Anthropologists Contemplate the Future Role of Psychiatry

Sandra Steingard, MD
19
2239

Anthropologists who study the psychiatric field recently had papers published in two highly influential journals. The New England Journal of Medicine featured a commentary by Gardner and Kleinman, “Medicine and the Mind — The Consequences of Psychiatry’s Identity Crisis” while “Merging Intensive Peer Support and Dialogic Practice: Implementation Lessons From Parachute NYC” by Hopper and colleagues was in Psychiatric Services. Arthur Kleinman and Kim Hopper are leaders in their field. For this reason alone, these papers are worthy of review. While they both call for or describe reform initiatives, they point us in different directions with regard to the future role of psychiatrists.

Gardner and Kleinman posit that psychiatry is a field in crisis. They point out the limitations of our knowledge base, noting that “psychiatric diagnoses and medications proliferate under the banner of scientific medicine, though there is no comprehensive biologic understanding of either the causes or the treatments of psychiatric disorders.” They refer to historian Anne Harrington’s suggestion that one response would be for psychiatry to constrict its purview to those most severely impaired. Gardner and Kleinman reject that, calling for a new generation “of geriatric, addiction, and social psychiatry.” I am sympathetic to their call for strengthening resources for providing psychotherapy. But they seemed to equate psychotherapy with psychodynamic approaches with no acknowledgement that the failures of the psychoanalysts may have contributed to the overwhelming hegemony of the so-called “biological” psychiatrists. I share their wish that research funding be allocated to fields other than basic biologic research. However, I was surprised that scholars of such breadth support — or at least appear to support — buttressing psychiatry’s hold as leaders in research and program development. I need some convincing that the problems we agree exist will be best addressed within my profession. In recent years, I have been most impressed by approaches to mental distress that emanate from outside of psychiatry.

The paper by Hopper and colleagues describes one such initiative, the Parachute NYC project. Funded by a federal innovation grant from the Centers for Medicare and Medicaid Services (CMS), this was an implementation of need-adapted treatment (NAT) in New York City. Adapted from a Swedish program of the same name, the aim was to train teams who would be able to go to individual’s homes early in a first experience of psychosis and work with them and their families to help them through the crisis. Peer respite services were also developed. Professionals and peers were trained together in both need-adapted treatment (Open Dialogue evolved from NAT) and Intentional Peer Support. An extensive summary can be found in this “White Paper.”

Hopper and colleagues were embedded in this project and their perspective is shared in the white paper as well as in another elegant article by Cubellis, a co-author of this paper and a member of their team. (For more on this style of anthropology from this same group —  kind of an anthropology of anthropologists — see this paper).

Oddly, while the Gardner and Kleinman paper is explicitly critical of psychiatry (and was met by much consternation in some of the circles I frequent), it seemed to conclude with the kind of triumphalist note I have heard again and again over the years. In essence, they suggest that with a shift in resources, psychiatry might finally get it right.

The Hopper paper, on the other hand, is describing a program that embraces a profound shift in how we think about the problems of those who seek our help; NAT differs from other approaches in that it is fundamentally not a medical enterprise. Intentional Peer Support is, by definition, non-medical and explicitly eschews the medical frame. Physicians can be included in an NAT team but ideally in the restricted way that is more aligned with Harrington’s proposal. Medical knowledge can be offered but is not specifically privileged.  IPS offers the notion that there are multiple worldviews and each one is respected. NAT and Open Dialogue introduce the notion of polyphony — multiple perspectives are not only tolerated but valued. Critically, peers worked alongside professionals, at least aspirationally, as equal partners on the teams. As Hopper puts it, “The fancy term for what Parachute attempted is ‘counterhegemonic,’ which describes an innovation that not only challenges professional and institutional interests but also seems to diverge from common clinical sense.”

