What Are Best Practices For Psychosis And What Gets In The Way?

Research investigates clinicians’ perspectives on best care practices and the complicated realities of providing care in the face of agency limitations and mechanized interventions.

Zenobia Morrill
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In a new paper, Dr. Nev Jones and a team of researchers investigate the experiences and challenges faced by front-line providers who work with individuals experiencing psychosis. In their examination of clinician perspectives on what constitutes best practices and what gets in the way, the researchers found that clinicians emphasize the importance of the therapeutic relationship and personalization of interventions in providing quality care. Several challenges, including systemic and structural barriers, make the provision of these practices difficult.

“Our goal was to lay some of the initial groundwork for intervention and/or policy changes needed to improve the overall experience of the typically multi-faceted and multicomponent services received by clients with psychosis served within the public mental health system and ultimately their impact,” Jones and colleagues write.

Photo Credit: Dave Emmett, “Psychosis” (Flickr)

While increasing emphasis has been placed on promoting specific, evidence-based interventions for psychosis, and minimizing barriers to treatment, critics of this “dissemination and implementation” movement have expressed concerns that these interventions are pre-packaged and ill-fitted to practical resources and community needs. Jones and colleagues write that the development of these protocols come out of academic settings with resources that aren’t commonly accessible within the broader community. Additionally, some express concern that access to psychotropic drugs has overshadowed efforts to provide access to therapy.

Jones and her team draw on previous research which found “that providers can harbor significant doubts about the applicability of findings from clinical trials to their clients as well as concerns about the potential misuse of research findings to narrowly dictate rather than inform clinical practice.”

The current study explores this disconnect between research and actual delivery of treatment in community settings. The researchers highlight “the perspectives of front-line community providers regarding best practices, clinical ideals, and barriers to quality improvement for clients with psychosis.”

The hope for this project is to improve the quality of services typically provided to adults with psychosis.  By centering the focus outside of academia to instead examine provider experiences within the public mental health system, this research uniquely addresses challenges involved in organizational capacity and critical policy and fiscal restraints.

In this study, there were two primary objectives: to examine providers’ (1) “values and ideal with respect to working with/serving clients experiencing psychosis,” and (2) “current state of services and perceived barriers to improving these services for clients with psychosis.”

Thirty-two clinicians were interviewed through focus groups in addition to two individual interviews (6 men, 28 women). These 34 participants ranged in levels of experience and expertise, and participatory methods were utilized throughout the research process. Jones also engaged in intensive ethnographic observation throughout the community health agency milieu, and this provided context that informs data collection and analysis.

The researchers organized their findings into three overarching categories:

  • Service and engagement values (or participants’ clinical ideals)
  • Detrimental macrolevel constraints on service quality (structural and political reasons why clinical ideals may go unrealized)
  • More proximal clinical challenges tied to the multifaceted, multicomponent

Service engagement values

Clinicians expressed the centrality of the therapeutic relationship as the foundation of quality services. Specific techniques were described as secondary and best used flexibly, with room to tailor and personalize approaches. For example, one participant stated:

“For me, in any clinical work that I do, I take it as an approach of ‘we’re in a relationship together.’ I am a human being in this, you’re a human being in this, together we create something that hopefully changes me, and it also changes you.”

Further, participants emphasized building this relationship by “engaging with the subjective meaning of psychosis” by exploring the client’s experiences of psychosis and perceived connections and convictions. Jones and colleagues write:

“Cutting across these discussions of meaning was a belief that psychotic symptoms must be taken seriously—that is, understood as experiences that should be explored and discussed on the client’s own terms.”

The current state of services—detrimental macrolevel constraints on service quality

The themes identified in this category demonstrated that clinicians’ attempts to provide treatment were challenged by “broader sociopolitical marginalization of serious mental illness, constraints imposed by billing and funding mechanisms, staff preparation, and the mechanization of behavioral health interventions.” These barriers were described as interconnected and synergistic. Staff preparation referred to the difficulty of recruited and retaining trained staff members to work in a marginalized center for less pay than other opportunities might offer.

In a discussion about manualized behavioral interventions, clinicians reflected on the following:

“Clin 1: ‘To be good at [working with voices/psychosis], a certain amount of [struggling together] is necessary.’

