Nearly all of us who have been involved with mental health policy, practice, or research for any length of time have participated in multi-stakeholder meetings, collaborations, or relationships of one kind or another gone awry. And while there are many reasons that interpersonal dynamics can (and do) deteriorate, when it comes to mental health, by far the most common scenario is an interpersonal break-down across clear identarian lines. And these divisions occur both in terms of the issues—of what is being discussed, proposed, or reviewed—and the emotions involved (and, by extension, the style or mode of interaction).
While there is an obvious relationship between issues and emotions (or ‘affect’), there are also ways in which—in your average mental health setting—they are orthogonal. That is, if a given service topic—whether involuntary commitment or antipsychotic withdrawal—has not only personally affected us (as individuals), but also our friends, and a sociopolitical group we strongly identity with, it’s likely that the issue itself will engender deep emotions, some conscious and some not. If, instead, we’re wearing a strictly professional hat, have never ourselves experienced the issue or intervention in question, and our professional ‘in group’ sees little in the way of controversy (for instance, it’s generally assumed that whatever is being discussed is a good, unproblematic thing)—it’s easy to stay calm, cool and collected: to discuss the issue with perceived ‘neutrality,’ to maintain emotional distance. Nothing should surprise us about this.
In fact, one could go so far as to define at least one major form of ‘privilege’ in such contexts as the capacity to remain emotionally unaffected, ‘untriggered,’ calm, neutral—because whatever is being discussed does not bear the weight of a policy or intervention that has in the past, or could in the future, radically shape one’s own mind, body, rights, future, career, and community. And yet, so often, the ability to stay ‘neutral’ is framed as a skill, achievement, and sign of professionalism and maturity. (Or even an indicator of a ‘normal,’ healthy ‘personality.’) The individuals in our boardroom or public hearing who don’t get upset are the ones who really should be there, this logic leads us to conclude—who should be the decision makers. Conversely, reacting emotionally, getting upset, getting flustered, raising one’s voice, is seen as a sign of individual weakness. In some contexts, this might be seen as correctable (‘learning to act more professionally’); in others, even more insidiously, as a sign of deeper, underlying pathology (for example, ‘unstable mood or emotions,’ ‘interpersonal lability,’ or a disordered personality). Within this logic, the anger, despair, frustration, confusion, and shame of the proverbial ‘other’ is all too easily used to confirm existing forms of psychiatric othering and justify gatekeeping strategies and policies that create space only for those service users/survivors who don’t get visibly angry or sad, raise their voices, or ‘emote.’
And now we want to make two points about this all—first, that judgments of the so-called ‘angry consumer’ in fact deeply reinforce divisions (and divisiveness) within mental health policy and services, and even the very emotions they seek to avoid or circumvent; and second, that the only way we can engage in meaningful co-production is not to gloss over histories and legacies of collective exclusion and disempowerment and all the individual pain and anger that goes along with it, but rather to validate and actively work through difficult feelings and emotions: both our own and others’ discomfort.
Whenever a friend, colleague or associate expresses their dismay that some consumer or family member is ‘too angry,’ ‘unprofessional,’ ‘unproductive’ or ‘unable to get along with others,’ we always ask them to try and imagine what that person has, or may have, experienced. In general, people end up advocates or activists precisely due to an express personal and political commitment to the improvement or transformation of systems and services, very often undergirded by a series of painful experiences. As a given group ‘coolly and calmly’ discusses involuntary commitment, for example, the individual may have in their mind the images and memories of riding in a police car to a local ER in handcuffs, of a charge nurse stripping them of all their personal belongings and leaving them to wander around a sometimes frightening ward in a hospital gown three sizes too large and only a t-shirt and underwear beneath. Or discussion might turn to policy concerning antipsychotics and immediately, coloring their own experience of this discussion, are the memories of years or decades spent on drugs that left them too mentally flat and exhausted to do anything, or seriously physically ill, from metabolic or neurological side effects. Some of them—or rather, some of us—also have friends, close and not-so-close, who have ended up casualties of the system in any number of different ways—incarcerated, trapped in state institutions, in poverty, living in SROs or IMDs or group homes where there is little prospect of anything like a ‘normal’ life. And these memories, these experiences, these times we have witnessed the fates of others who are and are not ‘us,’ who are our brothers and sisters and comrades, are often, so often, deeply painful. It hurts to remember, and the images—her eyes, that day, how dim and lifeless they looked when the orderly took her away; the urge to hit something, maybe yourself, mixed with despair, and along with it the color of the cement and the play of the shadows in the corner of the hospital room, waiting to be cleared. Listening to a voicemail from your supervisor, saying you were suspended or terminated, and how your body went limp.
