Great article and I enjoyed reading the case studies. The quote “voice hearing is neither dangerous nor uncommon. It’s a natural phenomenon that some experience to a higher and more manifest degree than others, especially those that are exposed to childhood trauma” was interesting to me, as my research into this movement has led me to some very interesting cross-cultural research into what we in the west call schizophrenia. The most illuminating is when I stumbled upon research that showed that in East Asian countries where there is a strong spirituality and cultural tradition related to hearing voices of ancestors. There are people in these countries who report hearing voices that aren’t there, but they are not particularly scared of or bothered by the voices, as they believe they are the voices of their ancestor spirits. The voices usually nag them about things in their lives they could be improving – clean the house more, eat less junk. I think this could be such a crucial distinction for people in western countries dealing with ‘medicalized’ schizophrenia, that they are ‘dangerously crazy with a broken brain’. It’s more- listen, nothing is wrong with your brain. if you grew up in China, maybe you would be fine, just with nagging ancestor spirits. You just were not given a positive framework to hear the voices – and combined with trauma, it was just some very bad luck .
I would also add that another positive nonpathologizing community intervention could be increased case management support for anyone who needs it. I have worked in community mental health clinics in America providing case management to individuals receiving mental health treatment, who are also living in poverty and receiving state insurance/ medicaid. The biggest issues these people were dealing with were related to systemic issues that go along with poverty and associated issues – criminal justice involvement that wealthier people don’t have to deal with like charges for marijuana possession, drunk driving, etc, being targeted for living in low income areas ; transportation issues making it hard to keep a job or get to any appointments; literacy issues related to filling out paperwork or maintaining benefits; for women, child custody battles and abusive partners; difficulties navigating housing subsidy applications and keeping up with paperwork and rent in keeping the subsidies etc etc etc. None of these issues have anything to do with ‘mental illness’ and I often felt my case management work in helping people pay their rent was a lot more useful than the nebulous therapy/psychiatry they were also receiving at my agency.
This is beautifully written. One of the things that resonated with me was how dehumanizing it is to be forcefully medicated with cocktails of drugs while attempting to work through an existential crisis. I was lucky not to be forcefully committed when I as a struggling teenaged girl, but I was dragged to a psychiatrist who put me on pretty much every antidepressant on the market in alternating dosages and combinations.
At the time I was able to articulate some of the sources of my profound angst and anxiety- entering high school, struggling socially, the terror of being noticed by boys and starting relationships-with the ‘wrong kinds of boys’, only because they were the only ones who seemed interested in me- finally making a good female friend, who stopped being interested in spending time with me once she started a serious relationship . I couldn’t articulate problems with my home environment that led to me to be so vulnerable to social rejection and sexual exploitation. I had no basis for comparison for what is ‘normal’ for parents.
My mother accompanied me to every psychiatrist appointment, and sat next to me and described how I was doing, as if I wasn’t there- but she was one of the primary sources of my ‘mental problems’, though I didn’t know how to say. She was a towering figure to me and my younger brother, subject to intense, dizzyingly rapid mood swings, and red-hot fits of rage, which although she often tried to contain the worst of them from us (retreating to her bedroom to slam her closet door over and over and screaming profanities at the top of her lungs) – still felt like a direct threat to our safety. She would become frail and weepy, wrapping blankets around her on the living room couch and sobbing quietly, blowing her nose over and over, saying her head hurt or her stomach hurt. She could be bouncy and childishly silly and hyperactive, which as a child felt fun but also slightly dangerous, because she was acting like a kid, not a mom. Even in her ‘normal’ state she was imperious, opinionated, controlling- she had very strong opinions and we were terrified to do or think anything that went against her judgment, which was somewhat capricious and devastatingly cruel.