Clin 2: ‘It’s a more relational way of working.’

Clin 1: ‘Right.’ [Multiple participants sigh in agreement, shake their heads]

Clin 3: ‘Somewhere along the way that got taken out of the mental health field, and more behavioral approaches where the service user is seeing somebody that delivers an intervention [took over], but really—’

Clin 4: ‘Then you measure it.’ [Multiple members shake their heads, sigh]”

Proximal challenges and constraints

The participating clinicians discussed the extent to which they were aware that their client struggled regarding access to basic needs (housing, food, and transportation), and were often residents within disadvantaged neighborhoods. The challenge of providing therapeutic needs amid clients’ unaddressed basic needs was featured across participants’ stories.

In addition to balancing these needs, clinicians were also faced with the task of balancing their role in the client’s life and negotiating boundaries. Clinicians often found themselves assuming various roles while providing treatment through “clinical interventions, housing support, care coordination, daily living, and self-care with clients experiencing psychosis.” Working across these different interpersonal spheres was described as complicated, particularly within approaches centered around validating clients’ subjective experiences. One clinician shared the following:

“A guy who was a voice hearer, and one of his voices ended up being my voice, was saying things that I wasn’t saying or feeling. I, at the time, just took the approach of being like, ‘I didn’t say that. Here’s what is real about our relationship.’ I do not know, now I’m not sure if that was the best way to do it.”

Implications

Jones and the research team underscore how this work illustrates a need for research focused on strengthening agency and provider capacities to work within systems and the complicated realities of serving individuals with psychosis. This contrasts with exclusively providing specific, decontextualized interventions, such as, “cognitive-behavioral therapy for psychosis group or brief trauma-focused intervention.”

Overall, these findings demonstrate that “providers in the public mental health system typically interact with clients in multiple, multifaceted ways, struggle to meet overwhelming human needs (and degrees of socioeconomic disadvantage) and navigate complex moral and ethical challenges, all under the auspices of a heavily bureaucratized and underresourced service system.”

Rather than continuing the focus on implementation, Jones and team recommend shifting toward adaptation. This applies to both personalizing at the micro-level with the fortified client-therapist relationship, but at the macro-level within complicated agencies and structures.

 

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C Jones, N., Rosen, C., Helm, S., O’Neill, S., Davidson, L., & Shattell, M. (2018). Psychosis in public mental health: Provider perspectives on clinical relationships and barriers to the improvement of services. The American journal of Orthopsychiatry. (Link)

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32 COMMENTS

        • Fiachra,
          I’m curious what you think of someone who experiences delusions? I have worked with clients who seem to have a disconnection from reality (which is the basic definition of psychosis), and I have had no problems connecting to them based on their emotional state, like fear or anger. Using the term “psychosis” is no different than talking about depression or anxiety. To me it is simply a temporary emotional/sensory/cognitive experience (although many of those whom I work with would say it feels more permanent, like ongoing hopelessness or suicidal thoughts) People I work with who experience symptoms of psychosis aren’t permanently in this state, which is why I object to schizophrenia as a diagnosis, for instance. Also, we have no scientific way to measure these experiences.

      • “Why wouldn’t a therapist be able to work with someone who experiences voices or other hallucinations?”

        Because therapists are not trained to see people as anything than “other.”

        Healers who have been through their own dark night know that what you are calling “psychosis” is not a break from reality, which is based solely on mainstream thinking–and which I believe most of us in here reject wholly because it has already proven to be destructive by polarizing humanity and creating marginalized populations. That is not human nature, to my mind, but more of repeating generational abuse. We can unlearn this, should we choose to do so.

        What you call “psychosis” can also be perceived as expanding one’s own personal reality. It is a process occurring that has profound healing information within it, as well as precise guidance for an individual’s growth path. It is the breakdown of the old to make way for a new and more personally aligned reality to emerge. One has to understand personal symbols, highly creative processes, and grounding, to get this. And I don’t recall learning any of this in my training. This information came with the energy healing I did.

        That’s where integral mind/body/spirit and validating, creative healing happened for me, as opposed to simply feeling “othered,” as is all I got from any aspect of “mental health” services.

