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This is exactly why I stopped participating in this community.
This article can be summed up with the title, “Old Man Yells at Cloud.”
You know, this is why I don’t have time for this community anymore. First because, an article like this one is on the front page, which is a complete and total waste of time and space. Second, because there’s then a discussion thread so long that were I to actually try to do anything other than skim it, I’d be here for hours. But since I’m up early this morning for no clear reason, I’ll go ahead and have something to say:
In reality, speaking as both a chronic pain sufferer and a therapist working with sufferers of chronic pain, the issue is actually incredibly simple:
Doctors were encouraged, and chose to, prescribe opioids like candy in ridiculous ways making lots of money doing it, while no one cared about the consequences. Then, when the consequences of such reckless and unprofessional prescribing practices started to enter mainstream consciousness, and doctors began to face scrutiny and inquiry, the chosen strategy has been to deny any accountability and focus completely blaming the patient, who was guilty of nothing other than FOLLOWING DOCTORS ORDERS.
That said, denying an opiod problem is patently absurd. Claiming that the problem neatly rests only with unprescribed / recreational / street use and not through prescription is patently absurd. There is and has been a massive problem with opioid prescribing – and the fault and responsibility lies with the PRESCRIBERS not the patients following instructions. The outrage among chronic pain sufferers, including myself, is at being treated like criminals when we did nothing wrong. The outrage is NOT because changes are coming. Changes need to come. Its that right now the wrong kind of changes are happening.
Thankfully there are good complimentary or alternative supports for chronic pain issues in addition to or in lieu of drugs. We are working in my local community to offer, health and wellness, mindfulness and meditation, acceptance and commitment based therapy for chronic pain, naturalistic alternatives all presented in the form of community groups and individual support coaches. We’re also offering harm-reduction approach support in dealing with withdrawal from opiods if that is a situation a person finds themselves in.
How do we better organize a group, or a campaign or a movement the can successfully force psychiatry to confront its malpractice?
That’s what I want, and that’s what I personally believe is the most important and potentially effective tactic we can utilize. Psychiatry claims that it is a professional discipline, and in particular a medical discipline. As such, it follows that it is bound by the same ethical standards and codes as the rest of medicine.
If that’s true, then psychiatry has one question above all others that it must answer in order to be taken seriously by anyone: by what ethical or professional standard do you justify long term prescription of medications for which there is no scientific evidence showing their efficacy, and in the face of scientific evidence showing their harm? How does that no violate ethical codes of medicine? When prescribers tell “patients” they are permanently ill and that long term use of antipsychotics are “necessary medical treatment” how are they not committing fraud, malpractice?
Personally, I want a campaign of malpractice lawsuits against psychiatric prescribers, combined with suits against the FDA directly challenging their approval of drugs with insufficient research, and at times fraudulent research. I feel that this is a tactic that has not really been tried. Sure there have been lawsuits against big pharma, but I think those largely miss the point. Big Pharma can afford to payout a billion dollars as just “the cost of doing business.” You start suing practitioners for malpractice, and the government directly, I think you both get more traction AND do more to gain mainstream media attention.
Besides, its the biggest question out there: how can long term prescribing of anti-psychotics possibly be justified as ethical and responsible medical practice, according to ethical standards for medicine?
I just wanted to point out that the link which says “Full Text” points only to an abstract. I was really hoping for the full study, but its behind a paywall.
Overall, I’m not quite was optimistic that we are witnessing a turning tide even if the waters are stirred. Half of the internal bickering withing psychiatric institutions, even the ones where there is internal criticism of diagnostic validity or various treatment, have to do with competing financial stakeholders and squabbles over who holds the power. I was well-reminded by a fellow MIAer back when Insel of the NIMH made his famous denunciation of the DSM, that his comments amounted to nothing more than a turf war. The NIMH was doubling down on neuroscience research and the biomedical model, just just wanted to be at the center of the money, rather than the APA.
There’s lots of other infighting of this nature that has as much to do with battles for power and influence as it does any kind of crisis of conscience within the institutions. I am of course still pleased that criticisms of psychiatry and mental health system at large have become increasingly mainstream. That helps me as an advocate because I can deny/refute the attacks that anything I am advocating is “fringe.” It’s not fringe anymore. However, the reasons behind most of the internal criticisms, and the recommended changes or solutions proposed by those making the critiques within the institutions are as bad as ever.
And the public at large remains basically as unaware as ever. And the public at large, I believe actually wants there to be a mechanism for “dealing with” the annoying, the inconvenient, and the “maladapted” of society and are perfectly comfortable with the convenient lie that Psychiatry is necessary and serves and important, legitimate, functional purpose.
So turning tied? I can’t quite join you in that optimism. Ripples in the water? Sure, though in fairness those have been found in many different periods of psychiatry’s history without translating fundamentally weakening the institution itself.
The point of sharing my view is not to be gloomy for gloom’s sake. It’s because if anyone is just sitting around waiting for psychiatry to dismantle itself, you are going to be waiting for a long, long time. We have a nearly insurmountable task against an unspeakably powerful (politically, legally, financially) adversary and none of its internal squabbles will be enough to bring it down.
This tide won’t turn passively. We force it to turn with our blood sweat and tears.
Picketing works when you have a sizeable group of people to do it. When you don’t, people just think a few “outside the mainstream” radicals are doing something “silly.” Ten people holding signs looks like something “crazy” that people just ignore rather than something “serious” that they might be missing out on and want to find out more..
I would suggest other guerrilla tactics until a community has a hundred or so people committed to a visible action like picketing. Examples would be anonymously plastering messaging on the signs, walls, doors of psychiatric lock-up facilities, letter to editor writing campaigns, plaster 8.5×11 factsheets or slogans on public benches, public billboards – and while doing that use the same free advertising options to host local meet-ups, build local teams shooting for a goal of 100 people per county…. then start talking about picketing.
I work in Oregon. I would be interested in understanding more of your families situation, on the off chance that there are untapped remedies for expediting your daughters release.
If you are interesting/willing to discuss it, you can contact me at [email protected]
You are not alone!
I’m trying to figure out what this article actually tells us.
One thing might be that the emphasis on pathologizing every aspect of living has led to an inflated mental health system that costs tax payers a lot of money.
Perhaps it allows us to speculate exactly who is taking home all of this money within the system. But I can tell you once thing, it sure as hell aint me or my friends.
I would really appreciate your perspective here. I feel like as a practitioner with a graduate educational background that emphasized CBT, and as someone who has worked for organizations recommending or prioritizing CBT as a preferred mode of therapy, I ought to be less confused about some of the core concepts. Yet, my experience over the years has been to hear many different things about the “essential” features of CBT that are often contradictory.
My question comes without an preconceived judgement: simply put, do you feel it is accurate to say that an essential feature of CBT in all (or most) of its variations is a process of (a) identifying unhelpful and/or problematic thoughts, (b) identifying more helpful and/or accurate thoughts and (c) working to replace problematic thoughts with accurate and helpful thoughts?
I know that there is more nuance to CBT, so I don’t mean to imply that this is the only component involved. I only wanted to hear if you felt like it is accurate to say that this is one distinguishing feature of CBT as an overall approach?
Thanks for your time!
I’m sorry but the “average mental health professional” in this story counts pyschiatrists, psychologists, and PMHNPs.
The bulk of the mental health field, believe it or not, is not comprise of psychiatric prescribers. It is comprised of marriage and family therapists, social workers, and case managers, most of whom work for organizations, not in any sort of private practice. I held one of the highest paid mental health jobs with my former agency, do you know how much money I made? $17 an hour. Today, I make less than 45k a year, and I get paid ABOVE the average in the county. The number of people like me, social workers, therapists or case managers, totally dwarfs the number of psychiatrists, psychologists or psychiatric prescribers – who, yes do get paid a lot more and also represent a far smaller percentage of “mental health professionals” overall.
Headlines like this really make me angry, because I participate in this community for accurate information – not just headlines that we like because this suit our predisoposed biases based on her belief system.
I hope that when the time comes, I am not a coward.
That’s what I’m most afraid of. That when the day comes, and I am confident that it will, when I have to face a beating, or arrest, or imprisonment – that I will run. The kind of stand I am advocating actually scares me half to death. I don’t feel particularly courageous, or strong. But I want to be. I sincerely believe that making that stand is the right thing to do, and I can only hope that my conviction will overcome my cowardice.