My father was wholly her servant, and tried to be a peacemaker and source of calm, but always deferred to her. He had cultivated a ‘mask’ of calm cheerfulness, which he worked very hard to maintain. However, his mask could slip easily. He also was subject to bouts of rage, and of storming out of the room during a conflict, and also would resort to violence when furious- slamming objects down on the table, slamming drawers and doors . He was also judgmental and imperious- both of my parents had high intelligence, and were not ashamed of it- even as a young child if I showed him something I drew or wrote, he would pause too long in assessing it seriously, his face awash in disapproval, his judgement clear. “It’s ok,” he would say, somewhat disdainfully, or “It’s…nice” unconvincingly.
I think it was the worst thing for me when dragged to the guidance counselor and to a psychiatrist was the message from everyone that *I* was the problem. I was a 15 year old girl who went to school everyday, didn’t do any drugs, and was an honors student, whose only crime was cutting shallow lines in my skin with a safety pin (and perhaps my ‘willingness’ to date the ‘bad boys’ who were asking me out)- rather than anyone bothering to look at the powerfully confining and oppressive social forces weighing me down at school and at home to the point I was existentially suffocating.
If I had been given the space and time, and taken to a better environment rather than told I have a brain disease and given cocktails of medications, who knows how much better my late teens and early 20s could have turned out? The description in this article of ADHD camps and your idea of a holistic, creative space, would’ve been paradise compared to the chemical prisons I was subjected to. And in fact, I found more healing in the generic summer camps I started attending, a new social environment where a lot of people didn’t know each other and were eager to make new friends- than any of the ‘mental health treatment’ I received.
Great article, very well written and an important issue. Having worked in several Community Mental health clinics, which are funded by Medicaid/state insurance and therefore serve individuals living at or below the poverty level, I will say that many people who accumulate mental health diagnoses and intensive treatment, are not necessarily more ‘mentally ill’ or ‘severe’ or ‘dysfunctional’ than those who never seek treatment, but will end up in the system due to extreme desperate circumstances brought on by their poverty. For example, I worked with one woman who was in her 60s and who was struggling with homelessness. She was actually a very mentally stable person, considering everything she’d been through. She and her boyfriend lived in a small standalone garage during the warmer months with no electricity or facilities. In the coldest months, they would make sure they had alcohol in their systems then check themselves into a 30 day inpatient rehab facility, because it was warm. Her kids were grown and she had grandkids, but if she had faced a custody situation, her rehab stays could have easily been used against her.
The two times I went into the ‘psych ward’ or ‘behavioral health inpatient unit’ as an adult were markedly different for two reasons- the first time, I was eager to take medication. The second time, I was wary to take medication.
Both hospitalizations were very clearly brought on by life stressors, and by my relationship with my husband who always put an inordinate amount of pressure on me to remain at jobs that I couldn’t stand. I have been working in social work/ social services and have hated this career choice for years but have not been able to find any lateral career changes to leave the sector. Both hospitalizations were when I got to the point that the worker exploitation and toxic work environment at my job reached a point that I quit in frustration, and my husband was furious that I had. Both times I went to the inpatient unit because it was the only way I could get away from him, as I didn’t have any close friends or family I could stay with (my parents were, frankly, worse than him). The second time, on top of that, we had a young daughter, and the level of stress of caring for a baby on top of working full time was making me justifiably crazy, as many mothers in America can attest to. So, pretty super obvious environmental causes for my emotional distress. Not that any of the staff at the inpatient facility seemed to care or address these issues.
It was astonishing to me during my second hospitalization, the way I was treated for refusing medication. Almost every staff I interacted with – the psychiatric nurse practitioner who was assigned to me, the mental health technicians, the nurses, had a reaction of serious concern and alarm, and it was clear they were reading my ‘med refusal’ as a ‘sign of my mental illness’ and ‘treatment resistance’ and ‘unwillingness to get well’. I was treated like a misbehaving child who was not doing a good enough job of being sorry/ taking accountability. I tried not to get into a ‘global’ discussion of whether the medication was even effective for anyone (seemed overly antagonistic, when everyone else on my ward was taking several psych meds), and simply stated to the staff that I was going through life stressors that I needed to get away from, and did not feel like being medicated through them was what I needed right now.
