Reimagining Crisis Support: A Conversation with Tina Minkowitz

Editor’s Note: This article was first published on our affiliate site, Mad in Mexico. This article comprises a conversation between Mad in Mexico’s Luis Gerardo Arroyo Lynn and Tina Minkowitz, a lawyer specializing in international human rights involved in the United Nations Committee on the Rights of Persons with Disabilities (CRPD).

Silhouette of two people, made of wood, make the gesture of holding hands in a gesture of support and accompaniment.

Luis Arroyo: Thank you again, Tina, for giving me the opportunity to talk to you. The idea of ​​the interview is to talk about the work you have been doing and especially the book you wrote Reimagining Crisis Support: Matrix, Roadmap and Policies. I had the opportunity to read it when it was published in English, and now it has been translated into Spanish. It is an incredible book, I really liked it, and the idea is to give more people the opportunity to have access to this information, which I think is really valuable, so that’s the main goal for talking about this book, and other topics surrounding it, so I don’t know if you want to start the conversation a little bit about your perspective, the work that you’ve been doing and How all this translates into this book.

Tina Minkowitz: [Laughs and doubts how to start]

Arroyo: I know it’s a very complex question.

Minkowitz: It is, because the book is actually very small, it’s very short, but it’s made up of many different pieces, so I would really like to be able to discuss it with people, propose that people study it. That may sound a little arrogant, you know, to be thinking so much about myself that people should study my work in detail, but when I look at myself I see that I have a lot of different perspectives.

I started the book project for two reasons. One, the main reason, is that there were all these reforms underway, mainly in Latin American countries that are pioneers in legal capacity and are even going in the direction of abolishing forced psychiatry; now in 2023, Mexico has made a reform that activists agree has the possibility of abolishing forced psychiatry, except when it is imposed through the penal system as a security measure in case the person has been declared not responsible for a crime.

That is, the legal framework and policies and practices for services and support still need to be created, because it is still very institutional, is what activists there have told me, but there are all these reforms underway. Peruvian reform is especially good regarding legal capacity, but it has not included the issue of healthcare and it has not addressed the short-term involuntary measures in the mental health system that are still in place. In talking to activists about it, it seemed that there is still the possibility of carrying out emergency interventions without informed, explicit and free consent, as is generally the case in the medical system; let’s say someone is in a car accident and is unconscious and bleeding, they may not be in a position to give free and informed consent, then it is assumed that certain measures can be taken to save the life and preserve the person’s health. Not that I know how it is in every country, but I know that here, and I’m thinking in terms of international law, if a person is conscious, if they are able to express themselves and can express themselves, then they have the right to refuse treatment, even if this means the rejection of life-saving measures. Even so, it seems that addressing the issue of personal crises, when forced psychiatry is being referenced on what is called an emergency basis, is conceived in law and politics in a medicalized way. Therefore, the response to emergencies is being medicalized.

I really don’t know how to approach the whole issue of medicalization and pathologization from a human rights framework, because it has been seen that it is a political issue and not only one of legal norms, or even international human rights laws, I couldn’t find a way to handle the issue, and it was through various avenues that I felt challenged to look for something that could address the need for positive policy in situations of personal crisis.

Other people have their own ideas about this; there is a document published by a group of authors, including Alberto Vásquez and Peter Stastny, in which they address crisis support, and I think they have a somewhat more conservative approach than me. I think at the same time there was in the United States, right at that time or shortly after, with the murders of George Floyd and Breonna Taylor, and other unarmed African-American people, that we had a strong resurgence or activation of a movement that calls attention on police violence, and this includes the way in which police violence occurs in response to people who are perceived as “mentally ill” or experiencing a personal crisis, and some of these cases of police killings occurred when relatives called the police to make an involuntary intervention, which is why it became a topic in public thought in the United States.

That was what led me to write this book, and also at the same time, or a couple of years before, the World Health Organization had begun to work on what the development of mental health policy frameworks should be like so that they comply with the CRPD, particularly the ban on involuntary measures, and while I was happy that someone was doing it, I really wasn’t comfortable with it being the WHO, because that keeps the power and the overall framework within the health system, within the mental health system, which is still an institutional perpetrator, is still in a hierarchy of power, while human rights really require developing policies from the perspective of the people affected, of the people who could use the supports whose rights have been violated by the system. So, although the WHO came to take my comments into consideration, it made me wonder, what would I do? What would I say about some of these issues? And that’s how I came to write the book.