I appreciate that point, and it makes sense to me. But I do question the effectiveness of “voice raising” alone, even as an act of public consciousness raising.
For one thing, what do we want the public to do when their awareness is elevated? Write their congress person? Or join the ranks for more voice raising? I argue that we more effectively gain the attention of a slumbering public through planned deliberate acts of defiance and disobedience. These are the things that terrify rulers, and also the things that rouse the attention of the masses.
I am 38 years old, which of course sets the limits of my experiential knowledge. I am too young to have experienced the civil rights movement directly, and yet I still feel that I have to do my best to understand the history. But the first major protests of national and international scale that I can remember were in the lead up to the Iraq War.
In the year before the start of the war, there were demonstrations of a scale we had not seen in decades, possibly ever. 1.5 million in New York City, 350,000 in Atlanta, 500,000 in San Francisco. And even larger numbers in other parts of the world. These demonstrations took very similar forms for the most part. Organizing efforts to get people to show up, gathering place, and then a series of planned speakers.
What was the outcome? I’ve recently talked about this with several different people in my life and not a single one of them even remembered that these demonstrations had even happened. They failed to establish themselves in cultural memory. We still went to war. We are STILL fighting. Whatever public consciousness raising might have been achieved did not translate into meaningful change.
Something was missing in these efforts, a missing ingredient essential to transformative action. I think I know what it is.
Your question, who is going to do them? Is a critical one, that I have to make sure I don’t avoid. Points well taken about the movement being small, about the challenges of getting people to do anything at all, etc. That all sounds right to me.
So perhaps we’re not at a place where we can engage in more direct resistant actions. But even if we’re still slowing gathering a movement, I want to be an early voice advocating for direct confrontation with illegitimate authority (confrontation does not automatically mean violence, and I am not advocating it) with an emphasis on planned disobedience and disruption as the tactic and tool of radical change. I think some people will need convincing, so I want to start talking about these things early and often. Even if we’re not quite there yet.
And of course this is an opinion, and others will see it differently. Their voices should be respected. But I want to try to persuade people to my point of view. 🙂
I appreciate this article and I am eager to read the book. I typically agree with the identification of the problems in psychiatry and mental health, but often disagree when it comes to prescriptions for meaningful change.
If you don’t just have a “rotten apple” but instead have a “rotten barrel,” you can’t “reform” the barrel. You must remove the barrel entirely and replace it with something else.
Turning to an institution “government” as fully corrupt and broken as the institution of psychiatry and expecting it to effectively regulate or legislate to reign in psychiatry is an exercise in futility.
Some people share my view that we have no choice but to seek more radical change. But there is then even more disagreement on the mechanism for those changes. A lot of energy is placed into organizing efforts that take the form of rallies, marches or protests that have the objective of putting a loudspeaker to the voice of dissent. The problem is, simply raising our voices in the hope that representatives of institutional corruption will somehow hear us and enact meaningful change (not appeasing superficial gestures) is pretty ludicrous.
These institutions don’t work for us. You can talk about the power of the “people” all you want, but that power is not in the ballot box (less than half the population votes at all and even if more did, the choice of candidates is always limited to those who can spend the most money given to them by privileged interests.) Holding a rally to loudly express our dissent or our demands for change does not actually bring change in itself. Ever. At any point in history.
The missing piece in our activism in modern times is defiance. Rebellion. Acts of deliberate and organized disobedience are what change the world. Holding a rally that the police endorse, within the spaces that the police and rulers sanction to simply say a lot of words until the police tell us its time to go home accomplishes absolutely nothing other than self catharsis. Our “action” is fully contained by institutional authorities, whose agendas are not in anyway disrupted or damaged by our activities.
We have done such a great job of glossing over the civil rights movement, to the point that now we throw around a few glib MLK quotes ripped from the context of the actual struggle and let ourselves somehow believe that just “marching” brought significant social gains. What brought those gains was civil disobedience, organizing events that had the goal of going somewhere and doing something that institutional authorities did NOT want done. The goal was not just to talk loudly, and it certainly did not entertain the ludicrous notion that just saying a bunch of words to power while acquiescing to their every demand would bring change.
Movements are different than protests. Movements that have any success make conscious, intentional disobedience, refusal and defiance of illegitimate authority the center of its mission. Marchers were ordered to turn around and go home on the bridge to Selma. They refused. The marched INTO police lines, not away from them. The did not see their oppressors as their “collaborative partners in peaceful protest.” The accepted the likelihood that they may be injured or killed. They want forward anyway. The objective of their activity was disobedience as symbol and act of change.
If we want to change institutionally corrupt systems, we have to first stop coming with our hat in hand to the very representatives of institutional corruption we oppose and ask them nicely to give us justice. Instead, organized activism needs to have concrete objectives of disobedience and disruption of status quo. It need not be violent, though our resistance to authority usually causes a violent reaction from that authority.
Marches should be about marching somewhere authorities don’t want us to be and refusing to leave. Protests should be about things like marching to city halls and occupying them indefinitely and refusing to leave until demands are met. It should be about stopping traffic, disrupting ordinary activities, sit-ins, die-ins, not as theater but as acts that don’t stop until there is change or until police carry us out against our will in handcuffs.
Simply gathering downtown with loud speakers and shouting for a while, and then going home with the police tell you do accomplishes little. History is good evidence of this. Powerful movements can have non-violent RESISTANCE at their core, but the word “resistance” is critical.
In the state of Oregon, unless you are civilly committed, under order of a judge, you have the right to refuse services.
But perhaps you are talking about the very problematic and oft abused short term case where someone ends up in the emergency room, and is determined by authorities there to be an immediate danger to themselves or other people int he community, and is held involuntarily and can be hospitalized involuntarily under authority of psychiatry for a brief period of time (brief averaging 2-3 days but in rare cases can extend for longer or can evolve into a civil commitment proceeding, with commitments lasting for 180 days with the possibility of being renewed.)
Because that is a big problem, and that power to hold someone in the ER as a safety risk is frequently abused. So is the mechanism of civil commitment.
The abstract says this is the first time its ever been seen that therapeutic alliance has a direct effect on outcomes. That is nonsense. It’s one of the most consistent findings around.
Here’s another one:
Wish I had a free link to the full text. It basically says that some people responded dramatically to therapeutic support in just a few interactions while others could work with a therapist for months on end and not see any improvement. And the distinguishing feature seemed to me how much the individual believed that the therapist had genuine empathy and love for the client. Yeah, the article published in Psychology of Addictive Behaviors journal used the word love. Said it should be the foundation of any useful interaction.
This is also my interpretation of appropriate boundaries, and also how my agency understands the idea of healthy, healing collaborative partnership in counseling.
I work in a rural community organization, so I’m not in any way trying to suggest that this is the dominant perspective throughout the system. Only to offer some hope that perhaps its also not totally “unique.”
Perhaps there is more of a struggle between perspectives, with scattered advocates and agencies that strongly endorse a more holistic and affirming way…
Thank you so much for this article. I am in strong support of peer respite services, and the primacy of persons with lived experiences in any healing process. We need to protect against the “institutionalization” of peer based support, as I cannot trust our system to integrate this essential and compassionate resource without totally corrupting it.
I am deeply concerned about the push toward increasing coercive treatment and institutionalization. That’s a bit of an understatement – this push is terrifying with the potential for lasting severe harm. It doubles down on everything that hasn’t worked, will never work and indeed can’t work and is driven by a desire to simply be “rid” of the nuisance of those “other people” as well as predatory fear-mongering about dangers and risks to the community.
Pair that with recent reporting on the renewed increase in money pharmaceuticals are putting into psychiatric drug research (after a period in which they appeared to be giving up on that effort in the absence of clear biomarkers) and it feels as though we are heading toward an extremely dark time. Now more than ever before we must consistently stand for what is accurate, reasoned, and truly evidence-informed – including pointing out the limits of what anyone (most especially those claiming institutional “authority”) actually know about the causes, course and best “treatment” for persons who experience more extreme emotional states.