        • I would encourage you to read up on Internal Family Systems by Schwartz. This model posits that we are all multiple selves, comprises of various parts and a “core self”. A person’s maladaptive states (e.g., self harm) are consequences of the loss of harmony in, and polarization of the internal self-system (such as when early childhood trauma occurs). Anyway, there’s a lot more but the point is that this view of the world isn’t pathologizing or “othering”. While therapy doesn’t work for some people, it surely helps others. I think for the people on this site unfortunately they’ve experienced the worse the system has to offer. There are many great therapists out there.

          • One of the people who helped me the most in bringing balance back to my life was a young man just starting out as a therapist. He was one of the most compassionate and empathetic people I’ve ever dealt with in my entire life. He allowed and encourage me to do my own work at the pace I was comfortable doing it. I was lucky to be matched with him when I went to the community mental health center for help. The screener who matched us together knew exactly what she was doing.

            I agree that there are a number of good therapists. However, I don’t find any of them to be working in institutions like the state “hospital” where I work. They all seem to be out in private practice and not involved with the “mental health system”. After he finished up his internship the young therapist I mentioned above got out of the mental health center and went into private practice on his own. He said that he wouldn’t have been able to work any longer for the center and still feel like he was ethical and truly helping people.

            The best therapist working where I do doesn’t work as a therapist but is employed doing paperwork, which is a grand waste of her talents. Very little true therapy goes on where I work because if therapy was truly going on people would find their voices and would begin speaking out about what they needed and about what they were not getting in terms of “good treatment”.

          • Stephen, I agree that the bulk of quality therapists go into private practice. The worst ones are in state hospitals from what I can tell. Hospitals can be pretty dehumanizing, and rarely do people feel better after experienced “the treatment.”

            I do expect to be in private practice in the next year or so, because like so many others, I have ethical concerns about how the system operates. I know for certain that we don’t need to diagnose in order to help (aka, listen and validate emotional pain). I also know that having a caseload of 80 clients is insane and doesn’t allow for clients to be seen nearly as frequently as ideal so they can move on with life sooner. In my view nearly all treatments should be short-term, but unfortunately people do get stuck in the current model being told they need lifelong treatment, like someone with diabetes (I tell my clients to think of treatment as short-term and that they don’t have a discernible illness like a bone fracture or cancer).

        • Alex, I’ll also mention that I notice quite a bit of over-generalizations made here on MIA when it comes to psychotherapy. There are so many different types of therapists with varied modalities. To say that ” (all) therapists are trained…” is simply ignoring the fact that all therapists are trained differently. There are therapy programs which focus on somatic work, career guidance, Gestalt, etc. Also, most therapists I know don’t take insurance and thus don’t diagnose. I think the majority of therapists whom people are talking about on MIA as unhelpful or abusive are those who work under psychiatrists in the medical model. Therapists in general aren’t trained with a heavy medical focus. In fact, for most of us there is only one “abnormal psychology” class we take in undergraduate or graduate school. We don’t see our clients as inherently ill or disordered but rather resilient and creative.

          • I agree, it is easy to make generalizations about therapists. There is a huge range of therapists out there with different philosophies and priorities. It is unfortunate that more and more new therapists are being trained in the DSM terminology and that insurance companies are expecting DSM diagnoses for payment. Which means that only people with enough money to afford private pay can have the range of choices that are available. But it is certainly not right to generalize about therapists as a group – they are really quite diverse, especially once you get outside of a public “mental health” agency setting.

          • Steve, yes, the emphasis on the DSM needs to change. Unfortunately, the whole damn system is centered around the DSM, which everyone here on MIA knows is a very flawed manual

          • I have no problem owning that I am generalizing, and it is based on my very extensive and thorough experience in the field for over 3 decades, wearing a variety of hats along the way, often concurrently. I’m not saying all therapists are abusive, I’ve had a couple of really nice ones, and competent in addition to being humane and sensitive.

            Still, after my education, training, and years and years of front lines experience in all of these systems related to “mental health/illness/disability,” I find the core paradigm to be inherently abusive (without even trying) to certain populations and/or people with culturally challenging ways of being (not talking about issues regarding violence toward others, that is an entirely different matter).