What I started with was thinking about what it would be to create a type of positive policy in relation to crises. It seems that the most convenient, the most elegant way of thinking, to conceptualize crisis support within the framework of the CRPD, is from article 12 and article 19. Support in decision-making and any other aspect of the exercise of legal capacity, which is already a clear obligation of States, as well as support to live independently and be included in the community. So I’ve been thinking about decision support as a way of understanding the necessary response in times of personal crisis, or as a sort of alternative to some aspects of, perhaps even the entirety of health treatment.

I wrote it in a document that I submitted on behalf of the Global Network of Psychiatry Users and Survivors that was part of the consultation process on General Comment No. 1, the General Comment on legal capacity in the CRPD Committee, so that idea was already in my mind, as opposed to the fact that decision support should be a paradigm that supplies any type of support needed, including support in crisis situations, instead of the medical, diagnosis-treatment model of mental health, rather than the way that people seem to want to think about it, which would be to think about decision support as suggesting where to go for mental health treatment. If you recognize the need for support in decision making, why think that what is needed is mental health treatment? What is needed is to really make decisions in relation to whatever is troubling you, whatever is creating a sense of urgency that makes you feel like it is a crisis, so I ended up thinking about how crises have to be defined and understood from the perspective of the affected person, whether it is a personal crisis or an interpersonal crisis, or a social crisis, it has to be understood in relation to the needs of conflict resolution and possibly support any individual who may be going through both at the same time.

Article 19 is important, because what happens is that instead of maintaining their home, maintaining their independent life in the community, the psychiatric system forcibly removes people from their environment and locks them up. Sometimes people try to create community with others within the institution, but it is a situation in which you are being supervised, you are being watched and monitored, and controlled, manipulated, and abused in various ways by other people, which is completely different from the type of horizontal relationships in the community, of support and solidarity. You can’t trust the people who are locking you up; trying to develop relationships of trust with the people who locked you up, to me it’s an abusive situation per se, even if that was the best thing people could do.

And of course, people also create some community with those who are locked up, but it seems to me that conceptualizing the need for support during crises in those two ways gives us a basis for thinking about it within a social model of disability. And they take us outside the framework of mental health, so that’s why I thought it was particularly important.

No one has addressed that aspect directly; that is, the CRPD Committee has not, no one that I know has accepted that framework, but I still think it is useful, and the CRPD Committee has incorporated some of what I have said about crisis support within the deinstitutionalization guidelines, but especially to get out of the medical model, so there is a paragraph in the guideline that says that people who experience individual crises should never be institutionalized, that such crises should not be considered a medical problem that requires treatment or a social problem that requires State intervention or forced psychiatric intervention. There is also a paragraph that establishes the need to guarantee support options outside the health system to cope with the crisis, anguish, or unusual perceptions, without there being a need for a psychiatric diagnosis, and that paragraph also refers to treating situations of trauma and the need for solidarity, because a kind of policy hook is created to establish a path of support outside the mental health system. The social model of disability must be conceptualized outside of any type of health system and within ordinary language.

Arroyo: This book, as you mention, is a little small, but it’s really complex in the sense that it has so many themes, so much content, I think it’s a great book.
I have a few questions. The first is: In the book you mention that there is no place for this concept of “best interpretation approach” when we talk about crisis support, so I assume that this best interpretation is like in the example you mentioned: You have a car accident and you receive medical treatment, people are doing the best they can to keep you alive, giving you medication and all the procedures you may need at that time, but you cannot give your consent. In crisis support, would it be a similar concept? How can we think about this idea of ​​“best interpretation” under this model? Should we get rid of it or do we have to think about it in a very different way?

Minkowitz: I mean, I’m just going back to what I actually say about it in the book, I think the thing is that there are different ways of thinking about what “the best interpretation” means. In an informal sense, when it comes to understanding what someone is expressing, what they are communicating verbally, or as an attempt to understand their non-verbal communication, it can be a bit of a guessing process, but some type of communication is attempted.