The role of peers – persons from all walks of life who self-identify with lived experiences of both extreme states as well as experiences with the misuses and abuses of our “mental health” system – has never been more critical. Nothing has been more powerful in my own efforts to be a compassionate partner in a fellow human’s journey than my willingness to honestly share my own history of struggle. Almost nothing is more important. Thank you again.
Proud anarchist here.
Well, let me humanize that with a dose of humility: I live and work in a capitalist society. I own a smart phone and I’m even guilty of really enjoying it. There are a lot of things about living in this society that are confusing to me – many conveniences within this system that I myself make use of.
It’s better today that the philosophical history of anarchist though continues to influence my own thinking and challenge me to question how I live each day.
So while “anarchists” may have been used as an epithet by Lieberman, I see it differently.
Anarchism in all its forms (which are diverse and sometimes even contradictory) essentially agrees in one principle and one task. It agrees in the principle that blind obedience to any authority is destructive. And it agrees that the task of “anarchist” is to examine any institution that claims the “authority” to curtail human freedom in any way and demand that it justify its right to do so.
If that institution cannot reasonable justify its need and right to exist, it should be done away with and, if even necessary, recreated from the bottom up rather than the top down.
Those are basic ideals that I’m very proud to hold. If someone wants to call me an “anarchist” I will feel a little bit of hypocrisy and contradiction in my life as I struggle to live out these ideas — but I’ll still reply, “thank you!”
I come down extremely strong on the side of individual choice across the board. That comes from my philosophical anarchist influences.
But that choice depends entirely on full and completely informed consent. To me, this is the bigger issue that come first. Right now people are making choices about drugs based on false information, or inadequate information. The falsehoods or inadequacies of information is so pervasive that it is clear in my mind that it is willful.
Right now, I believe the number of people choosing to take psychiatric drugs with truly and fully informed consent is exceedingly small. I feel like working to expose false information, distortions, and deceptions about both benefits and risks of drugs as well as the evidence base for medical model practice remains the most important and pressing task.
It’s fortunate that I feel that way, because if we really come to a day where the debate within a movement is between whether we support individual decision making or whether or not we support coercive intervention to prevent people from making decisions about treatment they want to make because we don’t agree with it, I can’t and won’t stand on the side of coercion.
Doesn’t it seem as though there is still a heavy amount of consciousness raising happening?
I feel like I notice slowly but steadily increasing public awareness to the no-clothes emperor that is psychiatry and the pharmeceutical industry. I note, still with some surprise, the increasing frequency in which real criticisms and real challenges to long-held dogmas are coming out in more mainstream media publications. Not often enough, and not with a consistent voice – but more than ever before.
Don’t misunderstand what I’m saying here. I am not trying to steer a movement nor am I saying others should slow down, speed up, or do things differently. I’m only musing – I think there’s still a lot of building to do before a cohesive movement will be able to translate is power into more effective and direction action on a large scale. I think – but nothing is stopping us from trying to do that sooner and faster wherever and however we can.
In my small community, I’m still having conversations with people who are actually listening, but are seriously confused about even the most simple things. It’s still shocking to some folks that mental illness is not accurately described as anything literally true. I mean, we’re still at the very basics for many, many people I think.
I’m sorry I want to share one more thought I had about the original article. I wanted to mention that I’m not sure I ever read Robert Whitaker’s comments about rising disability rates in the way that Timothy Kelly has.
When I first read Mad in America, I was early in my investigation of the research data and evidence supporting many of the claims about psychiatric medications. Thus I was curious, and open to the subject, but not very fully informed.
Robert Whitaker asks a question as way of piquing curiosity. That question is, if the claims of psychiatry are true – that we continue to know more and more about exactly what causes mental and emotional distress, that are treatments (i.e. medications) are more and more effective and overall we treat “mental illness” more effectively than we ever have before, then would we not expect to see some sort of impact on the number of people who enroll for social security disability due to a mental illness?
When I read that question, I had the reaction “yes, that is strange and does make me ask questions.” It was simply a teaser that got me intrigued to find out more about what we actually know about mental illness, and most specifically what we actually know about psychiatric medications and how they work. It doesn’t actually matter what kind of “teaser” leads up to the actual evidence that is presented. A teaser is only a teaser. It says, “hey this might be one reason why you would be interested in actually looking at research data about psychiatric drugs.”
Now, I never assumed for a second that there weren’t many intersecting and contributing causes for rising disability rates. But when specifically looking at disability for mental illness, I was still a bit surprised to see that our supposedly “amazing” and “best its ever been” treatment response to mental illness has had zero effect on those rates. That was interesting. It doesn’t prove anything. I don’t believe Whitaker ever said it did. As far as I can recall, he only said it is an interesting fact that can be one motivation for taking a closer look at what we know and don’t know about the efficacy of psychiatric medication prescribing as practiced in the industrialized west.
Reading Keller’s article left me feeling like the criticism of the idea that rising disability (due to mental illness) rates might cause us to ask questions about the effectiveness of our current standard of care model was sufficient to somehow invalidate the subsequent exhaustive research and literature review that is presented through the rest of the book. That makes no sense to me. Even if we can prove somehow that there is zero connection between increasing disability rates and the ineffectuality of our treatment models, the DATA presented from exhaustive peer-reviewed research describing what we know about the efficacy of pscyhiatric drugs and what we don’t know (despite regularly popular claims by psychiatry and pharmaceutical companies that we do) remains completely relevant and untouched by Mr. Keller’s arguments.
Perhaps I misunderstood the intent of Mr. Kellers article, at least as it relates to Whitaker. I do understand that the larger point of the article was to advocate for a decreasing emphasis on psychiatric medication misuse and decreasing emphasis on the abuses and human rights violations endemic within psychiatry. Instead, Mr. Keller advocates for a collaborative reform dialog that focuses on areas where he believes there is agreement (which I actually don’t believe, but nevertheless) such as social-economic issues, poverty and forms of structural oppression.
I’ve already commented on my critique if that latter argument in my post above. But the opening of Keller’s article, pinpointing Whitakers question about disability rates and Whitakers suggesting that the question can serve as an invitation for readers to look into what we know about psychiatric medications, then rebranding that as some kind of a “fatal flaw” to Whitaker’s actual thesis and evidence – that didn’t resonate with me. It’s not how I read it.
Thank you for the kind words! I wish I was better able to write quickly with less grammatical errors, but eh.. I guess my meaning still gets across.
I may be oversimplifying the issues here. I think I can hear that feedback if others feel I have done so. But I’ve been thinking about the original article by Timothy Kelly for a few days now. I keep coming back to one theme:
False dichotomy. I’m not sure I believe (and I don’t think a case has been sufficiently made) that focus on issues such as psychiatric medication prescribing practices that are unsupported by clear evidence, over prescribing, suppression of data that is in the public interest out of clinical trials on powerful drugs, lack of any concrete evidence in support of the efficacy of long term psychiatric drug you and a plethora of long term studies that suggest long term use may be contraindicated — not sure any of this precludes us from considering to taking action on the issues of institutional/structural violence, or engaging in class analysis. It’s not an either/or subject as far as I can see.
Standing opposed to psychiatric coercion, psychiatric manipulation through half truths or untruths (ie. chemical imbalances, saying that people have a literal disease and we know this for fact when we have no such proof or evidence whatsoever) does not have any relationship to whether or not we are also active and aware of structural oppression and the intersection of economic inequality and social injustice with mental and emotional health and wellness.
I don’t know about you, but I’m quite capable of holding more than one though in my head at the same time.
Apart from this, I don’t want to “reform” the institution or practice of psychiatry. What I mean to say is, in order for the practice of “psychiatric” to function in a way that would be consistent with my deepest values and sense of morality, it would look and function so completely different from anything we have today, that the word “reform” loses much of its meaning in this context.
As a therapist, I do believe that it is possible to have a meaningful, respectful, dignified and loving partnership with another human being where the therapist and that person collaborate together in a process of resolving suffering and cultivating internal strength and resiliency. But that process is led by the individual, not the therapist. Anyone can come together in these kinds of healing collaborations. Notions of power or authority in that process need to be deconstructed and done away with.