And now, imagine the effects, when that person is told—perhaps they’re even the sole ‘token’ representative of ‘people with lived experience’ in a given group or meeting—‘you’re too emotional,’ ‘you’re too angry,’ ‘don’t you *want* to collaborate,’ ‘why can’t you control what you say,’ ‘do you really think this is the best way to get what you want?’. Imagine what effect these words have, what they do, how they are heard, how they feel. Surely, it does not take too much thought to realize the potential damage likely to stem from repeating—here in the form of judgement, specifically the judgement that ‘excessive emotions’ are not okay, that a person who has or for lengthy periods in the past may have given up entirely on any prospect that they would ever amount to anything and been told so repeatedly, is now again told that they cannot or do not work well with others, are not good collaborators, need to work on their communication skills, won’t be invited back, are too angry and can’t control their emotions in public, however it goes.
Not only do such judgments, publicly or privately voiced, have a damaging and potentially re-traumatizing effect on service users individually, they also harm the entire policy-making and research process. The fact that there are strong emotions tells us something critically important. The emotional reactions we experience in response to particular political topics and issues can give us—not just the individual who is upset, but us, collectively—tremendous insight into those issues. If a person becomes angry and hostile in response to a discussion on involuntary commitment, for example, it is likely that they are reacting to something wrong with the discussion. Most often, in our experience, this stems from the perception that power in the conversation is unequal, that all perspectives are not equally valued, or that there is de facto, however subtle, silencing of views stemming from personal experience and/or collective advocacy. In such scenarios, an individual’s anger and even perceived hostility should not only be tolerated but valued, seen as an opportunity for deeper engaging with issues that area and remain extremely challenging, for which there is no consensus.
If service users/survivors who display strong emotions in mental health research and policy discussions are excluded, we send a strong message that the only purpose of service user involvement is to claim that one or more service user or survivors was involved in the conversation. If we truly value their contributions, not merely tokenize them, this requires that we actually accord credit to the experience of having used services as experiential expertise, with the understanding that such experiences, ‘normally’ and expectably, are often tied to strong emotions. If we are to truly listen to the perspectives of those who have been historically excluded and marginalized, then we need to listen to their emotional reactions as well as their words.
And now let us come back to an alternative to judgement and exclusion: in this alternative space, we accept that calm, cool, and collected conversations are largely a fantasy when it comes to conversations unavoidably embedded in legacies of discrimination, stigma, and exclusion. We assume that diverse stakeholders will bring with them anger, defensiveness, distrust. And then, instead of concluding that they are unprofessional, unpredictable, and too hard to work with, we’ll instead:
- Validate. We acknowledge the strong feelings, that anger, that frustration and confusion, are valid, justified, to be expected. We don’t say this in a paternalistic or condescending way. We—whomever of us ends up on the ‘calm and collected’ side, that is, tries to imagine where the ‘other’ is coming from, what they have been through. We ask ‘if that had been me, how might I feel’; we remind ourselves ‘there but for the grace of God go I.’
- Commit. We do not use ‘expressed emotion’ as a justification to excuse, judge or marginalize. We don’t even consider it. We remind ourselves that for whatever single service user/survivor might have been immediately involved, there are thousands with the same concerns, the same anger, the same views. And these people deserve—we would even go so far as to say morally obligate us—to be taken seriously, as problems that need to be worked through, not circumvented.
- Value. We recognize that often, a person’s strong emotions actually provide deep insights into the relational dynamics at play in whatever conversation we’re involved in. We take a look at what kinds of perspectives might be missing from the conversation that this person’s strong feelings may represent. We prepare to take responsibility for any ways we might be invalidating or minimizing a person’s experiences, emotional ties to peers and colleagues in their identity group, and political commitments. We acknowledge that sometimes, the people who are most triggered by a particular conversation are the ones who in fact have the most to contribute to it.
- Work Through. We embrace complexity, difficult, challenge. We prepare to feel uncomfortable, we prepare to feel and experience our own emotions (as well as, and in reaction to, others’). And we are also forgiving—of ourselves, and of others. If a facilitator or mediator is needed—because of the magnitude of what we’re trying to work through—we get one.
No joint venture is ever guaranteed to work. In the larger scheme of things, however, the greatest collective failure is not failure of this or that particular venture but rather avoidance of the deeper issues that, individually circumvented, in fact prevent the deeper and more difficult collective work of ‘co-production’ and deep collaboration from ever actually taking place.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.