I don’t think there’s a reason to stop communicating with the person at any time and just say, “okay, I’m going to take action because that’s my best interpretation of what I think that person wants.” I mean, there’s some situations where an action must be taken and whatever you do is going to have consequences. But if we do not have a clear agreement, and the choice is either to do nothing or to do something that affects your bodily integrity, we should not do anything if you do not agree. There are situations in which any of us act instinctively; for example you are standing in the middle of the street and there is a car coming and I push you out of the way instinctively, those kinds of things in everyday life do not necessarily imply anything about capacity or disability, though. In terms of the CRPD, the use of the concept of the “best interpretation” is like in the paradigmatic situation: when a person is in a coma, when someone really cannot communicate by any means.

We have to distinguish the rejection of any type of communication from non-communication as would occur in a coma, as occurs when facing hostility and aggression, especially in the way the psychiatric system has to guess and manipulate, where I may just shut up and refuse to communicate, and that shouldn’t be taken as a sign of “go ahead and do your best interpretation.” It has to be understood in context, and that’s why I don’t think the “best interpretation” should be applied by the psychiatric system or in the psychiatric system, and now we also have the deinstitutionalization guidelines that say that mental health services should be based on the affirmative, free, and informed expression of consent by the affected person.

Therefore, in terms of crisis situations, I think it is similar only in the sense that the person is still there, the person is still present, so there would be no need to do any kind of “best interpretation.” In any situation in which there was a need to assume a “better interpretation” I have always defended that it should not be that he simply made the decision according to my interpretation and I am leaving you with the consequences, I would need to tell you “this is what I am planning to do, this is the interpretation that I am making of your will,” and give you the opportunity to respond, to contradict me in some way, whether you could shake your head or do anything to indicate that “no, it is not” and then knowing is not the better performance, so I must go back and try again.

Some of this is built into the new Mexican legal capacity reform that was just enacted this year, and the Mexican health law reform that prohibits forced treatment also has some really good provisions on this; some of it is the reform of the general health law, but it is a specific part of mental health. I am reading from an English translation now:

“There is a possibility for the healthcare provider to act to preserve life and health (this does not refer only to mental health, but to health in general) in situations where the person cannot give consent to the treatment at a given time by any means, where there is no document stating your intention in advance and your condition is such that if the treatment is not administered immediately your life is exposed to imminent risk, or your physical integrity is exposed to irreversible damage, the healthcare professional will act immediately to preserve the health and life of the user,” and a few paragraphs below it says: “a person will not be considered incapable of giving consent if it is considered that they are mistaken or wrong, unconscious of their actions.”

This also speaks of reasonable adjustments, and it seems that the intention is very clear, and according to the people working on the bill it is about preventing the use of that permission for any type of mental health intervention. It also seems to me that if it is found that someone tried to commit suicide or may try to commit suicide, and is unconscious, it seems to me that this could allow measures that really save people’s lives, but not to hospitalize them, not to drug them. or give them electroshock, and if they are not unconscious they would have the right to say “just go away.”

There are all kinds of policies around suicide, if they really tell you to go away, you shouldn’t come back and say “well, now that you’re unconscious I can.” I mean, there are a lot of things that would have to be addressed about suicide in terms of consent. I think that many times it cannot be justified, but I think that there are times when it can be clear that the person’s intention is really to die and reject any type of measure to save their life, so I think it is the ethical and legal issues around suicide that need to be worked out in more detail, but in any case there are some parameters.

Arroyo: I think about the way we talk about crises: people think that we always have to act urgently, and it is assumed that we have to act instinctively, like you said, so I think the difference in the support approach in crisis is that we do not have to act urgently, as if I had to solve it in the moment, but rather it is a more patient process, with more communication and empathy, taking care of the other person, more like a caregiver, giving support, not trying to resolve the situation urgently, taking the situation with patience, always communicating with the person and trying to resolve the situation in the best interest of the person in crisis. So I was thinking, the idea or response that we have about crises is to medicalize, the idea of ​​crisis per se is permeated by psychiatric discourse, and this leads me to what you mention in the book: “crises are not a medical situation, they are personal and political,” crises are “a social situation, not a medical condition.”