If there is a place for “therapists” as a work career, the values and mission of that endeavor are completely different than that if institutional psychiatric in the united states today. I don’t see a place or a value in psychiatric as it is currently practiced, or as it’s mission is articulated by its institutional leaders. There’s nothing for me to “align” with. There’s nothing to “reform.”
Clinical Social Workers, Marriage and Family Therapists, Spiritual Life Coaches and the rest all have their own “group” challenges, and are not immune from needed critique and criticism. But I will say that my “on the ground” experience – both as a professional AND as a client of a counselor – has led me to conclude that these other professions are leaving psychiatry in the dust – at least on the ground in my community – as psychiatry becomes increasingly less relevant, and as greater attention toward psychiatry’s abuses and irrational evidence-absent dogmas continues to increase.
There’s nothing to reform. There are however, structural institutions of oppression that need to be resisted and dismantled.
A caveat to my comments: I may be getting up on my own soapbox a little bit and going beyond the scope of the article. I’ll leave that to others to judge.
My personal opinion is that attitudes toward psychosis and its corresponding biomedical labels (Schizophrenia, Schizoaffective, etc.) are especially bigoted and prejudicial. And we are in a pre-awareness stage when almost no one believes this is true and look at me like I am from Mars when I suggest this. (At least within the system.)
I feel like people given these labels are frequently written off. I believe that the mental health system treats folks who have been given such labels as “less than” and “other.” It’s a “those people” attitude often full of deeply patronizing or condescending assumptions. “Those people are sick. Those people cannot make good decisions for themselves. Those people will never experiencing meaningful healing.”
These attitudes lead to “services” that are focused on “managing” people with such labels, so that they are not inconvenient to the rest of us. Symptom suppression through drugging, restrictive “residential” programs, and treating people like they are 5-year olds.
I believe this is also why people don’t talk about trauma and psychosis. It’s just a “population” that has been written off. I believe that most people in mental health (from psychiatrists to social workers) don’t believe people who have experiences we label as “psychotic” can heal or live rich full lives. Instead they take the “feed and water” attitude that is so dehumanizing.
Attitudes in psychiatry and the mental health system more broadly may be pervasively problematic – but they are the worst of the worst when it comes to so-called “SPMI”
Thank you for the reply, and I totally agree.
Sometimes I try to hold a “agreement in essentials; freedom in nonessentials” sort of approach to community. Though I fully acknowledge the subjectivity of identifying what positions/stances are “essential” and what are not.
My best attempt so far is this: I can align with people who:
(1) Reject biomedical reductionism
(2) Reject psychopharmacology based on biomedical reductionism (leaving some openness to the possibility of selective-use approaches not based on biomedical reductionism)
(3) Believe in empirical accuracy (specifically, not claiming to more know than we know) and criticize claims to “truth” or “facts” that are unsupported by available evidence
(4) Oppose the dehumanization and disenfranchisement of minority groups, including persons labeled by a reductionist biomedical system as having a “mental illness” disease.
Anybody on board with those 4 things is my ally, from survivor to psychiatrist.
I appreciate the very clear and thoughtful description of what the term “antipsychiatry” means to you. It makes great sense to me. I wonder though, if others who identify with the term would agree with your interpretation?
To me, that has been one of the problem with labeling in this context. I have to take notice of the fact that while our community is extremely critical and skeptical of labeling when it comes to mental health, we spend a large amount of time trying to ascribe labels to ourselves or others and then define what does or does not “count” as part of those labels.
I suppose this is unavoidable – some labeling seems like it is a constraint of language and communication. But when it comes to the label “antipsychiatry” I still have a few questions:
First it seems to me that there is not agreement on what we’re talking about when we speak of “psychiatry.” Sometimes I read people making it very clear that they are making an institutional criticism of capital “P” psychiatry as it is represented through its governing bodies such as the APA. And in these cases, the criticism is tied to biomedical reductionism, bad science (including claiming to know more than you actually know), and human rights/dignity issues (coercion, lack of informed concent.)
But my experience is that there are also people describing themselves as “antipsychiatry” that are making an individual criticism in addition to any institutional criticism. In this case, the objection is to small “p” psychiatry, which is often not clearly defined. In some cases, it includes anyone providing any sort of service to an individual who identifies as experiencing some for of cognitive or emotional distress. So the small “p” word psychiatry is used, but is then inclusive of everything and everyone at an individual level – counselors, social workers, psychologists, family therapists, kids counselors, etc.
The position of this latter camp of small “p” antipsychiatry folks seems to be that if a person decided that what they wanted to do for a living in this world is learn more about human experiences and development and then serve other human beings experiencing emotional suffering, they are part of the problem. If I did these things without doing educational study of issues of class, poverty and inequality, theories of human behavior in social environments, effective empathetic communication and exploration of human relationships, then no one would have an issue with me voluntarily engaging with another person voluntarily choosing to engage with me in an emotional collaborative partnership.
Because this was how I wanted to live, and the kind of person I wanted to BE in relationship to my fellow human beings, it seemed only natural for me to look for ways to do this sort of thing as my career. I certainly did not want to go spend 40-50 hours a week making widgets for some corporation. But many times, when I listen to some who take the label “antipsychiatry” their small “p” criticism that seems inclusive of every single kind of collaborative partnership between a career human servant and an individual, I feel like people are basically saying, how dare you try to earn a living serving other people – you should have done that for free, and you should have done that without having in interest in any education that you might find useful.
So, I find myself strongly allied with criticism of big “P” psychiatry. And specifically, I oppose biomedical reductionism because I believe it to be anti-rational. I oppose the standard model of psychiatric prescribing that is an outflow of that reductionism for the same reasons. And I oppose the treatment of human beings as “other,” “lesser” people with less rights, less autonomy and less power. Wherever those attitudes arise, in Psychiatry, in politics, in social work, or in individuals, I stand opposed to them.
But I do not and cannot find myself aligned with any sort of small “p” antipsychiatry that is really just a sweeping generalization about any instance in which a person voluntarily partners with another person who has choosen a path of service as their working career. I am not aligned with the notion of “abolishing” any and every kind of counseling partnership between people. To me that is as antithetical to the idea of autonomy and choice as anything else.
In your article, I see nothing but a very clear and articulate capital “P” criticism of Psychiatry as an institution. But I’ve definitely experienced the small “p” attitudes as well and those make very little sense to me.
I’d like to respond.
In my opinion, modern psychiatry is the least helpful and most dangerous profession, for the very reason that it is actual anti-science. Claiming to know empirically more than you actually know is anti-science to the core. So taking a disease approach and making the profession revolve almost entirely around psychotropic medication, practicing in ways that are often contraindicated or outright antithetical to available evidence – that ought to be criminal malpractice.
I know that there are a tiny minority of rebel psychiatrists out there. But I believe this to be a fair institutional criticism.
Next come the non-prescribing human service fields you mention – psychologists, social workers and others you mention. I am a social worker, and I agree fully with your criticism. There is no “one right way” toward healing. There are definitely wrong ways, namely ways that make claims to truth without any rational or empirical basis, ways that lie or distort the truth about medications, or “counseling” or anything else. Those are the wrong ways.
But what is the “right” way for a person experiencing distress? I believe the only “right” way is the way the individual chooses for themselves. However, I’d like to point out how psychologists and social workers fall into the trap of advocating process-oriented counseling or “talking talking talking” as you described. Because there is a somewhat humanizing reason why this mistake gets made….
This mistake gets made by my fellow social workers and similar professions because we are reacting against the prevailing attitudes set by Psychiatry that feelings, talking, processing, meaning-making or self-exploration don’t matter. Only taking the right drugs matters, according to them. The prevailing attitude by the most powerful forces in our broken mental health system are big pharma and big psychiatry, i.e. the APA, NIMH and the sadly enabling NAMI.
The key to my own healing and recovery was a counselor who created a safe-place for me to talk and process. Everyone is different, that’s true. But in a world where the prevailing narrative is one of “don’t talk to me about your feelings, don’t tell me about your past, just shutup and take this pill,” I feel like social workers and other non-psychiatry professions often feel a strong reaction to that. I know I do.
