Exploring the Fault Lines in Mental Health Discourse: An Interview with Psychologist Justin Karter

He has served as the editor of the research news section of the Mad in America website since 2015. In addition, he has held executive board positions with the Society for Humanistic Psychology and the Society for Theoretical and Philosophical Psychology. Despite being a recent graduate and early career psychologist, he has published over 25 papers and textbook chapters on topics in critical psychology, critical psychiatry, and philosophy of psychology.

Ayurdhi Dhar: Tell us about your journey to Mad in America and whether it has changed you as a scholar, a clinician, or person.

Justin Karter: I didn’t have an interest in psychology until I finished my first masters in journalism. Instead, I have always been interested in stories—how they shape our experience of the world, and I also had an interest in politics and activism. In journalism, I learned how to listen for what’s not being said in stories, to pay attention to whose stories are being told and when, and what interests they serve. While completing my degree in journalism, I was introduced to a different kind of psychology.

I took a class in Humanistic and Phenomenological Psychology with Dr. Brent Robbins. I was hooked from the start. It offered a new way of thinking about myself and the world, of articulating and exploring the sort of malaise I felt at the time. Humanistic psychology offered vitality, imagination, and possibility at a time when I was starting to worry that the world was pretty stultifying, robotic, and algorithmic.

I was also involved with student activists across Pittsburgh who were organizing and trying to make our universities more just by divesting from fossil fuels and resisting student debt structures. We also supported adjunct instructors as they unionized. But it brought us into conflict with our university administration.

When I started participating in Society for Humanistic Psychology, the APA was coming to terms with their involvement in developing torture procedures for Guantanamo Bay. Many humanistic psychologists had been calling attention to that for years. I was lucky enough to meet Dr. Lisa Cosgrove, who later introduced me to Robert Whitaker of Mad in America.

All of that reading and editing research has shaped me. First, I became aware of the fault lines in the field. There is so much we don’t know about the brain, consciousness, or how people in their relational and environmental niches become who they are. These big questions and looking at all the fights kept me humble and also in awe at the complexity of our existence. They were fertile ground for different models and narratives— major disagreements among experts about what it means to have mental distress or mental illness or a mental disorder and how best to treat that. That’s been its own sort of education.

My very first research review for Mad in America had a critique of Cognitive-Behavioral Therapy. I received comments and emails from people who were happy or unhappy with the piece for a variety of reasons, everything from “how dare you critique a form of therapy when it’s the only viable alternative we have to Big Pharma” to “CBT and exposure is a form of thought control or emotional abuse, and your summary didn’t go far enough.”

It’s been a lesson from the start and a constant reminder that these theories and the research we cover here have very real impacts on people’s lives. Often people are in the midst of extreme suffering, and it’s not just intellectually interesting—these debates have real and immediate impacts on people. As the research news team, we break down the wall between the public and service users on one side and academic writing on the other—what’s in the Ivory Tower, locked behind pay walls. We provide plain language summaries of the research so they may be useful to people when they’re evaluating treatments or trying to make sense of why they’re feeling what they’re feeling.

We emphasize research that is critical of these prevailing theories and treatments, which are often ignored in the mainstream press. We emphasize the connection between people and their environments, which sadly is radical these days. We focus on social determinants, people’s life experiences, their identities, and how that shapes their mental health. We broaden the perspective that people might bring when they think about themselves and others and why they might be suffering.

Dhar: I’m glad we can bring some of that to the fore. You have written extensively about the DSM. What is your biggest critique of the systems of diagnoses that we use?

Karter: It’s a sort of fault line. All these big questions like: What does it mean to have a mental illness? What is a mental disorder? What does it mean to be in distress? How do we conceptualize that? How do we understand the causes and precipitants? Most debates in the mental health field take a position on diagnosis because you have to.

At Mad in America, I was constantly exposed to different ways of making sense of mental distress. In my scholarship, I tried to find a concise way of putting together all these debates so professionals could use it to think through their position and strive for consistency. They could develop humility about these disorder categories, about what we know and don’t know, and have critical consciousness about the institutions and historical factors that influence the development of these categories.

Also, it could help in thinking through how we could talk with clients in ways that honor their experience and aid them in coming to their own narrative for understanding their experience.