Minkowitz: You know, what you’re saying actually suggests that crisis may not even be the best word to use, because the concept of crisis seems to suggest that we have to act immediately and it’s a term that actually still has mental health connotations, which we need to get rid of, so it would be interesting to think of a different term, but for now we’ve chosen this one to think about how we actually characterize what’s going on.

Many things happen when someone feels in crisis. What are we talking about? What are the situations in which another person may decide that you need to go to psychiatry? Are we talking about situations where the person may sense that he is reaching the end of the rope and is going to, you know, take actions that could injure him? You could go to psychiatry, you could seek support, you could be seeking support from untrustworthy people who will hand you over to psychiatry or you could have experienced this with mental health professionals who were trusted, that’s where you learn to put your trust, and is betrayed.

I guess what I go back to is my personal experience, from the time when I was locked up in psychiatry, is that there are situations where I might have a sense of urgency about something that’s happening in my life, and that doesn’t necessarily mean that it’s always a situation where I’m at risk of being locked up by psychiatry or I’m experiencing madness or altered states of consciousness in any sense, and altered states aren’t necessarily always stressful. I think there’s a need to create different types of language that we have not even reached yet, to be able to talk about what we want to support from diversity such as madness. The Latin American movement seems to be settling on “las personas locas” as a way of understanding identity and diversity, psychosocial diversity.

Since writing the book I have sometimes used the framing of distress, diversity of behavior, communication of consciousness, trying to create something neutral. But this does not convey the full meaning of what is happening when a person really feels in crisis: “I really need support now, I don’t know what I’m going to do.” Sometimes it is a material situation, domestic abuse or some very intense confrontation with situations of discrimination, with violence, with being expelled from home or other material needs, need for food and shelter, there are so many different things that create a sense of urgency in someone’s life, and some of them can come from within you, emitted traumas, or just anything that happens in your life that you don’t know how to deal with and that you feel like dealing with it is important right now. You may feel like you’re coming to a path and it matters a lot what you choose, so I was trying to capture all of that as possibilities of what we might understand by personal crises, and what people might want. Some kind of support to cope with it; you might also want to go it alone, or you could rely on the people around you.

And I guess another thing that may not be a crisis from the person’s point of view, but where people need accommodation from others and probably some kind of support to continue living however they choose to live, is if the person is having intense altered states of consciousness that may be really revealing to them, may not be causing you distress at all, and may even be experienced as a great revelation, but it may keep you from really communicating with the rest of the world, staying in your own internal world. So there is a need for solidarity and for communication to be extended as much as possible in a way that allows the person to know that they still live in community, that they still have access to community, to support, to solidarity, to food and housing, to the basic needs of life, so at some of the levels of communication and connection they are very much in line with the “ombudsperson” model that Maths Jesperson and his colleagues created, which is designed to reach out to people who live in their own, isolated worlds, and create connections with them, create a relationship of trust, and if the person eventually comes to accept it supportive, but the description is largely helpful “it must be respected the limits of the person” in the offer of communication, in the offer of a relationship, in the offer of any particular type of support.

Arroyo: You just brought me to the question that I now have in mind, that is, who can or who should provide support in this framework? I was thinking at first, is it possible that the psychologist or psychiatrist should continue to participate, or should they be removed? But with what you’re saying, I was thinking that… well, maybe the person who should provide support is the person the person in crisis trusts, so if the person trusts someone, perhaps that person should be the one who should provide support in that scenario.

Minkowitz: I don’t know if I take the position in the book of whether mental health people should or shouldn’t be or if there’s a place for mental health people in crisis support. I border on the total abolition of psychiatry; I say some things of that nature, but I want to move away from the expert, hierarchical aspect of mental health professions and mental health services.

I think that if there is someone who is trusted, and who is trustworthy, that person would be in the best position to provide support. We really have to think and develop our skills to do that. It is complicated because if someone trusts me, if someone feels that he can trust me and feels that I am in a position to support him and I feel that too, so “yes, I am in this relationship with you and I am willing to be there for you right now,” that is ideal. There may be times when those who feel that I can’t necessarily do that. I could be very isolated, the crises that I am experiencing could be precisely that I am alone, that I lost all my close friendships and connections, so where do I go?