And that’s how we mess up…. it becomes easy to get tunnel vision. Talking is not always the answer. There is no “right” way other than what the individual identifies for themselves as helpful and needed. But in fairness I will tell you this, in working with folks I have found it amazing how many times people thank me and tell me they have never ever before had a safe place to simply tell there story in their own voice, and process the experiences of their life without judgement. I have ALSO worked with people who told me quite clearly, they had no need or desire to do anything of the sort. What was my response to them? To listen, to accept that they know best what they need, and then ASK them how I could be a positive part of their journey.
The same is true for the idea that there is a spiritual component to all of this. I have to ask the same question you did – says who? Personally, I think you are probably right. But many people do not interpret their lives that way. I respect that as well.
Basically, psychologists, social workers – all of us non-prescribing therapists – get it right when we see ourselves as servants rather than experts, and ASK the person we are serving what they need rather than TELL them what they need. That’s the key.
Thank you so very much for writing on this subject. One of the very first pieces of my ongoing “awakening” to the crisis in mental health came through my exposure to attitudes toward the label BPD. This label gets thrown around any time a professional is irritated by a client. At least if that client is a women. If the client is male, NPD or APD are the go to labels, but the effect is the same.
I don’t feel like this gets discussed enough. Thank you again.
It seems to me that one important task is to keep searching for a place of practice that holds service values that resonate with your own. Those places may be a minority, given the trajectory of the system, but they do exist. Once there, I have found that they bear only passing resemblance to graduate school. It is possible to practice within an agency or in private practice without making a diagnosis the cornerstone of the process. And no one can stop you from seeing diagnosis for what it really is, a subjective classification of subjectively identified symptoms. In my experience, the actual experience of partnering with an individual as a servant really has no connection to a diagnosis. It does if someone chooses to make such a connection.
Now, I’m speaking as a social worker. I’ve read some disturbing stuff about psychologists trying to get into the medication prescribing business. At that point, I think the rules change greatly. That would be a tragic thing, in my personal world view.
I think this is a too common occurrence. I think may people get into some form of a “helping” profession because they are really meeting their own emotional needs around their own turmoil. I suppose that would be OK if there was awareness and humility around that. But when people take on a veneer of expertise and “professionalism” to mask their own frail humanity, the results are often unfortunate.
That said, few things are universal. I’ve run into some therapists who were wonderful people, including one therapist with a traditional background that was very life changing for me personally, as the client in the room. She influence my own service values immensely.
Thank you for the comment. I definitely agree.
I’m not comfortable second guessing the statements of other people about their own experience just because it conflicts with my own worldview. That’s what institutional Psychiatry does. It says, if you say you experience things differently than i, the expert, am saying you experience things, its because you are wrong and too sick or ignorant to know your own experience “correctly.” Maybe i do know something the individual doesnt, but really thats not for me to say (i say this as someone who does not prescribe meds.) If someone says that medications they take are helpful to them, and the are aware of the costs that are also there, then its not my place to tell them their experience is wrong and i know whats best for them. That’s just as reprehensible as the kind of paternalistic dehumanizing attitudes of the system we stand against.
I really appreciated your comments. Thank you.
“Part of why I quit social work was that I had trouble with the notion of social work as a distinct profession. Our national organizations and schools insisted that both social workers be professionalized and at the same time defined the profession so broadly as to lack any meaning. Because of that desire to be recognized as professional but also lacking coherency, it was easy for social workers, particularly clinical social workers, to be tacked on to the mental health professional family, where psychiatrists run the show. ”
Wow, a very compelling reflection! I appreciate your perspective. I have to be very careful not to generalize my own individual experience, and I don’t get that right all the time. I work in a small town, deeply grassroots community agency that sits in the rural part of the country really away from a lot of the “machine” of the system. That’s just not the normal experience. Two years ago, I was stuck in the thick of the very worst of the system and was utterly miserable, and I quit. I have to keep in mind that my former experience is likely to be far more representative while my current experience is less likely to be.
As I was writing in this thread this morning, after my first post I had the uneasy feeling inside and thought to myself, “ugg, I really don’t want to be the position of defending the institution of social work.” I don’t care about what I’m labeled, I care about whether or not I’m able to engage in meaningful human service that is consistent with my values. Your comments helped me regain my center, and remember that the institution of social work, whatever its roots, has faced the same forces of managerialism and “professionalization.” In fact, there are some wonderful radicals out there strongly criticizing social work for more and more becoming an instrument for reinforcing untennable social “norms” rather than challenging these things.
Good, refreshing comments. The last thing I want is to become attached to a professional identity for its own sake. That said, my own unique experience in a small graduate program was a really beautiful one. I would characterize it as “radical and critical” rather than conventionalist. Many of the ideas I try to express at MIA have their roots in the time I spent in grad school, and prior to that, the time I spent in undergrad studying philosophy. These were good experiences for me. I can accept that I might be the exception to the rule, though. I combine those experiences with my personal encounter with serious emotional distress and my lived experiences engaging with other people.
I sincerely look forward to this continuing series. The bullet point conclusions you outline seem accurate to the entire spectrum of DSM diagnosis, particularly the statement that “x” diagnosis is a category name, not an explanation. I feel like this is true across the board.
Thank you for this comment. Grist for my thinking mill….
“Toward the end of my clinical practice, a part of what I did was seeing people in long term care facilities who also had psychiatric diagnoses. ”
Yikes. That’s sounds exactly like the position I was in for a year. I walked out of that job, without having any idea how I was going to keep a roof over my head, because it was so completely at odds with my own values. I could easily see how, at a different time or stage in my career, I would have simply retired altogether.
But social work as a profession is so, so much broader than that. In fact, most of the social workers I know from cohort have gone on to work in community development and grass roots organizing around social justice issues. It’s the minority who, like me, went seeking the opportunity to meet people one on one and become fellow travelers with them.
Here’s how my thinking goes so far…
I think that talking people in this community being “pro coercive psychiatry” is similar to calling people who are pro-choice “Pro-abortion.” I don’t know anyone who is “pro-abortion” as in, let’s go out and really try to maximize the number of abortions happening in the world. Instead, I know people who believe that the right of an individual woman to make a choice on the matter takes priority over other concerns. That’s a very different thing.
Similarly, consider our own lengthy discussion over the weekend. I talked about how, in my role at the ER, I’ve had to hospitalize someone involuntarily. But as we talked at length this weekend, it seemed to become clear that I don’t believe in forced treatment.
So I believe the “pro” is the issue here. I have met people, I am loathed to say, who I would argue truly are “pro” coercion and I don’t think that label reasonably fits anyone I’ve met here, even those that are grappling with tough issues and may not align perfectly with my own beliefs or values.
Well, that’s an interesting argument that I’m not discounting.
I guess it really depends on what psychiatry is these days. I still hold this, probably naive, notion that psychiatry in its roots was something very different than it is now. But that was then, this is now. So if the institution of psychiatry is truly dependent on prescribing drugs, and the government heavily subsidizes that, then perhaps what you predict is what would happen.
What I tend to suspect is there is always going to be enough people around who want to go to another person for consultation or support that people who want to will be able to squeek out a living doing that sort of human service.
Opps, replied to the wrong comment. Let me try again,
Your experience in school was completely opposite of my own. If I had had the experience that you seem to have had, I am reasonably sure I would have left as well. However my experience in school, including experience with the DSM, was drastically different.
My experience in practicing since school has shown me both sides of the spectrum. On one end are programs and agencies that seemed to have functioned much like you describe. On the other side of the spectrum – at least for my working experience – are programs that don’t look anything like what you described.
So I suspect that an individual social workers experience both in school and in the field can vary widely – especially since social work is a broad field that includes social justice advocacy, community organizing and development – basically anything on a micro or macro scale that has the goal of social justice and alliance with oppressed or marginalized populations.
Psychiatry, good or bad, right or wrong, exists apart from the government. By that I mean, if every penny of government money into government programs evaporated, if there was no medicaid and medicare, practicing psychiatrists would still exists.
By talking about “pro coercive psychiatry” you’ve built up a nice straw man to knock down, because I don’t believe you can point to anyone here who is any such thing.
This article brought tears to my eyes. I believe that the issue of class is one of the least discussed, most culturally taboo issues today. At the same time, I believe that the issue of class, and attitudes towards poverty are one primary factor in the corruption and abuses of the mental health system today.
