This article is an invitation to open our perceptions to other approaches of supporting people through emotional crisis. Rather than pathologizing behavior we can use curious inquiry to explore the intelligence that is working. “What is this behavior serving or supporting?” or “What is the story that this metaphor is trying to tell?” or even, simply, “What happened?” Thus, with compassion we look for the intelligence that was used by the person in distress in order to survive.
Retraction, numbness, or dissociation are signs of intelligence that was effective in managing the situation and/or the emotions given the circumstances. Respecting our coping mechanisms as intelligence at work, we can then gently explore the layers of distancing (or numbness and retraction), giving it more space and support to be felt. This allows more understanding and wisdom to flow and brings relief. There is less need to compartmentalize and numb.
For transparency, I will say that decades ago I spent 15 months as a teenager in a conventional mental institution and was labeled with chronic schizophrenia. The passion fueling this article is a deep desire to be free from any form of oppression that makes my life smaller than it needs to be, but particularly mental health oppression (the drive to look “normal”) which has been my life’s work. I have learned that as I shed the layers of numbness, I can bring more light to that in me which makes me more whole, mature, and wise. Healing trauma allows more flow, flexibility in our thinking, and being more present, more accepting of difference and different perceptions of how life should be.
Whatever I resist persists; numbness or denial is the glue that serves as a barrier to enhancing self-awareness. We don’t need to override what we feel but rather gently explore it, seeing what emotions may come up along the way. And we can do this with other people whom we trust and who are willing to listen and are therefore a resource for becoming more grounded in our body. This way we can expand our relationship with our self, with others, with our family and perhaps our ancestors–and if we choose to take it to deeper levels, we can explore our relationship with the earth and the universe.
Each of us has the power to enhance our self-awareness and resolve the fixated or hardened parts of ourselves. Freedom is transcendence, elevating our awareness. Thus, we can clear our perceptual lens and let more of the world into us. That’s the core of the peer-run respite/Soteria house approach to emotional crisis response, and it contrasts strikingly from the approach of conventional psychiatry.
To help bring light to these differences, I invited diverse people to take part in a dialogue. Each person invited had experience being either a service recipient in a peer-run respite, a Soteria House, or a conventional setting, and/or experience as a staff member of any of these. Much gratitude and appreciation goes to Cindy Hadge, Adrian Bernard, and Burt Mooney for sharing their wisdom and experience in our dialogue, and special thanks to Grace Silvia who co-wrote the specific comparisons of these different approaches which are explained below.
To clarify language, the term “peer-run respite” refers to an alternative to being admitted to a psychiatric institution and instead offers a voluntary, home-like, trauma-sensitive setting in the community where people are assisted through the crisis. Similar to peer-run respites but different in some ways, the Soteria model primarily uses peers for its staff and is founded on principles of voluntary stay and the recovery model, including minimal use of neuroleptic drugs. The original Soteria house was founded by a psychiatrist, not a peer, and as a research study it had specific guidelines that prevented participation by some groups of people. Both of these programs are spreading around the world and are evolving. Some do things differently, sometimes by choice and sometimes because of the funding source and/or policy environment.
All quotes in this article are from our dialogue participants; their words bring clarity to the comparisons of emotional crisis response.
My therapist said, ‘Let’s talk about your childhood’. I said ‘the house is on fire, I want to figure out how to sleep.
I was locked in an isolation room with nothing but a toilet and they told me that was for my safety. It did not feel safe.
The conventional approach understands presenting behaviors as reflecting a disturbed, diseased, or chemically imbalanced mind. Underlying emotional crisis is not typically considered. On the other hand, peer-run respites/Soteria houses understand emotional crisis as something that may happen when circumstances exceed a person’s current capacity to effectively cope. Crisis response behaviors are often seen as having important meaning for the person’s life and may be related to trauma.
Many times people in clinical roles get set up with the impossible expectation that you have control over people and if they don’t do well it is your fault. In peer work I know I don’t have control over someone else. In fact I probably don’t know what is best for them. I would have to talk to them and hear their story in the context of their distress. I am not going to assume that I know. I partner with them, to try and be honest and vulnerable regarding what is coming up for me and what my limitations are. Hopefully I am creating a space for them to find their own solution, to use their inner wisdom to figure out what path makes sense for them.