What is not part of the public discourse is thinking about how the presentation and the experience of different types of mental distress change cross-culturally and historically, as your work, Ayurdhi, shows. The narratives we have available to us profoundly shape our experience, and over time or cross-culturally, we have different ways of thinking and different concepts available to us. So it’s not just how we think about ourselves but how we experience ourselves and our world in an embodied way—what’s salient to us, what we attend to, and what we don’t.

If we think about disorders as discrete categories that exist in nature and we’re just naming them, we miss the opportunity to think about how people are making sense of themselves, of their own story, which is at the heart of psychotherapy.

Lisa Cosgrove and Robert Whitaker’s book, Psychiatry Under the Influence, looks at the institutional players that play a role in shaping how disorders get defined in the DSM. I mean pharma funding, physician pressures, and special interest groups. For instance, PTSD diagnosis has a lot to do with post-Vietnam War veterans advocating for their own best interest to ensure that the symptoms they were experiencing would be treated by the country that sent them to war. So it had to be defined in a way so that PTSD could be a long-standing condition.

We take for granted that symptoms that are listed in the DSM are somehow core symptoms to the experience of that disorder. But network research suggests otherwise. For instance, with major depressive disorder, symptoms in the DSM-5 have more to do with what historically has been defined as depression in the DSM than what’s consistently reported by people as their experience of depression.

Dhar: With Sarah Kamens, you have written about an ecological model of diagnoses that would develop “conceptual competence.” Could you tell us about this and what would it look like with a patient?

Karter: The idea was to produce a way of thinking about diagnoses that could train professionals and help them think critically about when and how they’re using it. What that actually looks like with a patient depends on who that person is, what they’re bringing in, etc. Culturally, there are a lot of models of madness circulating rapidly. People talk about mental health on TikTok, Instagram, and Twitter. People are learning about the neurodiversity movement, DSM definitions, and psychotherapeutic and psychoanalytic ideas.

We’re cobbling together a model for ourselves to understand our own behavior and the behavior of others, drawing more than ever from the psy-disciplines. It’s confusing for a lot of people, and rightfully so. Amid all the uncertainty, we tend to cling to something that seems the most concrete.

But this is also an opportunity to think creatively. Without an obvious answer, we’re forced to get creative in combining and creating a new language to understand ourselves and others. When somebody brings up a diagnosis, I hope to work through it, talk it through, and get to a place where we create a new language for that person. It should make sense to them or help them explain something they’ve been wondering about, providing a way forward.

Dhar: Being a new mother, I filled out a million depression screening instruments during different doctor visits. I know you have written about depression screenings. What have you found?

Karter: I did this work with Dr. Cosgrove. In 2016, the United States Preventive Services Task Force recommended screening everybody above 13 for major depressive disorder, especially in the postpartum period for women. This sounds pretty benign—it’s one more piece of paper to fill out. It’s a great thing. You catch people who would have fallen through the cracks.

Unfortunately, that’s not what the evidence suggested. We found Canada and the UK had decided not to implement mandated screening for depression because there wasn’t sufficient evidence that it would improve care. But the US decided to do it. So we reviewed the available research for screening collaboration with Dr. Brett Thombs, an expert on this topic. We found, as others had seen, that there wasn’t evidence that implementing these screenings would lead to improved patient outcomes.

And there are risks. Other countries might have made a different decision because, with government healthcare, you’re cautious about wasting resources. You pay more attention to the false positive problem and identify people at risk who aren’t actually at risk. In the US, the system is quite different.

So, one risk is that we treat people who otherwise wouldn’t need treatment, which diverts resources away from others. Also, through diagnostic overshadowing, it distracts from other things that might be going on. We are not denying that people, especially in the postpartum period, struggle or have depressive symptoms.

We didn’t find evidence that a questionnaire will lead to more support than having a skillful clinician check up on a struggling patient. In fact, a screening instrument makes it less likely that a clinician will have that conversation in a human way because it has been outsourced to the piece of paper which makes the decision for you.