I wrote in a past article that I imagined the experience of a rich, white, heterosexual man experiencing emotional distress would be vastly different than the experiences of a poor, black, bisexual woman. The former, I argued would be likely to have access to the best supports and the most designer programs, along with the power to pick and choose what he wanted to participate in, fire people he did not believe were serving him well, and remain hospital-free no matter how “eccentric” his behaviors became. The latter, I argued would most likely be picked up by police and brought to the hospital emergency room, given a diagnostic label of “mental illness” after 30 minutes of assessment, possibly involuntarily hospitalized, possibly forcibly drugged, and so on.
Attitudes towards poor people that we also label as “mentally ill” are heavily focused on “stability.” How do “we” keep “them” stable, meaning out of expensive hospitals and emergency rooms, out of doctors offices and not inconveniencing or irritating the rest of us non-poor people. In contrast, if a person is rich and powerful, the questions of professionals become “how do I work for YOU and what you want for yourself?”
Thank you for drawing further attention to these issues. I believe we need much, much, much more conversation about the issue of class in its intersection with the mental health system in the United States.
Thank you for your article.
If I were a psychiatrist, I believe that my personal position would be that the institution, the organization of psychiatry so fundamentally contradicts my personal values that I would want nothing to do with any of its professional associations. As long as the American Psychiatric Association is considered to be a voice of authority speaking for Psychiatry-as-Institution, I don’t feel like I would want to be associated professionally with that institution.
On the other hand, I also feel like I would struggle with the reality that I had very different motivations, values and beliefs toward my own individual practice of psychiatry. I would not want to stop seeing voluntary clients, and engaging in full-time employment where my job is to connect empathetically to other human beings, listen to their stories, share in their emotions both the joys and the sorrows, and become a fellow-traveler in their journey, offering whatever suggestions or supports I can along the way.
But in order for me to do that, I don’t see how I could actually practice as a “Psychiatrist” as part of most institutions, as the institution of capital P Psychiatry has become so medicalized my primary duty would be to prescribe and manage drugs. I wouldn’t want to be a part of that. I would be ANTI-that. I don’t want to quibble about whether or not some type of drug can sometimes be helpful or not, though I tend to accept that human experiences are so diverse that certainly some drug will be helpful to some person in some context for some period of time. But I myself would not want to be a part of an institution that promotes unscientificly supported claims to legitimacy and unscientifically supported treatment approaches, such as the medication first, frequently and forever model that capital P Psychiatry subscribes to and promotes.
If I was a psychiatrist, I think I would want to stop calling myself a psychiatrist in favor or some other name that was not associated with the institution of psychiatry that so contradicted my own beliefs and values about service to other human beings. But on the other hand, for individuals who are practicing psychiatrists, I think it is a really stupid mistake to automatically demonize them or treat them as though they are automatically the enemy. I don’t see you that way. I don’t see people like Dan Fisher and other psychiatrists that way.
As a clinical social worker, I often find myself feeling very defensive. Because even though my professional training was not remotely connected to a medical model, nor was I steeped in the language of “mental illness” as a literal disease, nor was I taught that psychiatric medications were the answer, my profession still frequently gets lumped in under the umbrella of “anti-psychiatry.” In fact, the MIA community is inconsistent in its definition of anti-psychiatry, which can mean anything from being against the institution of Psychiatry in the West without taking issue with individual practicing therapists all the way to being against any one engaging in any counseling or support service with anybody, anywhere.
I feel able to stay that I oppose the institution of psychiatry and its representative leadership. I am “anti” that. On the other hand, I don’t have any opposition to individuals who desire to continue to work with people free from association with that institution. Psychiatrists who see themselves as counselors rather than “doctors” of the mind, are my brothers and sisters. Psychiatrists who do not adopt the evidence-absent model of literalizing “mental illness” and who see medications – at best – as a very last resort to be used sparingly and briefly are my comrades in arms.
So, I am not Anti-YOU. Nor do I want to force you out of a job, if your desire is to make a living by offering compassionate, non-coercive, non-directive support and relational partnership to people who would like to receive that from you. That’s all wonderful. But the institution of western psychiatry is anything but.
It’s getting late for me, but I just wanted to write and say how much I appreciated our discussion. Thank you for your observations and reflections, which have really invigorated my own thinking and questioning. One thing is certain, I’ve lost a great deal of sleep over this particular guy, and even more sleep about some of these issues more broadly.
I hope to continue losing sleep, until we have justice.
Again I’m befuddled by the “reply” system, because I don’t have reply options to later posts. I hope we can keep track of the exchange.
I’m sorry that in my meandering (my word for my own post) I failed to give direct answers. Let me try to rectify that.
You asked: “Are you, perhaps, inclined to defend what many “hospital” workers propose, is the supposed ‘necessity’ of so-called “emergency” forced IM (neuroleptic) drugging?”
My answer: No. With no qualification.
You also asked: “And, here’s one more question, if you are so inclined: Do you ever order and/or administer such drugging?”
My answer: No. Never. As a clinical social worker, I am not able to prescribe medications, and would not do so if I was able.
However, lest I sound like I’m on some sort of untouchable moral highground, the ED doctors can and do drug people. Sometimes before I’m even called. There decision is not in any way dependent on me. I can’t overrule, I can’t intervene. If I’m there, I can certainly advocate against it. But the truth is, in the rare instances when this happens it usually happens before I’m even called to the ER. It is not considered to be a decision that I have any say in.
As I said, in our small town ER, its rare that involuntary drugging with neuroleptics happens. But that’s unusual I think. In most cases I suspect that neuroleptics are used in ERs as first-line chemical restraints for almost anything that “bothers” the ER staff. It’s awful. The fact that its rare where I work is ridiculously lucky and not something I believe is representative of the mainstream experience at all.
A big part of my job when I come to the ER is convincing the medical Doctor that the person is safe to go home. That’s basically my mission and goal every time I come in. Rarely, I have the experience where I do not believe a person is safe to go home, as in the case where a person was experiencing unusual thoughts and beliefs leading him to feel that he needed to harm his neighbors. In those cases, you need to understand that at this point in time in 2014 I do not have the option to send him to jail. I have big, big problems with this anyway, but I don’t even have the option. The police will not take a person or charge a person they believe to be “mentally ill” in many cases. In this small town, they are even less inclined to do this, because they had an experience in their history in which a person who was labeled as “mentally ill” committed suicide in their jail. They believe that “mental illness” is a literal thing and that “sick” people shouldn’t be in jail.
The hospital staff won’t release him home, because they are liable. Doctors and hospitals can and have been successfully sued repeatedly for discharging people who then went on to either hurt themselves or other people in the community. As a matter of values, I’m not comfortable releasing him home, because of the active threat toward his neighbors. This creates quite a bind.
I agree with you as you described what you think should happen and what it would look like to support a person like the man I have described. I also described what I thought that support should look like, and it seemed to me that our values and general ideas were quite compatible. But that place doesn’t exist as an option right now.
You wrote: “Honestly, I cannot understand your decision, if what you’re saying is that you chose to ‘medicalize’ that man, keeping him out of the justice system…”
I respect what you say here and in your explanation that preceded it. I don’t know if I made the right decision. What I know is that my experience of the justice system is that it is a horrific nightmare of abuse rivaling anything we experience in the mental health system. Honestly, the truth is, when it comes to situations like the man I’ve been describing, I think we are completely trapped between terrible options. I don’t believe arrest is the right option. I also don’t believe forced drugging is the right option. I also don’t believe just sending him back next door to his neighbors when nothing has changed is the right option. This keeps me up many, many, many nights.
You asked me if I knew what became of the man I have been talking about. I do not know for certain, but I can guess – and my guess is heartbreaking.
My guess, based on what I know about how the system works, is that after he was sent to a acute psychiatric hospital, he was forced to take neuroleptics against his will. I don’t know for certain that happened, but it would most definitely be standard procedure for an inpatient hospital. I also imagine that he was involuntarily committed to the state for a maximum of six months. “Maximum” is actually BS, because they can just keep recommitting him over and over again indefinitely if they wanted to, and the system is so stacked against the individual person that this becomes both easy and likely.