At one point at one of my absurdly brief five minute sessions with my assigned psychiatric nurse practitioner, we discussed my discharge date, and he somewhat disdainfully referred to me not taking medication and said ‘I don’t even know what you’re getting out of being here anyway’. The implication was that the only reason for someone to stay in the psych ward was to be doped up with psych meds and monitored on them for a measly week, maybe two weeks tops. I mentioned that the most helpful thing was being able to spend time with and talk to the other patients on my ward, who were also struggling with life stressors. ‘oh, the milieu’ he said, using a clinical term for the unstructured social environment of residential treatment.
I had, actually, agreed to take wellbutrin on my first day there- I had taken it briefly for maybe eight months, about a year after my daughter was born. After one day of it in the psych ward, I felt more jittery and anxious than I had been before I took it, and said I was not going to take it any more. Rather than respect this decision, the nurses and techs all acted alarmed and concerned. “You haven’t even given it a chance to start working!” they said. “It hasn’t even gotten into your system- if you feel anxious that’s just your brain, NEEDING the medication”
I can relate to your mindset! I have been doing various forms of case management for years in different sectors, homeless services, drug rehab, community mental health, affordable housing, currently IDD…and briefly did a stint working for an agency that provided case management for individuals with special needs trusts. It was ‘private pay’ and billed per hour for case management time out of their trust accounts. We also did private case management available for anyone willing to pay, who didn’t have trusts with our agency. The rates were something like $150-$200/hour. I had productivity requirements of billing 3 hours of work a day, which didn’t sound like much, except the workload was so low, there wasn’t much going on. If I wanted to meet my requirement, I had to stretch out time for a bunch of different clients, come up with busywork etc to bill for. Even though this ‘time stretching’ is standard practice for Medicaid-billed case management (and I should mention- private pay lawyers essentially do this all the time when coming up with rates and estimating time spent on cases) I COULD NOT ethically in good conscience do this knowing it was people’s own real money. I honestly don’t know how people do things like this. I don’t know if some of it is imposter syndrome or pathological people pleasing or what….but I do have my master’s in counseling psychology and have worked on and off towards licensure- I really struggle to envision being comfortable with billing someone $150 of their own money to sit and talk to me for an hour.
I agree that focusing the narrative just on the social workers who go into private practice – that they are betraying the profession etc- makes it seem like the social workers are the problem- rather than the systems forcing them to go into private practice. Which is briefly mentioned at the beginning of this article. The funding and pay is abysmal for most social work positions and needed social service positions serving the underserved – sectors like affordable housing, homelessness, domestic violence, intellectual disabilities, nursing homes, etc. What’s so insulting and unsustainable is when these jobs require a 2-year or a 4-year degree – and pay the same as nearby retail positions that you can get without a high school diploma. To not get paid a living wage while also having to pay off student loan debt- this is the larger issue. It’s not that social workers are being selfish, it’s that they were sold a lie by colleges offering the BSW and MSW degrees. When the reality of that lie hits, if they are not already independently wealthy or married to a spouse who supports them, I feel social workers have no choice but to go into private practice.
We need to be able to have a nuanced conversation about the medicalization of gender distress. If there is to be a union between the LGBT/queer movement and the Mad in America/anti-psychiatry movement, I think we need to be willing to acknowledge that the very thing that the anti-psychiatry movement rallies against- over-medicalization and over-prescription for individual distress- is in fact flourishing in the medical treatment of transgender individuals.
As a former therapist, I think the medical model we use to treat individuals who are suffering from gender identity related distress, or who identify as transgender, has very poignant similarities to the way psychiatry historically treated individuals suffering from extreme emotional distress or labeled ‘mentally ill’. In both cases, the person’s feelings of distress are placed as existing only INSIDE of that individual person, de-contextualizing them from the culture and environment in which they live. This is taken even further when psychiatry and the medical establishment escalates this to the medicalization of someone’s suffering or of ‘being different’, to diagnose the person with a medical condition, causing a cascade of medical interventions to begin, such as life-altering medications and surgeries with sometimes debilitating side effects.