It provides concreteness that isn’t always justified. If somebody scores above the threshold on a PHQ-9, which was developed by Pfizer and has a high false positive rate, we’re likely to think, “this person has depression, and this is what we do for depression.” If we have a clinical interview with somebody and they tell us how they’re struggling, not feeling how they thought they would after birth, not getting social support, nervous about their relationship, having trouble finding food—then that points us to other solutions that might be more supportive. Screening lets the system off the hook.

We wanted to attend to women’s distress in a way that allowed for a broader conceptualization of what might be happening to them and provided a broader menu of support.

Dhar: Yes, we’re not saying there isn’t psychological distress for some in the postpartum period. I remember being extremely overwhelmed and worrying, “Is this postpartum depression?” This was despite all the critical research I had read on screenings. I had to remind myself this is normal, and it makes sense that I’m struggling given the lack of social and familial support. When there is an available narrative like postpartum depression that takes away context, all you have available to make sense of your anxieties is “this is a chemical, hormonal imbalance.”

Karter: A number of studies find that the groups screened for the mental disorder have worse outcomes than the control group. That raises the question of the Nocebo Effect. Is it helpful or harmful to think about ourselves in terms of “I might have a mental health problem”?

Dhar: Your dissertation is about psychosocial disability in the Global South. Tell us about your research.

Karter: There’s the movement for Global Mental Health and then the emerging movement for a global human rights-based approach to mental health. This one has a different identity category, “Psychosocial Disability,” with different assumptions about mental distress. I was curious about how people under this identity or advocating under it thought differently about what it meant to have mental distress or madness and how people with lived experience participated in research, policy, and practice in the movement for Global Mental Health.

The movement for Global Mental Health was a call to scale up services for mental disorders worldwide, especially in the low- and middle-income countries or Global South. It has been criticized widely for assuming that we can take the conceptual, diagnostic, and treatment approaches to mental health from the West and apply them in a top-down way in the Global South. This is without any critical reflexive analysis about what works and what doesn’t, about how we think about mental health here in the West—like our outcomes are wonderful!

That was being critiqued by service users. The consumer/survivor/ex-patient body of literature is remarkable and often ignored by mainstream psychology and psychiatry, but that’s slowly changing. Because of the move towards psychosocial disability, there’re now legal frameworks on the rights of people with disabilities. Rights-based organizations demand that people with lived experience be part of the process of developing research, practice, and policy in the psy-disciplines.

Suddenly, because of the “Nothing About Us Without Us” pressure, the movement for Global Mental Health was pressured to include people with lived experience. My participants were leaders in different psychosocial disability movements, had been involved in activism, and were from other countries and cultures. The majority identified at some point as having what was labeled a psychotic experience by mental health professionals, but they had come to make sense of it differently over time.

People journeyed through different models of mental health and initially thought about themselves through a biomedical approach which they found initially sometimes helpful. It connected them to resources and provided a narrative for making sense of their experience, but over time felt like it was missing things or was actively harmful. In addition, it justified having their rights restricted—they suffered inhumane treatment. Over time they became reformers of the field and became aware of the UN’s Convention on the Rights of Persons with Disabilities.

The psychosocial model suggests that disability emerges in an interaction between a person and their environment. The environment does not make accommodations, and that lack of ability to make room for that person in the world leads to a disability. This changed the frame and led them to push for more social determinants approaches to mental health.

Also, participants talked about having an a-ha moment where they started to think of themselves less as somebody who is suffering a deficit, but instead as somebody who was a rights holder—that I am a person who has rights that need to be respected, who can make certain demands, and speak about my needs, which I found empowering.

Dhar: What’s the process of getting people with psychosocial disabilities to the decision-making table? Who decides whom to invite—this service user or that one?

Karter: Participants spoke about being stuck between a rock and a hard place where they would be invited to participate in a project. Sometimes they’d be invited from the beginning, which is what’s recommended, that you include people in even the brainstorming and study design process. Sometimes they’d be called at the end to rubber stamp a problematic policy.

They felt they were being asked to provide their testimony or rubber stamp a policy so that the researchers or the policymakers could say they had lived experience input. They were aware if they turned that down, if they said, “no, this is not CRPD compliant,” or “I’m not going to participate in this process,” that some researchers and policymakers would shop around for somebody who would rubber stamp it. There’s a diversity of perspectives among people with lived experience. You could shop around and find somebody who was more friendly to forced treatment and still claim to have lived experience input.