Once committed, he will be ordered to do whatever the judge stipulates as the terms of his commitment. Usually that means taking medications, usually that means going to what’s called a “secure residential treatment facility” which are longer term, anywhere from three months to years. They are different sorts of prisons. His ability to be released from such a facility will be entirely dependent on whether or not his follows the rules and does everything the “professionals” say he should do.
It’s awful. I worked in an “secure residential treatment facility” for one year, because I was a naive fool who thought people who were there actually needed to be there. I quit without having any idea what my next job would be once I realized just how wrong I had been. My first article on MIA was called “Corrections Officers, not Clinicians” and it was about my journey of discovering that involuntary treatment programs like that one went against my deepest values.
So, you’ll get no argument from me that the path for this man once he was hospitalized is not a good one. But what about the alternative, going to jail?
Well, a night or two in the local jail isn’t going to solve anything, nor is it likely to remove the community risk unless the deeper underlying issues are addressed somehow. Setting aside the fact that the police would refuse to charge him, charging him with a serious crime leads to prison. In America, prisons are nightmares of violence, rape, brutality, and by the way – also places where persons CAN be forcibly drugged against their will, including drugged with neuroleptics. He would also be very likely to be in prison for far longer than he would be hospitalized or committed. How is that in any way a better option?
Both of the options I can see for this man are terrible. It’s why we so desperately need alternatives in the spirit of what you and I both previously described.
Not sure why, I see no reply button to your most recent comment in our discussion. Hope you find this reply and can keep it in some semblance of order.
Your question to me, of what about emergency room hospitalizations, is one of the questions that I struggle with the most. I’ve written pretty honestly here at MIA about how large this struggle is for me. Thankfully, its also a place where I feel very open to discussion. Let me try to paint the picture of where I am today on this:
Despite the few places where I feel conflicted and am still seeking answers, what feels right to me is to start with this statement: I don’t believe in forced treatment. I just don’t.
But one of my jobs is to work in the emergency room of a small-town community hospital serving a population of about 10,000 people and the surrounding rural area. I don’t work for the hospital, by that I mean that my wages come from a local community non-profit agency that offers voluntary support services to the small-town community. The services that people can ask to receive, if they want them, include things like advice and support with technical things like receiving health benefits, establishing health care, accessing other available financial resources, help with schooling, transportation assistance (especially when the local community is so rural) and so on. It can include community support groups that do things like swimming classes, yoga classes, grief support peer groups, smoking cessation support groups, mindfulness groups, and some voluntary counseling groups if there is interest and a group of people would like to explore certain topics together. It can include seeing an individual support person for counseling – where counseling takes the form of a person-directed process of talking and listening, that lasts only as long as the individual wishes and only takes the direction the individual chooses. And it includes partnerships with local causes such as Occupy Medical, where we hosted space for them to come down with volunteer doctors and community members and offer free medical care, screenings and connection to at least one doctor who will see people for free long-term if their income needs require it.
There’s a reason why I spent the time to write about the agency that pays me to work in the hospital in addition to my other job. Its so that when I tell you that I am evaluated by how many people I keep OUT of the hospital, you would have a better understanding of the agency values and philosophy that goes into having that expectation. While I do work in the ED, and I am in the position of making a decision about involuntarily hospitalizing someone or not, I am not encouraged to hospitalize in fact I’m discouraged from doing so. That’s not normal, as far as I am aware. It’s the only reason I’m even remotely willing to do the ED job – because I want people who come to the ED in some kind of a crisis to encounter someone who absolutely wants to do anything and everything under the sun OTHER than hospitalize.
The outcome of this basic disposition toward my work is this: in the last 12 months I have recommended inpatient hospitalization less than 5% of the time. Of those 5%, half were voluntary, people asking to go who had been before and felt like going again would help them (despite my incredulity!)
I’m not giving those statistics with pride. I’m giving them to put the situation in context. I continue to be deeply conflicted about my role in the 5% of people I worked with where hospitalization was the outcome. I ask myself the question, should I resign this position because sometimes it includes involuntary hospitalization, even if we are working to avoid that whenever possible? If I do resign, I’ll be replaced by someone who has far less qualms about involuntary treatment, so should I stay? I don’t know.
Let’s talk about that 5% of the time where I participated in hospitalizing someone. Actually lets look at the even smaller percent of the time when I participated in involuntarily hospitalizing someone. One instance where I recommended a person be hospitalized against there will was a situation in which a person had been brought to the emergency room after he had made the verbal threat that he was going to set his neighbors house on fire with them inside, and then proceeded to act on this threat by getting gasoline cans and heading to their home. This man had been in the street yelling loudly for some time prior, and it is a small town, so thankfully the police were on their way and intervened to stop this man from setting his neighbors house on fire.
The mans reasoning for wanting to burn his neighbors house and kill them inside it was due to a belief that they were in conspiracy with both aliens from another planet as well as ancient ghosts and tribal spirits that lived under his house. Their conspiracy was to steal his 5million dollars which he claimed to have due to writing most of the Top 40 music hits of the last 20 years.
I happened to know this man well, I like him, and I’ve seen him when he is not wrapped in the depths of these extreme states of thinking and feeling. But I also believe that he has ever capacity to carry out his threats and was apprehended in the middle of the act of carrying out his threat.
I do not believe I have a moral option to simply discharge him from the hospital and send him home. The lives and safety of his neighbor and their two children is as precious and important as this mans freedom. In this particular case, this was not a vague threat – the man actively tired to burn their house to the ground. Without a clear change in his disposition or intent, I can’t and won’t send him back home.
So what is to be done? I’ve talked about this with many from MIA and gotten a lot of different thoughts. One theme of thought is that the man should have been sent to jail. I balked at this because I don’t believe the man understands why what he is doing is wrong. In his mind, I think he is trying to protect himself from perceived danger. Other people argued that it does not matter because jail/prison is primarily about protecting society from danger, so that is where he would belong.
This is really, really hard for me to accept. Our prison system is as broken, abusive and inhumane as anything we talk about in psychiatry. So I’m not sure that just trading one problem for another equal problem is acceptable.
I feel like, in these extremely rare situations of a genuine clear danger to other people in the community, what we need more than anything is a completely different way of responding. I do believe that there are, and will continue to be, some rare situations in which the choice of an individual person must be weighed against the violation of other people’s safety. So while I still feel comfortable saying that I believe in the individuals right to make decisions about their own body, I don’t believe in an individual’s right to go murder someone else.
I would like to see “inpatient” programs that only took people that were the most immanent of dangers to others in the community, by the strictest criteria. I would like the only kind of drugs administered to be non-neuroleptic sedatives, and I those only if the individual voluntarily chooses them. One of the best things for acute distress of nearly any kind is sleep. Sleep and time. Sleep, time and safe kind people who talk to when you need it. I would want a place that was staffed primarily with peers and counselors (there’s no clear line here, many peers are counselors) who believed in relational dialog, talking and listening, empathy and tenderness, rather than prescriptive service. I would want the goal of such a place to be the least amount of restriction possible for the briefest time possible – and certain kinds of things would simply be off the table: seclusion and restraints – there are other ways to respond to a person who is aggressive or angry, seclusion in the way it is done in hospitals and restraints are both inhumane. Chemicals used involuntarily are also inhumane.
But we don’t have that today. So what does that mean for me? Should I quit working at the hospital altogether because in a tiny minority of circumstances I have to recommend that someone be hospitalized due to their immediate danger to other people? Or should I keep doing what I’m doing, which is looking for any and every alternative to hospitalization for people that I see in ED and successfully discharging more people back home with supports they chose for themselves than any other hospital in the state? Sometimes I feel like I’m doing important work that is consistent with my values even within such a broken system. We hospitalize less people than anywhere else. We have active values of seeking every positive and
voluntary alternative to hospitalization and we’re successful at this 9 out of 10 times.
In order to have a society in which no one was ever involuntarily hospitalized we need to do away with “psychiatric hospitals” altogether. Instead we need a completely new thing – not prison, not hospitals, but something else. It may still be a place where people who are immediately dangerous to their neighbors may go against their will until a way can be found for that danger to subside or be addressed. But the values of the place would not be medical but relational.