The range of beliefs and approaches to ‘how to be transgender’ within the transgender movement itself speaks to the inconsistencies of it being a ‘medical’ issue and somewhat of an acknowledgement that this doesn’t need to be ‘medical’ at all. Many people will say that they are transgender but feel no need to engage in any medical interventions at all- no hormone pills, no surgeries. Some of this group may ‘socially transition’- adopt a different name and pronouns, and start dressing in ways associated with the opposite sex. Others, however, will say that they need the pills and surgeries and are unable to live without them. Why can’t we examine this vast discrepancy? Isn’t this the heart of the issue?
The concept of ‘gender’ is very much social, environmental, and cultural, yet the left is not willing to acknowledge that this current medical model approach to being transgender abandons the idea that someone’s gender distress may be informed by our culturally enforced oppressive norms of gender and sex. Rather, for anyone seeking help from either the psychiatric/mental health treatment/therapeutic/medical establishment, it is a problem existing in the brain/mind/body of the individual experiencing the distress, which can be treated with medical interventions. Sound familiar? This is the very approach that psychiatry uses, the one many psychiatric survivors (including myself) have found to be so harmful and negatively life-altering.
In my Mental Health Counseling graduate program to become a therapist, and in various treatment facilities I worked at after, we were taught to practice from a ‘bio-psycho-social’ model- that we had to use a unified model in treating people that keeps in mind how these various factors inform a person’s experience. To my dismay, this is not actually used. People are medicalized and medicated instead of actually understanding them and helping them. Someone’s ‘culture’ becomes a box to check about their religious or ethnic background, rather than an examination of all the external influences on their beliefs about themselves, their worth as a person, their identities.
I appreciate you writing this, and as someone who also worked in homeless services it was validating to read. I provided community based case management to individuals who were homeless or ‘at risk of homelessness’ who were recently hospitalized for mental health or were currently seeing outpatient psychiatry and therapy at my agency. My case management program’s goal was to find the individuals on my caseload permanent housing. Of course, it was next to impossible in a housing crisis, and the county I worked in was mostly rural, with only a handful of actual towns- three of them were very upscale, and just one was run-down enough where you could find landlords willing to take someone with no rental history and a section 8 (housing choice voucher) rental subsidy.
The saddest thing though, was how many psych meds so many of them were on, and the ones on the most medications tended to be the ones who were or had been ‘street homeless’ and who had endured multiple psychiatric inpatient commitments. I had people on three, four, fix, six different medications.
We were required to have regular supervision meetings with one of the agency psychiatrists, I assume just so we could bill at a higher rate as a clinical service with psychiatric supervision. I hated these meetings because all of the case managers in my program were supposed to bring up clinical concerns that the psychiatrist would address or advise us on…the only thing is, ‘clinical presentation/symptoms’ of the ‘mental illnesses’ of the people we worked with was the last thing any of us cared about. We cared about shelter placement, section 8 subsidy applications, application approvals, deadlines to find housing with the subsidy before you lose it, finding a rental apartment, the person’s income (or lack thereof), social security income applications, food stamps, probation officers; a mountain of real-world practical problems with being homeless and struggling with low income. So in these meetings we would sit in mostly silence and try to dredge up any information resembling something ‘clinical’ or ‘symptoms’ .
These people did not need psych meds. They needed PERMANENT, SAFE HOUSING – and not just a crummy, dirty, bug-infested apartment in a crime-ridden area of town, with a slumlord landlord who won’t even fix the broken toilet. They needed STABLE INCOME. If they were freaking out, having panic attacks, aggression, hearing voices, you name it, don’t we think this was more because they were in horrible, desperate circumstances, fighting a broken system that shut them down at every turn, rather than a “mental illness” ? Were their brains ‘diseased’ or was it perfectly understandable for them to have the emotional/behavioral struggles they had based on how they had been treated by everyone their whole lives, and how desperate and in crisis they were now?