Dhar: How do service-user and survivor movements get co-opted? Can you think of an example?

Karter: Participants in the Global South were aware that most of the researchers they interacted with in the movement for Global Mental Health were western-based researchers with institutional power, often White, from the US, Canada, the UK. They saw this as an extension of colonialism—the idea that we, the West, know the answers, the objective truth, and we’re going to advance the rest of the world and force them to use what we use.

One of my participants brilliantly said this is the “grandchild of the colonialism of 500 years ago.” She explained, “In Latin America, we’ve had dictatorship after dictatorship, extractivism, free trade agreements where workers are paid under minimum wage, have no rights, they count the times they go to the bathroom.” She said that the movement for Global Mental Health operates from the same logic as these other policies brought to the Global South by the Global North: “It’s a newer manifestation of that White supremacism, egocentric view.”

She made an explicit link between the Global North extraction of resources through slavery, mining, ongoing exploitation of labor in her country, and the way the movement for global mental health was treating her (a person with lived experience)—coming to mine data from her to pursue their donor funding and support their academic careers on her back.

She told the story of a psychologist who opened up a peer support group that they led and charged money for people to enter. This was infuriating, a travesty for her. It was a sort of perversion of her goals, of what she was trying to offer the community. This co-option is doing the same thing that people with lived experience are doing, which is offering peer support or group psychotherapy, but doing it from a Western researcher’s perspective—charging money to get in and spreading their own narratives about psychosis to the group—changing how safe people feel to explore different explanations.

Dhar: It always amazes me how much people on the ground know and how little we listen to them. I had my physiotherapist in India talk about withdrawal from benzodiazepines among his patients. There is a lot of information on the ground amongst people we would consider not worth listening to.

Karter: There are also many possibilities right now because there are so many shifting narratives around mental health. There are some big cracks that the public is becoming more aware of—as in the narrow chemical imbalance theory and the DSM.

But as narratives shift, the forces and systems we’re operating within are trying to take advantage—for example, the right-wing authoritarian pickup of the chemical imbalance theory. Critics have pointed out that the chemical imbalance theory served neoliberalism and the right-wing political agenda because it depoliticized stress. Now that we’re seeing the serotonin hypothesis fall away, the right will try to use it as justification for defunding mental health treatments. As we’re questioning these narratives, they are going to be used to justify existing injustices.

Dhar: You’re also a humanistic-existential clinician with a relational bent to your practice, and you are very critical of how psy-disciplines deal with people’s distress. How does a humanistic psychologist work in a world where the first line of intervention is the drug-based treatment?

Karter: The field of psychotherapy is under threat by the neoliberal culture that wants to turn it into an AI chatbot—a set of flowchart responses that will lead to a corrective thought. What’s fundamentally countercultural is also what’s healing about psychotherapy, and that’s the experience of being a version of yourself that can come forward because of another person. That’s the process of psychotherapy for me.

It’s hard even to articulate this because our language is built in a culture that thinks about people as individual beings. But in therapy, thoughts, feelings, or embodied sensations emerge in an inter-subjective space because the other person is contacting something within themselves that’s powerful that you also feel. They’re also reaching that because of something that you’re able to put into the room. So you get to experience yourself as a relational and open being over time. So if a good psychotherapy process is allowed to unfold, you get to be a different kind of self that our culture keeps telling us we can’t be.

Dhar: That idea of coming into different beings through others and with others is lacking and connects with the underlying idea that “I’m this contained self.”

Karter: It’s seductive because it’s challenging to get to the edge of what you can be certain about yourself and step over it because we’re under pressure from others to be consistent. It requires a lot of energy and vulnerability—to be open to being a different version of yourself.

Dhar: Or being different versions in different contexts. In psychology, the idea of multiple selves immediately connects with the negative idea of fragmentation.

Karter: I think we need different types of stories. I love finding a good piece of literature that captures a different way of being a self—seeing people who carry multiple selves with them or have their ancestors’ voices in their heads. Hopefully, these stories will help us think about ourselves differently, with the ultimate goal of not just feeling better but of being the kind of subject that is unruly and ungovernable.