            I have yet to see evidence to the contrary, even in dialogues on MIA. I’ve seen it overt and subtle on here. I’ve called it out, and the results have been mixed, but consistent with my experience up and down the “mental health” industrial complex.

            I have been through this on the therapist side of things, on the client side of things, on the social worker side of things, on the professional advocacy side of things, and on the activist side of things. I have lived with diagnoses and a head full of neurotoxins and I have released all of that and have moved on with my life completely and fully. That was a dramatic and revealing process of awakening and radical life change.

            So that’s fine to say that this is my experience because it is. Thing is, my experience has been vast in this particular arena, and I’ll repeat, I’ve yet to experience anything different from anyone in the field. I believe there is a lot of programming that takes place in training. I rejected it, and I paid for that. That’s yet another problem in the field, its extreme myopia. Indeed, it’s my personal opinion, based on my personal experience. What else is reality?

            I’ve also had a witness for 33 years in my partner, who eventually went to work for social services and totally got what I’d been talking about for all these years. Made his jaw drop, repeatedly. We both share the same opinion here, based on our personal experiences together in all of this.

            Would you instead prefer to pay some researcher to hear a different truth because you don’t like mine?

            Back to main point, however: What you call “psychosis” is an indicator of core change and consciousness expansion happening. A good guide can take this person through an amazing life-changing transformation. If a guide happens to be a “psychotherapist,” so be it. I’d like to meet him or her, because then, I’d know a psychotherapist who actually IS qualified to deal with what you are calling “psychosis.” But if you are calling it that, then the likelihood that you could guide this person to transformation is not very high. I believe this stands to reason, considering how people react to the word “psychosis,” and all that is inherently attached to it.

            It’s really a process of change, and people do fear change, the way they fear “psychosis.”

          • Alex,
            We don’t live in a world which embraces different experiences like “psychosis”. We are too often pushed in a direction of conformity.

            Most of the people I see who fit this experience of psychosis are folks who are hearing derogatory voices, fear that the government is harassing them, thinking their house is bugged, and so forth. These folks are disturbed by their experiences and it’s been difficult for them or myself to see how it is “transformative” in any sense. Unless you consider terror transformative.

            I’m glad to hear that you admit you are generalizing. I get that your experiences fit a certain perspective, but it doesn’t mean that the field on the whole fits your experience. I have also experienced some of what you have as a client and a therapist, and I can say my experiences have been mixed. In general I find that independent practitioners are more likely to treat their clients without having to pathologize their experiences.

            I will also note that my agency, the largest in my state, has spent at least $100,000 to train and supervise clinicians on EMDR. This treatment is specifically designed to end treatment as soon as possible. The EMDR model is nonpathologizing. This goes against what people on MIA generally think of community MH settings. We are aiming to end care sooner rather than later, because we recognize that when people stay in the system forever, they often don’t improve and sometimes get worse. EMDR therapists work with doctors to ensure that medication dosing is lowered and tritration occurs as EMDR begins to show signs of improving client well being and symptom profile. The end goal is the get the client off any psychotropics. MIA should celebrate such models and see this as true progress. However, I’ve yet to see an EMDR related article on this site. I’ve searched for one in the archives and can’t find anything. This doesn’t surprise me, since the bent on MIA is against most mainstream treatments. That is unfortunate because it does provide real relief to folks who suffer from various forms of trauma.

          • “We don’t live in a world which embraces different experiences like “psychosis”. We are too often pushed in a direction of conformity.”

            So? Doesn’t mean we can’t muster the courage to be different. Change certainly won’t occur from conforming. What is activism, if not going against social oppression? Which is what “pushed in the direction of conformity” is, spot on. How about we *not* conform, and see what happens. Keep trying. The strongest willed will pave the way and break ground, making it easier for others.

            “Most of the people I see who fit this experience of psychosis are folks who are hearing derogatory voices, fear that the government is harassing them, thinking their house is bugged, and so forth. These folks are disturbed by their experiences and it’s been difficult for them or myself to see how it is “transformative” in any sense. Unless you consider terror transformative.”

            I went through this exactly, verbatim. And I know exactly what it was, it was the moment I began to withdraw from neurotoxins. I got over it eventually, with good healing.