Despite heralding a radical shift for which some of us yearn, Hopper’s paper is decidedly somber. Although I suspect Hopper and colleagues support the initiatives embedded in Parachute NYC, they ironically share the sentiment of Mueser who wrote a commentary for Psychiatric Services earlier this year on the future of Open Dialogue initiatives. Mueser doubted that there are resources available to implement this way of working; he did not think the available evidence base on Open Dialogue was strong enough to warrant further research support. Hopper wonders if Mueser was right but for the wrong reasons: “It may be that organizations that signed on to the Parachute project may not have fully understood how radical it was. In the end, this may have contributed to its difficulty in sustaining itself when the grant ended.”

There are groups who continue to try to implement aspects of NAT and I work among them. Many of us find that this offers a profoundly humane way of working. For me, the humility and transparency of this way of working has become the only antidote to the problems raised by Gardner and Kleinman. It is entirely in keeping with Harrington’s suggestion that psychiatry constrict its purview; I am a member of a team but not the leader. My colleague who shares her own experience of psychosis is often more helpful to the person at the center of concern than I am.

But there is a conundrum. Will the system support such “counter-hegemonic practice”? If we do not garner adequate support, will we be doomed to failure? Hopper raises this concern in his conclusion: “to settle for partial and fragmentary adaptations may be to so rig the chances of success as to all but ensure further evidence of its elusiveness.”

Open Dialogue teaches one to tolerate uncertainty. It is helpful training for those of us who find we have no choice but to continue to bring this way of working into our clinics despite the challenges we face.

19 COMMENTS

  1. ‘The Hopper paper, on the other hand, is describing a program that embraces a profound shift in how we think about the problems of those who seek our help; ”

    That stings to someone who was ‘spiked’ with benzos and had a knife planted on them for police to be able to create an acute stress reaction to have them talk and be ‘verballed’ up (I assume you understand the ‘hard torture’ nature of what was done here), kidnapped and then subjected to 7 hours of interrogation. Still I guess the people who were seeking help are not to be held to account for their criminal conduct, despite the fact they have destroyed a persons life in the process. I suppose at some point I will have to accept the reasoning that I was asking for it. The short skirt, the ‘come get me’ eyes……..hey I know how we can obtain consent, spike em with benzos and have thugs hold them down while we do it. At what point did these people loose their minds and think they were able to act like rapists and claim good faith?
    .
    Not all are ‘seeking’ this supposed help Dr Stiengard.

    • I agree, boans, some of us weren’t seeking help. Like for example, when I was illegally dragged out of the comfort of my own bed in the middle of the night by five paramedics. While the sixth paramedic told the other five that what they were doing was illegal, since I was neither a danger to myself, nor anyone else. Merely, because I had a sleep walking/talking issue, once ever in my life. I was medically unnecessarily shipped a long distance to this now FBI convicted, former ELCA Lutheran hospital employed, criminal doctor.

      https://www.justice.gov/usao-ndil/pr/oak-brook-doctor-convicted-kickback-scheme-sacred-heart-hospital
      https://chicagoist.com/2013/04/16/chicago_hospital_owner_doctors_arre.php

      Or when I was minding my own business, lying in a public park, watching the clouds float by. While also trying to mentally come to grips with the staggering medical/religious betrayal with which I’d previously dealt. And the fact that I’d found the medical proof that the antidepressants and antipsychotics can create psychosis, via anticholinergic toxidrome. When a policeman came up to me and forced me to go to a hospital, for lying in a public park, minding my own business, trying to enjoy a beautiful September morn.

      Based upon a “medically clear” diagnosis at that hospital, I was once again, medically unnecessarily, shipped in the middle of the night to Kuchipudi’s psychiatric “snowing” partner in crime. Because a doctor at that hospital broke the HIPPA laws, and because that criminal psychiatrist had been incorrectly listing me as her “out patient” at a hospital I’d never been to before, I later learned from an insurance company.

      Or when a psychologist/artist wanted to give me an artist of the year award, then handed me an “art manager” contract. Which was actually an I want to steal all profits from your artwork, all your work, take control of your story, and eventually steal all your family’s money contract. Get away from me, attempted thief.