At Soteria the staff never judged us or tried to guide us to any particular therapy. A part of myself knew what I had to go through and the staff were there to support me … without my being drugged, coerced and diagnosed… I was very blessed to have been in an environment where I could have that experience and come out the other end and learn who I am.
The goal of the conventional approach is to reduce or eliminate symptoms, making the person easier to manage and conform to dominant cultural norms. It is believed that the person in crisis does not know what is best for themselves. Thus, the focus is on modifying behavior. In contrast, peer-run respites/Soteria houses create a mutually respectful space where compassion is offered and individual choice is honored. The person in crisis realizes they are not alone, can reclaim their power, and come to find meaning in their crisis experience. The focus is on deepening self-awareness.
The conventional approach is very fear-based. Success is for you to not hear voices or not have big feelings. In peer respite, the question is how do you make sense of it and what is the context of your distress. There is a belief that no matter how unusual the experience or belief is somehow if you look at someone’s life experience it makes sense.
Whose safety are we talking about? It is often more about staff feeling safe.
I began working where I had been an inpatient. Staff said, ’Oh you are a different person’. I said, I was always in here you just were not looking. You were telling me, take your meds and be happy with a very limited life.
What does research data show? Considering the conventional approach, a review of over 100 studies worldwide concluded, “The immediate post-discharge period is a time of marked risk, but rates of suicide remain high for many years after discharge.” Another study concluded “Suicide risk increased during the entire admission and post-discharge period, but peaked in the first week of admission and the first week post-discharge.”
Specific to psychopharmaceutical interventions: there are some short- and long-term benefits for some patients; however, long-term data shows significant debilitating effects, including 20-year lower life expectancy and interference with long-term recovery for many. Conversely, data show significant benefit of peer respite and Soteria House approaches on many levels. Data for peer respite shows improvements in self-esteem, empowerment, social activity, and self-rated mental health symptoms; cost savings; 70% reduction in use of inpatient or emergency services; and more.
The rates of suicides go up after being in the hospital. Forced hospitalization is increasing suicide. What the person has learned is, don’t talk about it because that is what alleged help looks like. They did not lose the feelings. They learn how to lie to get out of the hospital. People who are talking about suicide are not doing it. It is sad to be at that place in your life and get tackled onto the pavement by police because you might hurt yourself, How does that make sense? To get psych drugs, medication, is not talking about the context of your distress.
In terms of the power dynamic, the conventional approach is characterized by a power over approach. Decisions are guided or imposed by professionals whose expert knowledge is unquestioned. The focus is on compliance; the approach is often coercive, which is often experienced by the person in crisis as a violation. In response, the person in crisis may withdraw, comply, or act out in anger in reaction to the coercion and not being seen, heard, or understood.
Hospital staff want me regulated and stable which to me means numb and dumb.
When conventional staff ask about safety and your response is ‘I am not feeling safe’, the staff response was ‘we are going to keep you safe. Now take off all your cloths in front of this stranger and put them in a paper bag. I will take away your phone and all your stuff and lock you in a room’… A part of safety is transparency. If there are rules, be transparent. Tell me what is going on – even if I cannot respond verbally; keep me informed.
In contrast, the peer-run respite/Soteria house approach is power with, where decisions are guided by the person in crisis, whose knowledge of themselves and their situation is honored. The focus is on creating a safe space by listening, exploring the person’s experience and perspective, and supporting them in thinking and feeling their way through the crisis, even if it means going into the unknown and tolerating uncertainty.
I was not safe in my body as a young person… Working in peer respite now it is a constant training process to get people to think differently about what safety means… we tend to make sure to not go down the slippery slope of control and power over. It is a constant, honest negotiation with each other and with ourselves. I have a different relationship with the word, safety. It is a beautiful thing now because I do internally feel safe in myself and who I am in the world.
Another domain is “being with versus doing to.” The conventional approach is to evaluate the person and either minimize or eliminate behaviors, feelings, or ideas considered problematic, primarily using psychiatric drugs. Those in emotional crisis may respond with a need to protect or defend themselves due to being pressured to accept the definition of their experience as a chemical imbalance/mental illness, and to accept the diagnosis and treatment imposed on them. However, the peer-run respite/Soteria house supporter’s intention is to create a safe “being with” space by listening to the person in crisis, exploring together literal or symbolic meaning within the crisis, and supporting the person to move towards meeting their expressed needs and desires.