            But not before I was TERRORIZED by some very cruel therapists–from PsyDocs to Psychiatrists to LCSWs to MFTs, you name it, and I’m not joking about that. I had to heal from that, too, which was way more complex, tricky, and intricate than healing from drugs toxicity.

            Healing from social abuse is very hard, but it’s doable. However, not while being in an environment which casts such negative projections, as a rule, thinking it’s neutral. It’s not neutral, it’s demeaning in the most dispiriting ways. That’s what I’m saying.

            Indeed I consider terror transformative. Our most challenging emotions ARE transformative, that’s exactly the point. It is all part of the human experience. Not all have the courage, fortitude, or corporeal equipment to carry this in their bodies. Thank God for those that do. That would be a hero’s journey, and it’s also awakening. But people need to guidance to get to the other side.

            Honestly, I don’t feel in synch with MIA, we do not have the same objectives or perspective. To me, this only echoes the paradigm of the system, regardless of how it challenges it in other ways. Still, I appreciate that diverse voices can interact here.

            Please do not generalize me, personally, to the group, because that would, indeed, be a misrepresentation of who I am. I am neither enmeshed nor dependent on this group. I most definitely march to the beat of my own drummer, and it works for me. I’d hope to encourage others to do the same, to be true to themselves, and FUCK CONFORMITY.

          • “I’m glad to hear that you admit you are generalizing. I get that your experiences fit a certain perspective, but it doesn’t mean that the field on the whole fits your experience.”

            No kidding. And yet, have you read the thousands upon thousands of testimonials which talk about how therapy screwed them up and how so-called “mental health” services failed them unequivocally? How it robbed them of money, family, quality of life? It’s online all over the place, starting here on MIA.

            Do you think it’s just the drugs? Or just the DSM? There are actually people behind all of this.

            Whoever is not an abuser in a dysfunctional system is an enabler. A professional field with this much controversy and resistance and suicide in the midst of it is seriously suspect. In my 57 years on this planet, I’ve never seen such a friggin’ mess like this field is. You can defend it all you like, but it will not change the reality that this “mental health” industry has failed. How can it bring health & well-being to people when the field itself is so incredibly unhealthy? That follows no logic, and I believe it is a given by now. I’m certainly not the only person in this world who feels the mh system is toxic waste.

            The sooner one faces reality, the easier and more fluidly change will occur.

          • Alex,
            Not surprisingly you didn’t respond to my points about EMDR. I think that is because EMDR contradicts your general perspective of the MH system as being abusive. EMDR is non-pathologizing and quite compassionate. I do wonder why nobody on MIA has posted a blog about it? Strange, don’t you think?

            You are fine to think of me as an “enabler”. You aren’t in the room with me and my clients, nor do I think you have ever visited my MH center (in Colorado), so continue to generalize the entire system without having any direct experience with what I am doing NOW.

            I understand that plenty of people feel harmed by the system and that the system has failed them. I also understand that the folks on MIA are only one segment of people who have been in the system. There are tens of thousands of people who also feel helped by the system, so how do you reconcile this?

            I don’t believe the MH system has entirely failed everyone. I think that we live in a toxic world of capitalism which views everyone as expendable. The problem is much larger than any one system. SSA, Congress, Housing Authorities, Big Business, Legal system, and so forth are all contributors to human suffering.

            The reality is that many clients come in to see me because of early childhood events in their lives. They also come in because of other unmet needs, like housing or income. They do not feel it is the MH system which is the main culprit in their lives. MIA posters have had particularly bad experiences in the MH system, but it’s distorted to think that their experiences reflect everyone’s experience in the system.

          • Shaun, I have to be honest here. My wish is not to fight and argue. I do not want to go point by point because this is not how I desire to dialogue. To my mind, it does not serve other than to agitate and create even more static in the communication. There is a lot of energy here to wade through, and I try to just cut to the chase.

            I did not respond to EMDR in the above post because I already said in a previous dialogue not too long ago that I’ve heard good things about EMDR and I would never argue for whatever works for a person. Even someone on the psych drugs who feels helped by them I would not argue with, nor would I put my story in their face.

