people or doing enhanced interrogation is largely viewed in the same way. The gov of the USA is largely indifferent to the welfare of its citizens: nuclear waste here and there, GMO’s, herbicides, insecticides, various drugs, wars, etc. When psychiatry is criticized money is at stake–not truth or the welfare of persons. If the Elite cared about people the USA would not have killed somewhere between 20 and 30 million innocent citizens of foreign nations since WWII.

    • Good comment… psychiatry is nothing more than a strip-mining project targeted at sucking money out of the young, uneducated, poor, vulnerable, and distressed (and out of their insurers) by feeding them harmful drugs disguised as “treatments” for illusory “illnesses”. Those turning the gears of the machine are primarily very wealthy, white, male, old psychiatrists and lawmakers. The psychiatric scam is disgusting and despicable and demands a much more forceful response from our citizenry than it’s getting currently.

  17. Thanks both for this conversation about having conversations. It dusted off a lot of my thinking and reminded me often as I read through the textual dialogue of my own thinking over the years.

    Superstition is a very innate and powerful flaw in human thinking, and it takes on many voices. Each age has been in awe of some elaborate untruth, and perhaps no more so than in its encounters with madness.

    The medical model is a modernist superstition in a postmodern world. Unfortunately — at least unfortunate for some — is that in this postmodern world, “alternative” means, often by default, an “alternative” form of magical or superstitious thinking. Like the power of positive thinking or being at one with the universe, which I admit, is where madness gets its dancing shoes on.

    Narratives compete, and always will. It’s an uphill struggle to explain to people who have been cajoled into thinking their superstitious belief in flawed hypotheses are no more than institutionalised superstitions. This is especially a dreadful counterpoint to make from a base of a non-person. Non-person being any person declared mad.

    But the biggest struggle (and not just my attempt here to sound coherent) is to construct a counternarrative as bold and persuasive as the “drugs saved my life” mantra, so often repeated by those inclined towards magical thinking.

    As all land animals will tell you if they could — water saved their life, along with appropriate sources of food.

    And ultimately nothing saves a life. We are truly mortal beings after the age of about 35.

    But again, much thanks. If I had anything more sensible to add I truly would. You both pretty much nailed a common though sadly narrow experience.