Great article and I enjoyed reading the case studies. The quote “voice hearing is neither dangerous nor uncommon. It’s a natural phenomenon that some experience to a higher and more manifest degree than others, especially those that are exposed to childhood trauma” was interesting to me, as my research into this movement has led me to some very interesting cross-cultural research into what we in the west call schizophrenia. The most illuminating is when I stumbled upon research that showed that in East Asian countries where there is a strong spirituality and cultural tradition related to hearing voices of ancestors. There are people in these countries who report hearing voices that aren’t there, but they are not particularly scared of or bothered by the voices, as they believe they are the voices of their ancestor spirits. The voices usually nag them about things in their lives they could be improving – clean the house more, eat less junk. I think this could be such a crucial distinction for people in western countries dealing with ‘medicalized’ schizophrenia, that they are ‘dangerously crazy with a broken brain’. It’s more- listen, nothing is wrong with your brain. if you grew up in China, maybe you would be fine, just with nagging ancestor spirits. You just were not given a positive framework to hear the voices – and combined with trauma, it was just some very bad luck .
I would also add that another positive nonpathologizing community intervention could be increased case management support for anyone who needs it. I have worked in community mental health clinics in America providing case management to individuals receiving mental health treatment, who are also living in poverty and receiving state insurance/ medicaid. The biggest issues these people were dealing with were related to systemic issues that go along with poverty and associated issues – criminal justice involvement that wealthier people don’t have to deal with like charges for marijuana possession, drunk driving, etc, being targeted for living in low income areas ; transportation issues making it hard to keep a job or get to any appointments; literacy issues related to filling out paperwork or maintaining benefits; for women, child custody battles and abusive partners; difficulties navigating housing subsidy applications and keeping up with paperwork and rent in keeping the subsidies etc etc etc. None of these issues have anything to do with ‘mental illness’ and I often felt my case management work in helping people pay their rent was a lot more useful than the nebulous therapy/psychiatry they were also receiving at my agency.
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This is beautifully written. One of the things that resonated with me was how dehumanizing it is to be forcefully medicated with cocktails of drugs while attempting to work through an existential crisis. I was lucky not to be forcefully committed when I as a struggling teenaged girl, but I was dragged to a psychiatrist who put me on pretty much every antidepressant on the market in alternating dosages and combinations.
At the time I was able to articulate some of the sources of my profound angst and anxiety- entering high school, struggling socially, the terror of being noticed by boys and starting relationships-with the ‘wrong kinds of boys’, only because they were the only ones who seemed interested in me- finally making a good female friend, who stopped being interested in spending time with me once she started a serious relationship . I couldn’t articulate problems with my home environment that led to me to be so vulnerable to social rejection and sexual exploitation. I had no basis for comparison for what is ‘normal’ for parents.
My mother accompanied me to every psychiatrist appointment, and sat next to me and described how I was doing, as if I wasn’t there- but she was one of the primary sources of my ‘mental problems’, though I didn’t know how to say. She was a towering figure to me and my younger brother, subject to intense, dizzyingly rapid mood swings, and red-hot fits of rage, which although she often tried to contain the worst of them from us (retreating to her bedroom to slam her closet door over and over and screaming profanities at the top of her lungs) – still felt like a direct threat to our safety. She would become frail and weepy, wrapping blankets around her on the living room couch and sobbing quietly, blowing her nose over and over, saying her head hurt or her stomach hurt. She could be bouncy and childishly silly and hyperactive, which as a child felt fun but also slightly dangerous, because she was acting like a kid, not a mom. Even in her ‘normal’ state she was imperious, opinionated, controlling- she had very strong opinions and we were terrified to do or think anything that went against her judgment, which was somewhat capricious and devastatingly cruel.