            I would instead respect their decision they make for themselves and were they to ever want to hear about my experience because they are starting to question things, I’d gladly offer it. EMDR is fine with me, but I certainly don’t think it’s the be all end all in any respect, if there even is such a thing which I doubt. Still, it’s a good tool for some.

            At this point, given that you work with people in what you feel is a healing capacity, I’d only be interested in dialoguing about what best helps people in their quest for relief from chronic suffering and a feeling of justice in the world. Arguing like this will never accomplish this, and will only create more of the same. For many, it only recreates trauma, and that’s something I know well enough about to not feed, at least not consciously.

            I’ve been where you are, in that same mindset. What I went through changed my beliefs because I took the journey, filled with all sorts of archetypes and “hallucinations” (as you would put it), and also what you would call “psychosis,” and it was profound and I was not silent in this. It lasted for a few years and I never recoiled from society, although I felt as though I was walking around in a glass booth, visibly sweating from anxiety all the time–literally, day and night. I was detoxing profusely, and it was obvious. Yet totally benign to others. I was always respectful of boundaries, what you would call “meek,” during this time. I walked around terrified, to use your word. But determined to heal and get back my self-respect.

            I was withdrawn in a way, and reaching out in another way, with my heart. The results were more than fascinating and telling, how people responded to differences, even to someone who was obviously suffering, and trying desperately to heal.

            I’d go nuts trying to get this across to you, were I to be sitting in your office. I’d feel so terribly invalidated and invisible, and ultimately drained. Same results as with the others.

            Fortunately, I can turn off my computer and get back to my physical reality, which I enjoy a great deal these days. Engaging in these same issues at a conflict level only takes me back to all that crap I’m trying to leave behind.

            From your responses to me and in other dialogues I’ve read, I’d say you are not sensitive to those of us who were wounded and harmed by the system. You are not hearing our hearts. Fortunately, we’re not depending on that, but I think that’s why you are experiencing the friction as you are. This is what happens when a therapist is not hearing a person’s heart, but instead, is reinterpreting the information in a way that is putting you on the defensive, rather than seeking truth. Can’t do both at the same time.

            This is how being an activist is a conundrum for me. I believe this is important, but I also believe it may compromise our health and well-being to be constantly arguing, when people really are suffering daily. I don’t see how this is helping one bit.

            This is what I call “therapy brain.” It overworks us to the point of draining our energies, and it can trigger things like trauma and psychosis. It’s exactly why I’m not a fan.

            Just trying to make my point as clearly as I can. Again, it’s really nothing personal, but this dialogue is a perfect example of what I’m talking about. At least for me, it makes my point.

          • Thanks for the response, Alex. The truth is that the internet will always be a place of conflict and disagreement. I prefer face-to-face interaction much more because it fosters more understanding and appreciation for context. There will always be differences of opinion about what is best and what needs to change in society. The world is not black-and-white, and because of this it causes us all some level of anxiety in terms of understanding and acceptance of it’s complexities. You are right that arguing on the internet rarely solves anything, and too often subjects ourselves to more anxiety and upset.

            To be frank, Alex, I don’t think posting on MIA is going to change much. I think the best way for all of us to change the system is by advocating for change at the levels of power that can actually make a systemic difference. We do need to reeducate the world when it comes to “mental illness”, as clearly people have been told lies. Unfortunately, MIA isn’t in the mainstream, and so very few people even hear the messages about real concern for the status quo. I don’t know what the answer is, other than focusing on ourselves and our choices and advocating for systemic change (beyond posting on an internet forum). I, for instance, can stop working in a system which I think is very flawed. That won’t change how the system works, but I will at least know that I am following my own ethics. Be well.

          • “I don’t think posting on MIA is going to change much.”

            Yes, I agree. For me, it’s been another leg in my journey of truth-seeking. Interacting on here around these issues with such a diversely thinking and cross-cultural group has been of great value to me, personally. In that sense, it has led to some change because it influences my work and my humanity. My communication has shifted on many levels thanks to these dialogues.

            But you’re right, it is limited for a variety of different reasons, mostly because of what I said regarding the same old paradigm. I really do think that “be the change” is the way to go. I believe that this is energetically sound, and truth to the core.

            “I think the best way for all of us to change the system is by advocating for change at the levels of power that can actually make a systemic difference.”

