The Social-Emotional Distress Field, or How I Divorced “Mental Health”

For two and a half years, until last April, I worked as an occupational therapist in two public mental health inpatient units in Melbourne, Australia.

During my work, I experienced a devastating process of disillusioning and moral injury, witnessing the mental health field’s harmful behaviours towards our clients. This experience brought me to the edge of madness, as well as many physical illnesses.

At this crisis point, I realised that resigning from my job was not enough. I needed to divorce from the Mental Health field as a whole.

Inspired by testimony therapy, I decided to write a document combining a divorce declaration (following the traditional Jewish divorce format) with a rationale for my divorce, a testimony of what I witnessed at work and my commitment to a better alternative.

The personal is political
—Anonymous

And if you should desist from deceiving
And if you should confess to the crime
It won’t be enough these days to say sorry,
Sorry won’t save you this time.
—Karine Polwart, “Sorry”

…because he always wanted to be different from what he was, but he didn’t want to change
—Michael Ende, The Neverending Story

Occupational therapists may be among the last to give up hope for effective treatment
—Lorna Jean King

On the 25^th of May, 2023; on the 5^th day of the Jewish Moon of Sivan, year 5783; the evening of the Shavuot holiday—the Day of Script Giving,

In the Melbourne metropolis, AKA Naarm, on the land of the Wurundjeri people of the Kulin nation, sitting on the Yarra River,

I, Tamar Ben-Barak, Daughter of Zilla and Jacob, also known by the nicknames Ima, Tamari, Tamaroola, Timie, Tehini&Honey, Gooli, Mip, Doobah and Kushkush,

Initiated by my own will, with no pressure or coercion,

I hereby divorce, dismiss and discharge the Mental Health field from being my professional partner, and declare it disqualified for marriage: an unsuitable partner, disrecommended to any faithful professional who wishes to work with people experiencing emotional distress.

Just like many of my divorced girlfriends, I found this partner too toxic for me, and too abusive for my moral, ethical and professional stance.

I base this declaration on my observations of the Mental Health field as a developmental OT who worked in two Mental Health Inpatient Units, on certain familiarity with the Field’s research literature and academic libraries, on my personal experience as a trauma survivor, and the many conversations, lectures and testimonies of Psychiatric Survivors I was exposed to.

I suggest that the Mental Health field is an unsuitable partner for the following reasons:

1. The term “mental illness” does not fit for purpose. It doesn’t reflect the social-emotional and developmental etiology of extreme emotional distress. Many psychiatric diagnoses have poor validity and reliability. Furthermore, often they poorly reflect the person’s understanding of themselves, and offer little practical support to recipients.

(Note: some psychiatric diagnoses can be beneficial for certain people, depending on the person’s choice, circumstances and the person-centred features of the diagnostic process)

2. Currently, the Mental Health field seems to be dominated by a biomedical approach. Hence, it has limited ability to expand its view to include social-emotional and developmental processes in its core framework and baseline practices. There are a few different forces that maintain this and a big question mark about the nature and availability of the counter-forces needed to change it.

3. But even more so, the Mental Health field has a rich, prolonged history of professional aggression, cruel practices, disrespect, un-listening and trauma induction towards its recipients.

4. This history, and the continuation of these elements in current practices, have not been well-processed by the Field.

Mental Health professionals are not given systemic, adequate opportunity to reflect on this past-present continuum. They are not encouraged to process the emotional and intellectual themes of trauma, shame, guilt and responsibility encompassed in it. Hence, as a cohort, we cannot fully recover from past and present traumata inflicted on our clients by our professional ancestors, our colleagues—and ourselves.

5. This unprocessed guilt and shame, combined with the common change-resistant pattern of human institutions (medical institutes in particular), often leads to highly defensive responses, including further aggression, trauma denial and victim-blaming.

6. The concept of “insight” plays a significant role here: while it is recognised in some professional guidelines that insight is patchy by nature, the widespread norm is to identify people in distress as having either “good insight” or “poor insight”, and use it as a blanket term to describe the person as a whole. Thus, as soon as someone is identified as having “poor insight” in some respect, ALL their reflections about themselves, their needs and their healthcare are likely to be dismissed and ignored.

This pattern perpetuates the widespread stigma against people in extreme emotional distress.

7. As a result of trauma-induced interventions (together with treatments’ physiological properties), many psychiatric interventions and Mental Health services are directly and indirectly responsible for increased morbidity and mortality among their recipients. However, these are not well captured by research. For example, the prevalence of service-induced PTSD and suicidality and their main driving factors are yet unknown.

This stands in contrast to other areas of healthcare. For example, it is fairly easy to discover the rate of post-surgery infections (usually 2-7%, with up to 13% for urinary procedures, if you care to know) and the main healthcare workers’ behaviours that drive them. There is also evidence about post-traumatic features emerging from medical interventions (14-28% in children post-surgery, 50% following ICU admission). But psychiatry still didn’t internalise the tight correlation and likely causation between traumata and “mental illnesses”, and doesn’t take full responsibility for its actions.

8. Mental health professionals are not properly taught about trauma. In addition, many training programs over-emphasise “severe mental illnesses”, and under-cover anxiety and post-traumatic stress.

As a result, when assessing their clients, many mental health practitioners have a bias towards psychotic symptoms and away from post-traumatic features. Severe flashbacks, founded fears or defensive responses to intimidating interactions might easily be misinterpreted as “psychotic”. That can lead to escalation, wrong interventions, over-medication and unnecessary (and damaging) use of force.