My father was wholly her servant, and tried to be a peacemaker and source of calm, but always deferred to her. He had cultivated a ‘mask’ of calm cheerfulness, which he worked very hard to maintain. However, his mask could slip easily. He also was subject to bouts of rage, and of storming out of the room during a conflict, and also would resort to violence when furious- slamming objects down on the table, slamming drawers and doors . He was also judgmental and imperious- both of my parents had high intelligence, and were not ashamed of it- even as a young child if I showed him something I drew or wrote, he would pause too long in assessing it seriously, his face awash in disapproval, his judgement clear. “It’s ok,” he would say, somewhat disdainfully, or “It’s…nice” unconvincingly.
I think it was the worst thing for me when dragged to the guidance counselor and to a psychiatrist was the message from everyone that *I* was the problem. I was a 15 year old girl who went to school everyday, didn’t do any drugs, and was an honors student, whose only crime was cutting shallow lines in my skin with a safety pin (and perhaps my ‘willingness’ to date the ‘bad boys’ who were asking me out)- rather than anyone bothering to look at the powerfully confining and oppressive social forces weighing me down at school and at home to the point I was existentially suffocating.
If I had been given the space and time, and taken to a better environment rather than told I have a brain disease and given cocktails of medications, who knows how much better my late teens and early 20s could have turned out? The description in this article of ADHD camps and your idea of a holistic, creative space, would’ve been paradise compared to the chemical prisons I was subjected to. And in fact, I found more healing in the generic summer camps I started attending, a new social environment where a lot of people didn’t know each other and were eager to make new friends- than any of the ‘mental health treatment’ I received.
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Great article, very well written and an important issue. Having worked in several Community Mental health clinics, which are funded by Medicaid/state insurance and therefore serve individuals living at or below the poverty level, I will say that many people who accumulate mental health diagnoses and intensive treatment, are not necessarily more ‘mentally ill’ or ‘severe’ or ‘dysfunctional’ than those who never seek treatment, but will end up in the system due to extreme desperate circumstances brought on by their poverty. For example, I worked with one woman who was in her 60s and who was struggling with homelessness. She was actually a very mentally stable person, considering everything she’d been through. She and her boyfriend lived in a small standalone garage during the warmer months with no electricity or facilities. In the coldest months, they would make sure they had alcohol in their systems then check themselves into a 30 day inpatient rehab facility, because it was warm. Her kids were grown and she had grandkids, but if she had faced a custody situation, her rehab stays could have easily been used against her.
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The two times I went into the ‘psych ward’ or ‘behavioral health inpatient unit’ as an adult were markedly different for two reasons- the first time, I was eager to take medication. The second time, I was wary to take medication.
Both hospitalizations were very clearly brought on by life stressors, and by my relationship with my husband who always put an inordinate amount of pressure on me to remain at jobs that I couldn’t stand. I have been working in social work/ social services and have hated this career choice for years but have not been able to find any lateral career changes to leave the sector. Both hospitalizations were when I got to the point that the worker exploitation and toxic work environment at my job reached a point that I quit in frustration, and my husband was furious that I had. Both times I went to the inpatient unit because it was the only way I could get away from him, as I didn’t have any close friends or family I could stay with (my parents were, frankly, worse than him). The second time, on top of that, we had a young daughter, and the level of stress of caring for a baby on top of working full time was making me justifiably crazy, as many mothers in America can attest to. So, pretty super obvious environmental causes for my emotional distress. Not that any of the staff at the inpatient facility seemed to care or address these issues.
It was astonishing to me during my second hospitalization, the way I was treated for refusing medication. Almost every staff I interacted with – the psychiatric nurse practitioner who was assigned to me, the mental health technicians, the nurses, had a reaction of serious concern and alarm, and it was clear they were reading my ‘med refusal’ as a ‘sign of my mental illness’ and ‘treatment resistance’ and ‘unwillingness to get well’. I was treated like a misbehaving child who was not doing a good enough job of being sorry/ taking accountability. I tried not to get into a ‘global’ discussion of whether the medication was even effective for anyone (seemed overly antagonistic, when everyone else on my ward was taking several psych meds), and simply stated to the staff that I was going through life stressors that I needed to get away from, and did not feel like being medicated through them was what I needed right now.