            Not sure this is “the best way,” and I believe you are leaving out a lot of people and denying them their power. We all have the power to make change on some level, and again, I think that’s elementary. What you are saying is that people should give their power to those already in power. Noooooo friggin’ way is that sound, and it totally supports and feeds power imbalance. Isn’t that obvious to you?

            There are many aspects to change, each one having its own value. That’s important to keep in mind, considering that we’re talking about inclusion vs. exclusion, and the psychosocial effects thereof.

            “We do need to reeducate the world when it comes to “mental illness”, as clearly people have been told lies.”

            Yeah, we do the best we can here, but we also have diverse interpretations and perspectives of what this is, like nothing else before which has been vehemently disagreed upon. Furthermore, around here and in the system, people seem to favor the explanations of those who have not experienced it, as opposed to those of us with first hand experience of this phenomena. Makes no sense to me at all, and basically creates a false reality filled with delusionary thinking. When I say toxic, I mean toxic.

            People have their own truth to live and journeys to take. We all awaken at different levels, life leads us there one way or another, by hook or by crook. There are as many paths to awakening to truth as there are people on the planet. Each one is unique. We make it easier on ourselves when we accept inevitable change, and furthermore, embrace it.

            Why not at least agree that we’re all unique, and no more projections onto that? Then, perhaps, we can start appreciating differences rather than being intimidated by them, and therefore scapegoating them.

            Of course, we have to be ok with ourselves, first, or we will inevitably resort to projecting, othering, stigmatizing, marginalizing, etc. It’s not human nature to do so, but it would be the nature of a sick society. Let’s not get too well adjusted to that, you know what they say about being well-adjusted to a sick society…

            Be well, too, Shaun. Always an adventure exploring the energy with you. I appreciate your authenticity and courage.

  3. I’m glad that the challenges that counselors deal with such as their clients poverty and homelessness, came up as well as the issue of ethnicity, these are important issues. But I’m disappointed that this issue wasn’t raised: psychiatric abuse. What about the difficulty of working with people whose trust in the mental health system was destroyed due to forced psychiatric interventions? My daughter endured nearly eight frickin years of back to back involuntary treatment orders and being told where she could live and what treatment she had to accept at threat of going back to the hospital. She is basically institutionalized and programmed to fear mental health professionals She is also well versed into how to ‘hide symptoms’ or act ‘normal’ and otherwise hide the frightening chaos that often consumes her internal world. She knows better than anyone that you don’t disclose information to your counselor that could put you at risk of increased drugging.

    How are counselors going to establish honesty and trust in the current environment? Community mental health agencies should not ask their underpaid counselors and social workers to go into the trenches and deal with the ramifications caused by the other people they may never meet. Clients need a safe place to process the grief and trauma of having their liberties taken away, maybe even scream a bit. They need justice and the recognition of harm and for someone in the system to stand up and APOLOGIZE

    • @madmom: You make a good point about trusting therapists, social workers and other non psychiatric MH people. In the UK’s NHS they all report to the consultant – the psychiatrist. There is no contract of confidentiality, so you can assume everything you say goes to the psychiatrist , either in writing or team meetings.

      You cannot be open with your therapist because it can lead to involuntary hospitalisation or just very heavy duty persuasion to take ever more drugs.

      I think of psychologists as the listening arm of the psychiatrist.

      As a therapist relationship, that is unethical and there should be a contract of confidentiality or other Chinese wall.

      The upshot is that you don’t open up to the therapist, you play the game, and you will even say thank you the meds are great because you don’t want more shoved at you.

      Reluctantly I think psychology is best paid for privately with someone you can trust and won’t shop you to the psychiatrist.

    • I’ve dealt with only two community mental health centers. The first one was absolutely excellent and seemed to truly care about helping people resolve their issues and move on with their lives.