      No, I was not asking for help any of these times. The “mental health” workers are “omnipotent moral busy bodies” who need to learn to live and let live, and get out of the child abuse covering up business, instead.

      https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo

      https://www.madinamerica.com/2016/04/heal-for-life/

      You can’t speak out against child abuse in America today, without the Lutheran psychologists and psychiatrists incessantly attempting to murder you, or steal everything from you. Oh, but it’s just fine that Spirit cooking and pedophilia art is all the rage with the powers that shouldn’t be.

      http://ibankcoin.com/zeropointnow/2016/11/26/sick-lets-revisit-the-podesta-penchant-for-pedophilic-cannibalistic-and-satanic-art/#sthash.ARFkUJl8.dpbs

      https://www.amazon.com/Pedophilia-Empire-Chapter-Introduction-Disorder-ebook/dp/B0773QHGPT

      Upside down and backwards, America.

      • You know someone else I often wonder about the role the abuse my wife was subjected to played in her being able to use the Mental Health System to fuking destroy me.
        The Community Nurse would have seen her milk crate full of ‘medications’ but might have assumed they were mine. She did explain to me how over a number of years she had abused a young woman from a school she worked at for ‘troubled’ young girls. Having her detained against her will on many occasions. She was well practiced at using this system to get her point of view across. The “you just have to know what to tell them” comment. The drink spiking with her benzodiazepines, not a drug I would touch willingly. And then the rather bizarre relationship with her family.
        Like I said to Dr Steingard, maybe I just have to accept that these people are receiving support and I was asking for it. Imagine living in a world were your so delusional you think you can trust others in your community? Nah,, this is about getting the knife into their backs before they do it to you.
        Pink Floyd said it best “you have to be trusted, by the people that you lie to. So that when they turn their backs on you, you’ll get the chance to put the knife in”. I wonder if that might be the knife that the Community Nurse is having planted on his “patients” before he leaves the hospital to torture and kidnap another citizen.
        Rogue elements I hear them cry, bad apples. No, they did an investigation and what they found must have made them sick to the stomach, because they have continued to cover the truth with falsehoods.
        I feel sure that they honestly believe its just a matter of forcing it into them until they realise how good it is for them.

        Oh Voltaire, oh vanity, oh imbecility eh?

        My offer has been that if they will allow me access to a lawyer I will have my share of the property returned and leave this vile place. I get it that the paranoids are concerned about the wholesale theft of public monies and are using the Mental Health system and police to ensure compliance with a totalitarian model. Its a Police State. Fine i’ll leave y’all to it and wish you luck even, but count me out when it comes to convenience killings in Emergency Departments because you complain about some corrupt public servant who is torturing “mental patients” and receiving the support of his colleagues at some run down dump of a hospital.
        Still, better to reward my wife for her silence with my property than have to use the resources of the state to pay her off. And the disgraceful lawyer who was prepared to take money off a ‘nutjob’ but runs away when it turns out the nutjob has the proof. What sort of people are these?
        A corrupt Community Nurse who lies and tells police he needs assistance with his “patients” and then uses them to kidnap citizens, then lies to his colleagues and tells then he has obtained a police referral, for pats on the head from a psychiatrist? Like some sort of Oliver Twist tale where citizens are being delivered to Ariel Castro for treats lol. It’d be funny if it weren’t true.

      • Many of us who sought help got the exact opposite.

        Gaslighting is the word. 🙁

        “Just like insulin for diabetes.” “Antidepressants wouldn’t drive you psychotic if you weren’t already born defective.” “You’re just imagining or faking those seizures since Haldol never has that effect on anyone.”

        Lie on top of lie.