At one point at one of my absurdly brief five minute sessions with my assigned psychiatric nurse practitioner, we discussed my discharge date, and he somewhat disdainfully referred to me not taking medication and said ‘I don’t even know what you’re getting out of being here anyway’. The implication was that the only reason for someone to stay in the psych ward was to be doped up with psych meds and monitored on them for a measly week, maybe two weeks tops. I mentioned that the most helpful thing was being able to spend time with and talk to the other patients on my ward, who were also struggling with life stressors. ‘oh, the milieu’ he said, using a clinical term for the unstructured social environment of residential treatment.
I had, actually, agreed to take wellbutrin on my first day there- I had taken it briefly for maybe eight months, about a year after my daughter was born. After one day of it in the psych ward, I felt more jittery and anxious than I had been before I took it, and said I was not going to take it any more. Rather than respect this decision, the nurses and techs all acted alarmed and concerned. “You haven’t even given it a chance to start working!” they said. “It hasn’t even gotten into your system- if you feel anxious that’s just your brain, NEEDING the medication”
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and they prop up psychiatry and polymedication without questioning it….
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I can relate to your mindset! I have been doing various forms of case management for years in different sectors, homeless services, drug rehab, community mental health, affordable housing, currently IDD…and briefly did a stint working for an agency that provided case management for individuals with special needs trusts. It was ‘private pay’ and billed per hour for case management time out of their trust accounts. We also did private case management available for anyone willing to pay, who didn’t have trusts with our agency. The rates were something like $150-$200/hour. I had productivity requirements of billing 3 hours of work a day, which didn’t sound like much, except the workload was so low, there wasn’t much going on. If I wanted to meet my requirement, I had to stretch out time for a bunch of different clients, come up with busywork etc to bill for. Even though this ‘time stretching’ is standard practice for Medicaid-billed case management (and I should mention- private pay lawyers essentially do this all the time when coming up with rates and estimating time spent on cases) I COULD NOT ethically in good conscience do this knowing it was people’s own real money. I honestly don’t know how people do things like this. I don’t know if some of it is imposter syndrome or pathological people pleasing or what….but I do have my master’s in counseling psychology and have worked on and off towards licensure- I really struggle to envision being comfortable with billing someone $150 of their own money to sit and talk to me for an hour.
Report comment
I agree that focusing the narrative just on the social workers who go into private practice – that they are betraying the profession etc- makes it seem like the social workers are the problem- rather than the systems forcing them to go into private practice. Which is briefly mentioned at the beginning of this article. The funding and pay is abysmal for most social work positions and needed social service positions serving the underserved – sectors like affordable housing, homelessness, domestic violence, intellectual disabilities, nursing homes, etc. What’s so insulting and unsustainable is when these jobs require a 2-year or a 4-year degree – and pay the same as nearby retail positions that you can get without a high school diploma. To not get paid a living wage while also having to pay off student loan debt- this is the larger issue. It’s not that social workers are being selfish, it’s that they were sold a lie by colleges offering the BSW and MSW degrees. When the reality of that lie hits, if they are not already independently wealthy or married to a spouse who supports them, I feel social workers have no choice but to go into private practice.
Report comment
We need to be able to have a nuanced conversation about the medicalization of gender distress. If there is to be a union between the LGBT/queer movement and the Mad in America/anti-psychiatry movement, I think we need to be willing to acknowledge that the very thing that the anti-psychiatry movement rallies against- over-medicalization and over-prescription for individual distress- is in fact flourishing in the medical treatment of transgender individuals.
As a former therapist, I think the medical model we use to treat individuals who are suffering from gender identity related distress, or who identify as transgender, has very poignant similarities to the way psychiatry historically treated individuals suffering from extreme emotional distress or labeled ‘mentally ill’. In both cases, the person’s feelings of distress are placed as existing only INSIDE of that individual person, de-contextualizing them from the culture and environment in which they live. This is taken even further when psychiatry and the medical establishment escalates this to the medicalization of someone’s suffering or of ‘being different’, to diagnose the person with a medical condition, causing a cascade of medical interventions to begin, such as life-altering medications and surgeries with sometimes debilitating side effects.