9. Hence, the many good-hearted health professionals who wish to work well with people in distress are repeatedly failed by the field.

Many entre the field as new graduates. They follow their seniors’ lead and adopt inadequate norms and beliefs that hamper their ability to see the harm done in the name of treatment. Many others recognise this wrongness and try to work against it. I was one of them, and had many such good colleagues in my team. But over and over again, while creating small impacts in some situations, we rarely managed to impact the norm, change practices or influence the culture. The tide was way too strong.

10. All these features are not attributed to a single service, system or professional discipline: they stem from the Mental Health field itself. They are maintained by textbooks, libraries, university curriculums, widespread clinical norms, research priorities and research methodologies. Varied between different countries, this is still an international trend.

• • But don’t fret, there is hope around the corner 🙂

Engagement Declaration

While divorcing the Mental Health field, I am still committed to serving its recipients.

Hence, I hereby declare my engagement with the emerging field of Social-Emotional Distress.

By Social-Emotional Distress field, I mean the many initiations (many of them Lived Experienced-led), aimed to provide alternatives to Mental Health thinking and practices.

This includes (but is not limited to):

• Political and societal initiations such as the Recovery movement, the c/s/x movement, Mad Pride, Drop the Disorder and Recovery in the Bin (UK).
• Frameworks such as the Power Threat Meaning framework, the Dissociachotic framework, Suicide Narratives and Mad Studies.
• Focused approaches, specific services and other initiations, such as Maastricht approach, Hearing Voices Network, Open Dialogue, Alternatives to Suicide, Emotional CPR, Soteria Houses, AMEN – A Land Where Women Heal (Israel), ReAwaken Australia, Just Listening Community (Adelaide), DISCHARGE (Perth), Delancy Street Foundation (US), The Big Anxiety (Sydney) and Slice/Silence project (Melbourne).
• My contribution to this space is yet to be explored. I might harness my occupational therapist’s skills to develop a self-reflection tool and make it available to independent users. Or I might turn to peer support and establish an Alternative To Suicide group for junior doctors. Time will tell. My first task is to do what I am doing now: suggesting that the Social-Emotional Distress field is a valid entity; offering mental health activists a conceptual alternative that could decisively take us away from the catchy “mental illness” and “mental health” concepts and plant us in a fresh, fertile ground.

Clarifications

I am aware that the Social-Emotional Distress field has not been formally defined as such.

But I believe that there is a strong common thread between the frameworks and initiations mentioned above: prioritizing people’s experiences and opinions about themselves, and seeing their internal distress in the ultimate context of inter-personal and external forces.
I believe that grouping all of us under this conceptual umbrella is both theoretically valid and can be practical and beneficial for our cause.

I am also aware that many professionals who support and advocate for the Social-Emotional Distress viewpoint identify themselves as mental health practitioners. Some of them are deeply committed to working within the current mental health structures. This stance is to be respected.

Yet, I believe that the Social-Emotional Distress principles are fundamentally different to the core theories, frameworks and practices of the Mental Health field.

I also believe that a real integration of the Social-Emotional Distress frameworks in the Mental Health field is not feasible, due to the sharp contrast between the two. More often than not, integration attempts would lead to tokenism, superficial language change, add-on duties that add to the professionals’ workload while not challenging or omitting conflicting actions (hence are prone to failure), and ongoing attempts to employ many Social-Emotional agents in the Mental Health institutions, keep them busy under the Field’s constraints, distract them from sensitive issues and prevent them from creating real impact. As has been visibly done so far.

For me, there is no real hope in such “integration” or “evolution”. I agree with the voices who say that the mental health system is “broken beyond repair”: this system is built upon a rotten field’s foundations. When building your house on quicksand, surely it is bound to crack.

Hence, I choose to see the initiations above as forming a valid, respectable field in the making.

I choose to identify myself with this field and differentiate myself from the Mental Health field.

I choose to believe that these two fields are incompatible.

And for the next four or five years, I choose to team up with others who work in this space, and together help this potential field to be established.

I choose to hope that with time and effort, this field would prove itself trustworthy, reliable and cost-effective in responding to people’s distress, and—big hope!—will eventually replace and dominate Mental Health-based services.

On the practical level, I choose to avoid working in “mental health”, until I find a designated Social-Emotional Distress service—or create one as an independent practitioner.

NOTE: According to the traditional Jewish law, a couple who has been divorced is not allowed to be in Yihud, which means “intimate seclusion”. That is, the former husband and wife should not live in the same living complex, and should not be together in a defined space with no other people to witness them.

Hence, I shall choose to operate in organisations that are tuned to Social-Emotional Distress thinking. When engaging with Mental Health agents, I will use my language smartly to avoid upfront conflict while upholding my values and affiliation. I will also connect to like-minded colleagues to avoid “mutual seclusion” with Mental Health agents. It might be tricky, but I will try it and see if it works.

Personal Note

I am a woman of strong emotions and even stronger attachment patterns. It is not always convenient, but this is the Tamar I need to live with. I cannot be someone else.
Regardless of how it eventuated, I accept that my professional identity is a significant part of my personality, and that professional belonging is highly important to me.
Hence, the Social-Emotional Distress field is where, for the time being, I want to belong.