With that, I also end by saying that there is a role for dedicated people who take on the role of being open to providing support in crises, and being open to establishing relationships even if they are short-term, which is kind of how the ombudsperson works, and is also in a sense what the mental health system attributes to itself. There is also peer support and personal assistance, which are more egalitarian approaches, so you don’t necessarily have to be in the mental health system. I’m actually starting to talk to a small group about exploring what we can do in terms of crisis support, aimed at the lesbian community probably in the United States, because I think you often want support, but if you’re looking for support beyond the people you already know and trust, you may very well want to have some idea of ​​who you’re talking to or whether they share some similar aspect of your experience.

In the United States there are some alternative lines of support, one based in the black community, another in the trans community, another basically in the survivor movement, in the peer support community, and each of them has their own community, their own ways to feel comfortable with each other, so we have to think about who could provide support in many different ways. Some ways may be pragmatic: If I’m a person who needs support now, how should I think about seeking support? And others will be, what should communities develop? How can our relationships with our family members, with our friends, with our communities in general, include mutual help? Some clearly do, if the person is experiencing some type of crisis or altered states of consciousness, which are not necessarily the same thing; we have to figure out our own language and concepts.

Arroyo: What comes to mind is that, as you mention, crisis is a term that is crossed by psychiatry, by medicine, so in that way we have a psychiatrization of common language, every time we talk about anguish, sadness, depression, anxiety, all those concepts are taken by psychiatry or psychiatry is always present in those ideas, so, what I like about your approach is that crisis support is an alternative to medicalization, it is an alternative to psychiatry in that sense, but also as you mention, it seems that there is always the presence of medicine, of psychiatry, we are trying a social approach, mutual support groups, peer support, but it seems that psychiatry always tries to be present. So, as you are a human rights defender, a psychiatric survivor, how does this book confront the idea of ​​mental health? How can we think about mental health in a way that is outside of psychiatry or medicine? Is it possible or do we have to build a new concept or idea?

Minkowitz: I don’t consider myself a mental health advocate. When someone recently tried to introduce me that way at a conference I spoke at, I flatly rejected it; I’m not a mental health advocate, I’m a survivor. I am a human rights defender and in many ways my defense is against everything that the mental health system represents. I don’t know if there can be a concept of mental health separate from mental health systems; so it’s not just psychiatry and medicalization.

You cannot separate the concept of mental health from the practices of that system, the powers and prerogatives that it claims and still struggles to maintain, all this globalization of mental health agendas. We are fighting against this at the UN all the time; there is a resolution being worked on now in New York to include mental health in the sustainable development goals, and there are people from the disability community working and campaigning for this resolution to be withdrawn, so it doesn’t get approved. But now it’s about to happen, and they’re trying to mitigate the damage it could do, but the mental health system is always trying to get more resources for itself, insinuate itself into every aspect of life, proclaiming yourself an expert in everything, subsuming every aspect of the fulfillment of human rights in “this is necessary because of the bad impact on mental health.”

Homelessness, poverty, discrimination, violence, all of this has a terrible impact on mental health but, therefore, “here we are as mental health professionals, they have to bring us into all these situations so that we can be there to care for people after the violence and harm has been done. By the way, they should not be doing this kind of damage and we have to speak out about it because we are the experts, because everything is about the negative impact on mental health.”

I am speaking very frankly about this. I don’t think there is anything particularly unfair in what I am saying, when I talk about the WHO. There is part of that organization that is trying to create and transform policy in line with the CRPD, but I think there are mixed motivations and mixed impacts, which in the end amounts to a kind of forced coupling of the human rights agenda of victims and survivors of psychiatric abuse, with the agenda of the mental health system, to continue their power, to solidify and strengthen their power, resources, reach, and reputation, which are fundamentally incompatible. Particularly as long as that system continues to perpetrate and has not resigned and accepted responsibility, they cannot say that they are accepting accountability when they simply continue in the power, when they continue to make decisions about how to respond to the injustices that have been committed against us. It cannot work that way. Our demands for justice are more serious and far-reaching; we do not accept it.