The range of beliefs and approaches to ‘how to be transgender’ within the transgender movement itself speaks to the inconsistencies of it being a ‘medical’ issue and somewhat of an acknowledgement that this doesn’t need to be ‘medical’ at all. Many people will say that they are transgender but feel no need to engage in any medical interventions at all- no hormone pills, no surgeries. Some of this group may ‘socially transition’- adopt a different name and pronouns, and start dressing in ways associated with the opposite sex. Others, however, will say that they need the pills and surgeries and are unable to live without them. Why can’t we examine this vast discrepancy? Isn’t this the heart of the issue?
The concept of ‘gender’ is very much social, environmental, and cultural, yet the left is not willing to acknowledge that this current medical model approach to being transgender abandons the idea that someone’s gender distress may be informed by our culturally enforced oppressive norms of gender and sex. Rather, for anyone seeking help from either the psychiatric/mental health treatment/therapeutic/medical establishment, it is a problem existing in the brain/mind/body of the individual experiencing the distress, which can be treated with medical interventions. Sound familiar? This is the very approach that psychiatry uses, the one many psychiatric survivors (including myself) have found to be so harmful and negatively life-altering.
In my Mental Health Counseling graduate program to become a therapist, and in various treatment facilities I worked at after, we were taught to practice from a ‘bio-psycho-social’ model- that we had to use a unified model in treating people that keeps in mind how these various factors inform a person’s experience. To my dismay, this is not actually used. People are medicalized and medicated instead of actually understanding them and helping them. Someone’s ‘culture’ becomes a box to check about their religious or ethnic background, rather than an examination of all the external influences on their beliefs about themselves, their worth as a person, their identities.
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I appreciate you writing this, and as someone who also worked in homeless services it was validating to read. I provided community based case management to individuals who were homeless or ‘at risk of homelessness’ who were recently hospitalized for mental health or were currently seeing outpatient psychiatry and therapy at my agency. My case management program’s goal was to find the individuals on my caseload permanent housing. Of course, it was next to impossible in a housing crisis, and the county I worked in was mostly rural, with only a handful of actual towns- three of them were very upscale, and just one was run-down enough where you could find landlords willing to take someone with no rental history and a section 8 (housing choice voucher) rental subsidy.
The saddest thing though, was how many psych meds so many of them were on, and the ones on the most medications tended to be the ones who were or had been ‘street homeless’ and who had endured multiple psychiatric inpatient commitments. I had people on three, four, fix, six different medications.
We were required to have regular supervision meetings with one of the agency psychiatrists, I assume just so we could bill at a higher rate as a clinical service with psychiatric supervision. I hated these meetings because all of the case managers in my program were supposed to bring up clinical concerns that the psychiatrist would address or advise us on…the only thing is, ‘clinical presentation/symptoms’ of the ‘mental illnesses’ of the people we worked with was the last thing any of us cared about. We cared about shelter placement, section 8 subsidy applications, application approvals, deadlines to find housing with the subsidy before you lose it, finding a rental apartment, the person’s income (or lack thereof), social security income applications, food stamps, probation officers; a mountain of real-world practical problems with being homeless and struggling with low income. So in these meetings we would sit in mostly silence and try to dredge up any information resembling something ‘clinical’ or ‘symptoms’ .
These people did not need psych meds. They needed PERMANENT, SAFE HOUSING – and not just a crummy, dirty, bug-infested apartment in a crime-ridden area of town, with a slumlord landlord who won’t even fix the broken toilet. They needed STABLE INCOME. If they were freaking out, having panic attacks, aggression, hearing voices, you name it, don’t we think this was more because they were in horrible, desperate circumstances, fighting a broken system that shut them down at every turn, rather than a “mental illness” ? Were their brains ‘diseased’ or was it perfectly understandable for them to have the emotional/behavioral struggles they had based on how they had been treated by everyone their whole lives, and how desperate and in crisis they were now?
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