        • I thank Sandra to this day for pointing out to me how broad the interpretation of the term “emergency” can be in an environment where you wish to over ride a persons human and civil rights. You don’t want to take drugs willingly? That constitutes and emergency and we need to have 15 thugs pin you down and force this down your throat. You lack insight and “i’m the boss around here” lol
          But this also applies to the term “help”, i mean technically this guy, a psychiatrist was helping some people

          https://en.m.wikipedia.org/wiki/Radovan_Karadžić

          Well, until they decided that it might not constitute help, and may even be war crimes but …. definitional issues. Ain’t war Hell?
          Seems he is suffering from a dissociative disorder these days, ie his colleagues have dissociated themselves from him. Still, tall poppy syndrome.
          Our newspapers told to not call it a Euthanasia Bill (too many negative associations with the National Socialists in Germany they tell me), it’s “Voluntary Assisted Dying” . Anyone here want to talk about the “voluntary” nature of treatment when it comes to mental health? Not a mental health issue wanting to die? Luckily the guy who is ignoring the protections of the Mental Health Act tells us he will observe the protections in his Euthanaisa Bill. And our Treasurer bemoaning the cost of care for the elderly and mentally ill. Saw a poster they could use in government offices, it just needs translating from German.

          • Says Doc Karadzic went from psychiatry to New Age “quantum medicine.” LOL

            Funny how shrinks so often turn to demagoguery too. Psychiatry is more about politics than medicine.

            Read 1984. In the part where O’Brien tortures Smith he uses psychiatric jargon. Including “saving you from yourself” and warning him he needs to be made “sane.”

          • Yes Rachel, I”ve been shocked by how many of them are Islamophobes. Which brings me back to Karadzic and his treatment of those young men. I mean our own Prime Minister said that Islam is a “death cult”, and so wasn’t Karadzic merely helping them along their way? One lead pill is all thats required and treatment is over.
            Slandering people as “mad” has been used for an awfully long time, and it is as shown by Dr Moncrieff a political act. Nothing to do with medicine, its about power. The analogy to rape is valid though avoided like the plague by these professionals. A bit like our government not wanting the association with National Socialists when they present a Euthanasia Bill that has basically been translated from German to our Parliament. (Surely ALL of their ideas couldn’t have been bad?).
            Take away the status of “patient” and what have you got? A victim of some serious criminal offences that is denied any remedy for the damage that is done to them.
            I mean consider, the Community Nurse knew I wasn’t going to consent so he arranges for me to be ‘spiked’ with a date rape drug and then has police point weapons at me to obtain my consent. Where did he learn that technique? Medical School or the football club?
            Eight years later and the Australian Health Practitioners Regulation Agency is defending his ‘treatment’ of his “patient” (shows a level of ignorance beyond imbecility. I specifically showed them why I was NOT a patient and pointed to the section of the Act but they prefer the false narrative as its then back to the donuts) and saying by not informing doctors of the spiking his duty of care was met. Nothing like diligence when investigating complaints and enuring the safety of the public huh? A Kangaroo Court in Australia, who’d have thought lol

  2. Parachute NYC did have difficulty sustaining itself after the grant ran out, and it is now kaput. The story is the same with practically all of the better programs. The original Soteria Project was defunded because it ran counter to the direction charted by the NIMH. I’m pretty cynical about the matter because I know that even new programs manage to expand the “mental health” treatment system, and in that manner contribute to whatever “epidemic” in personal problems we may be experiencing. The demands for additional patient/ex-patient “mental health” workers and paraprofessionals could not be sustained without an inexhaustible reservoir of potential patients to keep the “experts” in business. I can’t wait until archeologists puzzle over the historical role of psychiatrists, unfortunately, I think I’m going to be a rather longer wait than I would like. Nonetheless, I’m already there.

  3. Article 1

    1. For the purposes of this Convention, the term “torture” means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.

    Just in case. The “soft tortures” are the ones that involve the psychological realm and are both diffiult to prove and may or may not involve damage to the individual. So for example there wouldn’t be an 8 year old Aboriginal boy in my State that doesn’t know about the use of mock executions by police. I’ve witnessed it being done. Similarly the threats of having someone raped in the cells to have them comply is another common use of ‘soft torture’.

    However, it is when there is also an actual physical assault that we step up into the realm of ‘hard tortures’. And it has been difficult for me to have being ‘spiked’ with a date rape drug as being an “assault on my person” despite it being an offeence under the “Assault on Persons” division of the Criminal Code.