      The second center is one of the most abusive collections of people I’ve ever dealt with. This place works to keep from helping people and puts all kinds of roadblocks in the way of providing people with what they need to find recovery for themselves. They lie to people when you seek help. All they want to do is hand out the drugs. I had to call someone in the highest level of state government to intercede with this center to force them to provide talk therapy for me. I was lucky that I knew someone who knew the number of the person I needed to call. Many people seeking help from this clinic do not have access to these kinds of things and so can’t demand better treatment for themselves. The financial officer of the center who interviewed me to see if I could qualify for a scholarship to pay for the therapy quietly told me at the end of our session that the center would do all kinds of things to dissuade me from pursuing my quest for help and that I had to be ready for it and to fight them tooth and nail. It’s got to be pretty damned bad when an employee of the center warns people to be ready for terrible behavior on the part of staff in the center. And in the end, the person that they eventually found for me to see for therapy was a student. This sounds arrogant to say, but I knew more about therapy than she did and helped her understand how to go about dealing with people in a helpful manner. That was kind of weird in that I was the one helping her and I was the one seeking help. What’s wrong with that picture?

  4. I guess what I’m asking for is for social workers and counselors and psychologists to adopt to the reality represented by tens of thousands of psychiatric survivors who are out of the closet and who identify with having been harmed and silenced by mental health care professionals and ‘experts.’ Why not immediately improve the mental health system experience from the perspective of clients by adding the following question – or one like it – to your current intake interviews: “Do you identify with having been harmed by psychiatric treatment either forced or voluntary?”

    • Unfortunatley it’s not going to happen because it is all held in place by massive drug fraud and it has corrupted everything around it – there is too much money in it.

      There are things people can do though. A business even if it is fraud can’t thrive without business. Many of the people going to their ‘doctors’ don’t really need to go. Now we have the internet we can inform people of the dangers and show them the hypocrisy.

    • I agree 100%. My first question to anyone I’d see now in a therapeutic setting would be, “What other ‘treatment’ have you received before? And how did you feel about it?” Same question re: diagnoses. It’s essential at this point, because so many have been harmed by their “treatment.”

  5. @streetphoto: I think we agree. What I’ve seen in the uk is that a private psychologist is great, he works for you and he is the guy you can trust your life with, well hopefully.

    The state NHS “clinical psychologists” work for the psychiatrist, and provide ammunition to drug you or incarcerate you. They are not on your side. That’s why I say , the basic problem is the psychiatrist, who is just a drug pusher but has a whole gang of people working for him. He is the roadblock to enlightenment.

  6. “Overall, these findings demonstrate that “providers in the public mental health system typically interact with clients in multiple, multifaceted ways, struggle to meet overwhelming human needs (and degrees of socioeconomic disadvantage) and navigate complex moral and ethical challenges, all under the auspices of a heavily bureaucratized and underresourced service system.”’

    This sums up the challenges quite well. A large number of clients who are seen by community mental health agencies are significantly under-resourced and thus have many unmet basic human needs which they are attempting to get met through multiple bureaucratic government and nonprofit systems.

    • And most of the community mental health centers have no real desire to actually help these under-resourced people find what they need to live decent lives. At least this was my experience with the mental health clinic in the city where I live. They are absolutely useless to people other than to hand out the drugs and to make sure that people are taking the drugs. They have no counselors or therapists who work with people. There is one social worker that you can see for fifteen minutes every three months!

      • Oh yeah, the psychiatrists are very quick to go down to the mental health court and swear out a petition on anyone who they think is not being compliant with the drugs or who might be doing something that the psychiatrists don’t agree with. They’re really good about doing this for their so-called “clients”.

      • I think it’s unfair to say “most of the community MH centers have not real desire to actually help…” Sounds like this is your experience with ONE MH center, so again it’s unfair to generalize to ALL centers. My MH center works with people to find jobs, apply for SSA benefits if they want to, go back to school, attain permanent housing, attain basic needs like clothing, furniture, and food, and so forth. Clients choose here if they see a doctor. They choose if they take pills or not. I think everyone should have these choices so they can decide what is right for them. Also, the MH center you describe is more of a pill factory, sounds like how PCPs operate, not how MH centers run in my state. In my state every MH center has more therapists and social workers than prescribers. Also, in my state psychiatrists are too busy to deal with MH courts. There are very few people who are actually court ordered for treatment here. Most short-term certs are dropped after folks leave the hospital after a week. Twenty years ago the landscape looked a lot different. I know of clients who spent years hospitalized for things like basic depression, because unfortunately insurance companies willingly paid for such “treatment”. This to me is unjustifiable and unethical treatment.