First the WHO proposed and drafted a new guide on what they called “legislation related to mental health,” but then in the second generation it was “legislation related to human rights and mental health,” which was very overreaching, because they were not just saying “hey, follow the CRPD, do something else like Mexico has done, to get rid of forced psychiatry,” they are really trying to propose political frameworks through legislation, and not just policies about what the mental health system should do, but policies about legal capacity, policies about the elimination of the insanity defense, and non-imputability, and you cannot do that when you as a health agency are responsible to the ministries of government health, which is through the World Health Assembly like the WHO. You cannot take care of the rights of the victims of psychiatry and the psychiatry agency at the same time, it cannot be done, you cannot be the health agency and say “this is how human rights have to apply to health agencies.” You cannot be the ones to develop that kind of guidance.

I would like to see the CRPD Committee Guidelines on Deinstitutionalization used as a framework, and there is a lot in there that essentially puts the mental health system aside, saying that they should not be in control of the housing (because they and other agencies that have managed the institutions should not be in control of the housing to people leaving institutions), or people living in the community, they should also not be in charge of service development, and my preference would be to see an agency based on a social model of disability, such as a development agency of supports for people with disabilities from within a social model, or within a social services agency in general. Experience and knowledge may have to come from different streams.

I’m still struggling to conceptualize this, so I would like to see at the UN level the CRPD committee, the UN disability human rights sector, give some focus on the rights of people with psychosocial disabilities and survivors of psychiatric institutionalization, as they should do with each of the specific groups. I think it is justified, because often there are very different barriers in terms of the needs of justice and basic human needs. I would like to see the development of funding streams and policy that is not in the hands of the mental health system, and so, I actually have a model of how I think about this, which is a bill in the United States called the “Disability Integration Act.”

I mentioned in the book that the mental health system is not going away, so people can end up meeting their needs through the mental health system as far as support and even if they want to use psychiatric drugs, if they want use different forms of psychotherapy or counseling that are based in the mental health system, but there should also be the option of contracting personal assistance directly, getting funding for peer support, or finding other ways to create your own networks of support, support that may not require funding. There could be many different ways to create the types of supports needed and that should be encouraged to be outside the mental health system and for the policy to be located in any agency that deals with supports for people with disabilities in general.

And so, having said that, I also know that depending on the context in particular countries, and the role played by mental health professionals and mental health services in these countries, I think there are different ways that people are going to relate to the concept of mental health, and what role mental health services could play. So my impression is that in Latin American countries the direction of advocacy has been to transform mental health, even to think that perhaps it does not have to be based on diagnosis and treatment, so that would put it closer to a true social model, even if it is located within the health system, and only to conceptualize health as more about well-being and not about illness. I understand that that may become the way we move forward in this area, as it seems to be in some of those countries, where the more progressive legal developments are taking place.

Arroyo: With this last part I was thinking that there are mental health organizations that seem to be trying to take a more human rights approach just to perpetuate their power, the hierarchies, and remain the ones in control of what we think is well-being and what is not, so this idea of ​​crisis support, this whole approach, is trying in a sense to turn things around and put mental health just as something apart, not something that defines what it is to be in a “well-being situation” or not, it may only be an alternative that people can decide to take.
So, with this I remember something that is in your book, and what I want to conclude with, and that is that “crisis support is not in the dimension of mental health services, but in the realization of restorative or transformative justice.” I think that this phrase, by itself, puts the idea of ​​crisis not in a mental health framework but in a human rights approach framework. Can you explain more about this idea of ​​restorative justice from the point of view of a crisis support scenario?

Minkowitz: What I’m saying is that support is not a mental health service; it could be more closely aligned with restorative justice or transformative justice, the mobilization of the community to care for a person in pain.

Understanding that grief needs the strength of community to create resilience and mutual understanding, and I also say that support is linked to restorative justice and in crises it can be confronting the impact of one’s own past choices and the full scope of one’s experiences of harm from the actions of others. I think we typically understand restorative or transformative justice to mean a type of response to interpersonal harm, of interpersonal conflict, but what I was trying to convey is that the concept of restorative and transformative justice, the way it tries to mobilize the community… I’m still exploring it. I think that crisis support doesn’t necessarily have to be the mobilization of a lot of people. It may be a one-on-one thing, but due to its nature, support can be as varied as personal crises.

I think the way crisis support is practiced tends to involve more than one person. Especially if it’s supporting someone over a period of time, it can’t just be one person doing it, because they’re going to get tired… I find myself taking a lot of different perspectives here, because I want to conceptualize supports from the perspective of the person who wants the supports and is using them, and here I am looking at it myself from the perspective of someone who is being asked in the role of a person who provides support, and I think I still don’t quite have complete focus.