    We regularly see the police beating up mental patients to have them comply with doctors wishes,

    https://m.youtube.com/watch?v=rUOoRiI8HVU&t=385s

    This of course is “inherent in or incidental to lawful sanction” and thus not considered worthy of any attention. But in my instance the administration of benzodiazepines without knowledge occurred before I was taken into custody, and then the Community Nurse has conspired to conceal evidence of the ‘spiking’ from both police and the doctors at the hospital. He lies to police to have them attend and find the planted evidence, and then lies to his colleagues that he has a referral from police that he has had transported back to the hospital.

    This is his acquiescence, the concealment of the ‘spiking’.

    Why is it torture? The two do nots associated with acute stress reaction, do not force the person to talk, and do not administer benzodiazepines. Both are present in that he has requested police assistance to rough up his “patient” (a lie) and force them to talk, and the covert administration of benzos. One of the problems with walking so close to the line and using police to beat up patients to have them comply is it can be easy to cross the line.

    I’m assuming that iinformation such as the person has been spiked with benzodiazepines without knowledge might be information you would require when doing an assessment Dr Steingard? And this Community Nurse is concealing that information and documenting such important information as “damage to photograph” (not that it cost me 20 cents to repair but it did give me some explaining to do to the Consultant Psychiatrist)

    I’d put him down for conspiring to compound or conceal evidence of a criminal offence as well as attempt to pervert the course of justice but given that he managed to get police to assist him torturing and kidnapping is it any wonder they can’t find their copy of the criminal code?

    Still, refouling victims of torture using the services of Mental Health is easy. They are well versed in the use of gaslighting and soft tortures that often result in the death of their victims. And after a “formal investigation” I was told if I didn’t stop complaining they would fuking destroy me (not an idle threat from the very nice Operations Manager who arranged the fraudulent documents for the Law Centre. Nice touch putting the Clinical Directors name to it too Louise). Witnessed that too, though fortunately the public are so afraid they tend to turn a blind eye to what is being done in the name of medicine.

    I know the Minister telling my lawyers what they should do with the fraudulent documents they had has caused no end of problems. I mean they’re meant to be MY lawyers and here they are pretending to be the Chief Psychiatrist and writing letters to me from him telling me some of the most bizarre stuff. Mental Helath ppractitoners are time travellers and mind readers, he doesn’t even know what a burden of proof is…… made him look rather silly when Prof. Of Psychology read the rubbish they tried to ‘poison’ me with. Poison pen letters eh? From frauds pretending to be the Chief Psychiatrist no less. Where does the principle of the Mental Health Law Centre get off on covering up tortures and kidnappings for the Government?

    I would assume such things wouldn’t happen in America, least not the America I saw. Good news is that there’s been some people watching the whole time, just seeing where they will run with this. 8 years and the police still haven’t caught up lol. They’re still providing material support for the criminals. People are funny when they think they are above the law. Oh well, might find themselves being ‘referred’ for ‘treatment’.

  4. Dear Sandra,

    I always appreciate your articles. You are always so careful with the facts and try so hard not to over or understate things. You are willing to live with difficult, messy realities when surrounded by so many ideologues.

    I got thrown into this world of mental distress because the woman I love finally opened her own Pandora’s box after 20 years of marriage and we got sucked into it together as we tried to make sense of the hurt, pain and dysfunction and find a healing path forward, together, as a couple and as a family. Eleven years later we are still together on the journey, and I hope coming to the conclusion of this phase, though that may be wishful thinking.

    I’ve always wished I could find someone like you who would be willing to sit down and listen to the things we learned about fully implementing attachment concepts in a way that even the attachment theorists simply don’t understand because they limit themselves. And I wish I could share with someone like you about the true scope and nature of dissociation and how it underlies so much of what you would see in people’s signs of mental distress. My wife and I chose to live in her dissociation. We embraced it, breathed it, walked in it, and conquered it. I’ve helped her integrate most of those dissociated areas of her mind, and though we aren’t completely done, we know what needs to be done.