The supporter also tracks the impact of their own words and actions to ensure that the person in crisis feels listened to and validated. This approach invites openness in the person in emotional crisis and fosters the capacity to look at their inner experience which allows the person to move through the crisis and consider their hopes and intentions for the future.
The conventional approach is, We want to make you think in this box, in the world we are defining for you. Whereas in peer respite we walk alongside, we are a lot more open to people being able to experience their lives the way they want to be defined and how they want to experience it. We experience it together. It is a place where people can express deep and painful things. We don’t try and control them, we have multiple conversations. It is about what is leading to this, and how are you feeling about life and exploring that in a deeper way. We are a family essentially, as a community. We are here for each other, with each other. We walk with people through some pretty intense stuff.
Let’s consider trauma. In the conventional approach, problematic behaviors, emotions, and/or ideas are often understood to be caused by brain chemical imbalances (possibly with a genetic basis). Some consideration may be paid to trauma, but not as an underlying cause. Often, staff do not use a trauma-informed approach. Thus, re-traumatization occurs. Little consideration is paid to the traumatization of staff, other patients, and others witnessing various interventions. The use of psychiatric drugs may mask and compound the trauma.
Many times being in the hospital is not about healing trauma, or creating a life you want, or creating a family atmosphere. It is about containing and medicating someone to the point they don’t have energy to do anything. That is what recovery is. They can barely walk so they will not be any trouble.
Peer-run respites/Soteria houses understand that trauma may be involved in any life-interrupting crisis. Trauma may be individual, intergenerational, community, and/or historical and include the traumas of racism, sexism, poverty, and other forms of systemic oppression that impact people’s lives and are often perpetuated by the behavioral health, education, political, and criminal justice systems. The person in crisis is supported to trust their wisdom, come to their own understanding about their experience, and determine their next steps.
This worst moment I am having may be a catalyst for something great and wonderful versus a catastrophe.
Let’s consider relationality, or the way people are connected. The conventional supporter maintains a professional distance with the person in crisis. Generally, the collective wounds have not been named but rather they have been normalized with multi-system societal messages of “This is how life is” (e.g., racism, sexism, classism, etc.). Peer-run respite/Soteria house supporters engage emotionally and invite mutual learning, including sharing their crisis experiences and what has helped them if the person in crisis is interested and finds it helpful.
As the relationship deepens, the person in crisis may feel safer to explore what meaning the crisis and their emotions may hold for them. Engaging together invites insight and the integration of their experience. Thus, they may become free from learned reactions and past coping mechanisms and practice responding in ways that better serve them. This may lead to creating a life that is more aligned with their deeper self, values, and vision.
When people have more agency, feel stronger, have more community connection or supportive family then they are able to withstand unpacking things.
Lastly, let’s look at the use of law enforcement. Conventionally, law enforcement typically focuses on controlling the person in crisis, who is seen as volatile and potentially harmful to self or others. Sometimes aggressive interventions are used, up to and including lethal force. These interventions often have a harmful impact on the person in crisis, law enforcement personnel, witnesses, families, and the community. Conversely, peer-run respite/Soteria house stays are completely voluntary. When peer-run respite or Soteria House is available, there is often no need for law enforcement engagement. Staff and supporters focus on embodying trauma-sensitive ways to engage the person, including consideration for physical, environmental, and emotional safety.
I hope this article has illuminated some essential processes in healing from trauma, hurts, or humiliation, and/or the importance of respecting one’s need to protect their self. I invite you, dear reader, to open your heart and mind even wider and believe completely in the full potential of every human being. Each of us has the capacity to be a drop of medicine contributing to building healing communities. If you have read this article with an open mind then I want to share one last thought: If we do not see the other person in terms of their highest future potential then we are practicing attentional violence. We are taught that “this is the way things are” but I respectfully submit that this is seeing through a lens of hurt and pain.
As Otto Scharmer explains it, “Attentional violence is to not to be seen and recognized in terms of who you really are—in terms of your highest future possibility. Instead you are only seen in terms of your journey of the past, that is, in terms of the circumstances of the past, in terms of who you happen to be today.”
- International Peer Respite/Soteria Summit: https://www.alternatives-conference.org/peerrespitesoteriasummit
- Peer Respite Handbook: https://wildfloweralliance.org/peer-respite-handbook/)
- International Peer Respite/Soteria Summit: https://www.peerrespite-soteria.org/resources/
The Pocket Project: https://pocketproject.org/
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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