In that section of the book, I’m trying to describe what crisis support on the ground means. What we need is to discuss: When do you need support? When do I need support? Do I want a lot of people around me or do I want to be alone and left alone, and maybe talk to one person, maybe call another person if I feel like it? I think it’s necessary to develop further this aspect of what it really means: How do I want to be supported?

This is not in the sense that I’m going to make an advance directive; I think people use advance directives in a way that makes sense, but I don’t encourage advance directives because that encourages people to think of them as vulnerable, and the mental health system uses that. To some extent, mental health systems and also disability law and policy tend to view advance directives as if that is what support for people with psychosocial disabilities means, as if that is what supportive decision making is. I think that’s oversimplifying, I think you can never know in advance what you’re going to need. I know there are some people who would do it, but it’s not something I would do, because I think personal crises are contextual. Anguish and alteration of perceptions are contextual.

I think community mobilization should be a practice that is based on community solidarity, which doesn’t necessarily mean bringing together a bunch of people, but that the relationship that is trying to develop is about community or about connection, it is based on the sense that it is being in community with this person, about being companions with another human being. You may already be connected to the person, it may be someone who you love, someone you know, but it may also be a suffering human being, and that’s more the sense of community I’m talking about, community as solidarity.

Then there is the aspect of facing the impact of one’s own past choices. That is something that is encouraged in restorative justice, it is not usually thought of in terms of experiencing distress as a condition for support, but it is a dimension that seems to me to arise. In my personal experience, and when I am involved with other people and faced with the magnitude of the experience of harm from other actions, from past or present abuse, both of these things can be painful and are part of a situation that you experience as a crisis, and that’s not necessarily what’s thought of when we initially conceptualize crisis support. I think there’s often that kind of dimension, but I don’t really want to make any definitive statement that crisis support should be understood as restorative justice, although I think they are linked.

Arroyo: You mention that you are not trying to give a specific framework for people to use, something like “this is crisis support and we have to do things in a certain way,” but to give a toolbox that they can use from and for their own experience. I think this is one of the most valuable things about the book, that it is not a definitive answer, but the possibility of a different approach for crisis situations.
As we mentioned, this is a small book in terms of the number of pages but a really big book in terms of the content, so I know I’m missing a lot points, but I don’t know if you want to make one last comment or clarification?

Minkowitz: I wanted to talk about the co-optation of the use of the concept of crisis support by the mental health system. In the United States, after all the focus on police violence, there was a lot of attention to crisis support and highlighting some practices as good practices, some of which I agree are good practices, and some of which are not. But I wanted to address the public policy in response. We already had 911 as the number that was for the police, fire, rescue or ambulance, and so the 911 service has been handling all the distress crisis calls, because they can send to mental health services, but they could either send an ambulance, or they could send the police, or both, and it was essentially a medicalized and coercive response.

They created a nationwide “988” system using suicide prevention lines and, I don’t want to say anything that might not be correct, but what they do is that they will call the police to make an involuntary commitment if they believe that the person “needs it” because they are dangerous to themselves or others. So, it’s like a half-hearted reform because they don’t send the police right away, and they give people the option to talk to someone, but it’s risky in the same way as going to a psychiatric emergency room because you want support or renewal of your prescription is risky, because they have the power to do violence against you, they have the legal authority to do violence against you, you have no recourse, and then you will be criminalized if you resist, and maybe they will shoot you.

It’s a really abusive situation in which to put people who are trying to access support through any of these means, so I just wanted to draw attention to the need for people to look very carefully at any policies, documents, legislation, or anything of that nature that talks about crisis support, even if they say it’s a social model, whatever they say about it, just make sure you use your own judgment and read between the lines, use your own critical thinking. Make sure it’s something that’s really based on the perspective of survivors of psychiatry or survivors of institutional violence, or of people wanting support, instead of the old status quo that keeps mental health systems in power.

Arroyo: Thank you very much Tina. We have to make sure that pathologization and medicalization are not disguised in laws and reforms. I am really grateful for your time and for giving me the opportunity to talk to you.

* Tina’s book Reimagining Crisis Support: Matrix, Roadmap and Policies can be accessed through the link


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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