    I wish someone like you would be willing to read my feeble attempt to share what we learned about attachment concepts and dissociation. I tried to share them in my little blog, but I know they would never withstand critical scrutiny, as I just tried to share my observations about what worked and then tried to find a theoretical basis for why they worked, and so I’m sure I got a lot of it wrong even though what we did, did work.

    I’m glad you like Open Dialogue. Someone who practices it here in the States out West said what I do with my wife would be a good fit with their philosophy, but there’s no one here in Ohio for me to connect with.

    Anyway, I do wish you well and hope you find what you are looking for like my wife and I did.
    Sincerely,
    Sam
    https://samruck2.wordpress.com/

    • SamRuck. I think it’s great that you and your wife are fixing her. I have no idea why it bothers me, but I really would not want anyone diagnosing me, labeling me and telling me when I am fixed. I would not constantly want to sit on the edge of my chair, showing the many parts of me and having someone tell me that those parts are not functioning in the right way. As it happens, women are often thought to be the problem within a marriage.

      • Sam Plover,
        I looked back over my response just to make sure, but I never said I was ‘fixing’ my wife. I do NOT see that as the case. I have an older brother who tried to ‘fix’ his 2nd wife, and it didn’t end well.

        As for me and my wife, we live together, we interact together, I love her, I support her where she needs it. Yes, I do a lot of things intentionally to create a loving and safe environment for her to heal, but I never see myself as ‘fixing’ her despite her many dissociative issues. We are in this healing journey together. I have had to change in many, many ways to be a good healing companion for her. It’s not all about her: it’s about us.

        Yours,
        Sam

        • Sam I guess for me it is a trigger. I have started to resent the fact that indeed I had issues, but that it was not my issues I adopted but the fact that others saw and identified my issues. But no one ever told me years ago that everyone has issues. I can totally accept and respect your support of your wife, I just cringe when diagnostic labels are used and the naming of alters. I suppose one could say I am fearful to lose mine, but I also don’t want my husband to point them out to me, nor do I want a shrink or psychologist to point them out. If it works for you, that is great. Pardon me for my fear. I don’t want to offend anyone, I blurbed when I felt that fear.

  5. Dr. Steingard,
    Much gratitude and respect for all your ongoing endeavours. It takes courage and integrity to speak out and challenge the status quo of psychiatry. Your latest book looks to be very interesting and per Chapter 2 Introduction, also hopeful in that it “has become a new kind of norm” for more professionals to be critical of the DSM. It’s been shocking to learn how many lives have been damaged by egotistical, rigid psychiatrists who cling to their power and shamelessly force damaging labels and destructive treatments and drugs on people. Thanks again for all you do.

  6. Thank you Sandra for your contribution to people/society. and to MIA. It means so much for society to have even one person to be interested and explore the failure of systems. We would all be screwed if not for curiosity and insights and brains that will not accept systems that are clearly not there to ‘help’ people. The program you speak of NAT, sounds so rational, but I suspect it would need an awul lot of support. I doubt a shift created by psychiatry and it’s research could ever lead to anything healthy, it only leads to different ways of ‘believing’ that there is something ‘wrong’ with someone that needs to be treated and fixed. To make people feel more normal in the midst of chaos is to allow them to see/feel safe in a transparent atmosphere where he/she is not the ‘sick’ or faulty one. I think psychoanalysis is, or most often can be another dangerous tool. It is dangerous to keep people locked into thinking that THEY are the problem in need of fixing. I thank you for involving yourself to the degree you do. It gives me hope. Please never give up. I am very aware of the fact that funding programs is crucial, and the very people needing the support, the fights against oppression, are the ones with the least funds. One thing we do know for sure, it is impossible that psychiatry is in the least bit helpful, if it was, it would NEVER be the dark system it continues to be. I think one has to be clueless to support something so wicked. But therein lies the problem, people WILL have problems and that is what feeds these awful shrinks and their kids.