Thanks for the feedback. I guess I should clarify that the examples I had in my mind included one individual who took Zyprexa, one individual who took Seroquel (both of whom discontinued the drug but continue to claim that it was helpful to them for a specific period of time) and one person who took an SSRI but did not disclose to me which SSRI. The person taking the SSRI struck me as almost defensive in her strong insistence of how helpful the drug was to her – to the point that I actually had to step back some because I started to feel like I was imposing my values on to her experience in a coercive way, so I just accepted her perspective and moved on.
I’m so saddened that this is the new trend.
Laura thank you once again for such a beautiful and eloquent article. I truly feel like you have a powerful gift for writing and I continue to be touched on a regular basis by your articles, videos and activities for justice.
Many years ago, when I told a family friend that I was in undergraduate school studying philosophy, she scoffed and asked, “what are you going to do with that?” I replied, “Oh I dunno, be happy I guess?” I don’t know when in history the pursuit of knowledge for its own joy and inspiration got perverted into the pursuit of accomplishment, titles, status, and the like.
I fully agree with you that status, credentialing or degrees should not confer some sort of special privilege or status for anyone. And a system that uses such things in order to suppress voices or views or reinforce a rigid hierarchy is a system that needs to be toppled. I am sad that our system has turned the pursuit of knowledge into a rat race that has little to do with intellectual curiosity, passion and a searching for meaningful answers to the deepest questions of our lived experience – but instead is about competition and status, checking of credentialing checkboxes so you can then wave your letters around at others and claim authority without actually possessing a rational thought.
I feel so incredibly fortunate and privileged that I was mostly able to avoid that and got to learn for the joy of learning – in part, through the existential meaning making of studying philosophy and the social justice and human experience learning from studying in social work. And in part as part of a deeply passionate personal process of seeking to clarify my values and my understanding of the world in which I live and move and have my being. Lucky. Very lucky.
This is a huge problem of injustice – that doctors make a false equivalency between “getting well” and “being more manageable to the rest of us.”
“Well” is something that should be defined by the individual. But in our culture it is not. Instead “well” is a judgement made by other “professionals.” And “well” is defined to mean, “less likely to be disruptive, disturbing, costly, irritating or inconvenient to the rest of us.”
Thanks to both Phillip and Ron for the article and follow-up comments. My direct experience with psychiatric medications as well as the near direct experiences of two of my family members with psychiatric medications color how I understand the issue.
Ron, I am deeply appreciative of your tone and style in everything that I’ve seen you write. I struggle with high levels of emotion – passion, frustration, even anger – as I confront the realities of the mental health system. I feel like its a daily struggle to channel all those feelings into something that people would want to listen to. Because it doesn’t matter how “right” I think I am, no one *has to* listen to me. Ever. Preaching to the choir has limited usefulness, with its major value being catharsis. Advocating to others is more important, but has to come with the acceptance that absolutely no one out there has to listen to anything I say. So if I yell at them, or bring level 10 energy, anger, bombast, hyperbole and the like – other people will do exactly the same thing that I instinctually do in those situations – stop listening.
So I’m really struggling with how to be an effective advocate, not just a passionate one.
With that aside, I wanted to comment that I’m not actually sure if anyone I’ve ever known has ever had truly informed consent before taking a psychiatric medication. Certainly I agree in principle with individual freedom and choice. So in principle if someone was fully informed and uncoerced in making a decision to take a drug, I would not feel comfortable intervening and preventing them from doing that. But I wonder how many people would actually ever voluntarily choose psych drugs if they were truly fully informed about them?
I have known people who have elected psych drugs short term during a period where they felt they were in accute distress, and have spoken with them after the distress subsided and they stopped taking the drugs. Sometimes, almost surprisingly to my mind, they continue to maintain that selective use of the drugs was extremely helpful to them in getting through a seemingly unbearable distress state. These individuals stand alongside others, including myself, who feel that their own experiences with psych drugs were less positive – people who feel physically and emotionally damaged, who feel dependent, who feel that they were lied to (as I feel I was) so that they could not make informed decisions, etc.
Somehow we have to make room for everyone’s individual experiences. The goal, I believe and the value I hope we can share, is for individual freedom to make uncoerced, fully informed choices about ones own body. That’s what I want.
Thank you for the article! The issue of informed consent also comes down to a question of values, I think. There seems to be something that feels very much like excuse making to take an argument that goes something like, “well the person wanted it, so my hands were tied.” Thankfully, I’m not in a position to “prescribe” treatments of these sorts. But if I was, and a person came to me saying that the were absolutely certain they wanted ECT, I would not participate in them doing it, anymore than I would assist someone in having a lobotomy. It’s true that the individual can continue their attempts to receive certain “treatment,” but I don’t have to support it or be involved in it.
The other serious piece of this discussion is the matter of what actually constitutes “informed” consent. I personally suspect that informed consent is almost never obtained for nearly anything aside from possibly the most simple voluntary outpatient counseling. I believe that the system too frequently treats consent as a political game in which full, comprehensive information about “treatments” being proposed are presented with the complete description of possible benefits and risks, a review of the evidence – if any – about such a “treatment” and a reminder to the individual of their full range of rights, including the right to decline without reprisal, the right to withdraw consent at any given time, among others.
I believe there are two major biases that give “professionals” a much greater sense of freedom to rationalize and justify the lack of truly informed consent. The first is the nature of the dominant medical model that establishes a framework of “doctor” to “sick person” with all the paternalistic authority contained therein. The second, somewhat less discussed, is the issue of class. Poor people are seen as “other” in this society. A rich person will likely have infinitely more say, more information, and more consent in his or her own care than a poor person ever will.
The state mental health system, wrapped up in medicaid and medicare, and the disability system, which grants benefits at at or below the poverty line, overwhelmingly interacts with the economically marginalized. A person’s intellect, character, and basic status as a person are all seen completely differently as a torrent of cultural biases and bigotry run completely unchecked. “Those” people don’t know what’s best for them. But “we” do. So if we shade the truth a little bit, or gloss over the details, or talk of “evidence” that doesn’t really exist, that’s all OK because those “other” people really just need to do what we want and stay out of the way of the “real” people in the world.
Gosh thank you so much for this article. This subject of involuntary “treatment” or incarceration as I called it in the first article I ever wrote for MIA is one of the subjects I think the most about. It’s an area where I feel the most able to be open to discussion and influence.
Thankfully, I start with what I feel like is the “right” general principle for me: as a broad statement, I don’t believe in involuntary “treatment.” That belief was one I came to in part by naively accepting a position with a “secure psychiatric residential facility” under the deeply misguided belief that people who were there “needed” to be there and I was “helping” by working there. Wow was I wrong. I quit.
I admit that there are still some concrete particular situations that give me pause. I worked with a guy who was arrested for trying to set his neighbors on fire because he believed he was being commanded to do so. He was in the middle of the act when he was stopped. He was psychiatricly hospitalized.
It seems clear to me that I could not in good conscience simple advocate for him to be released right back to next door to the neighbors he tried to set on fire without some kind of change in his thinking or disposition. I feel like I have to be concerned about the safety of his neighbors. But in discussion here, some have advocated that the right choice was for him to go to jail. They point out that the main reason jail feels like the wrong choice is because of a misguided notion that somehow psychiatric hosptialization would be more kind or more helpful. People challenge that belief and I hear those challenges and they resonate with me. I still struggle a bit with the idea of putting someone in jail who doesn’t have a clear understanding that what they were doing was wrong. But this is circular, because it goes back to the point made that psychiatric hospitalization is not better in most cases (maybe all cases, but I try not to speak in absolutes.)
It feels like a very difficult and painful question. How do I honor both the individual experience distress and the community that may or may not be at safety risk by that distress? Long term, it seems clear to me that need a totally different way of trying to support people that doesn’t involve power institutions coercively intervening. But then I do run into some specific situations that still feel really hard and honestly no option I can think of feels like a good one.
Again, thank you for this article. I feel really open around this subject, including listening to other voices grappling with the issues here. Again, the thing I am fully confident about, is that my guiding principle is that I don’t believe in forced treatment.
“I want to elaborate on my second point. The way you have described the job of “social workers” and the rest of it as “helpers sent by government to help the poor” makes precisely my point.”
You put quotation marks around something I did not say. I’m not sent by the government. I don’t work for the government. I’m not paid by the government. The agency accepts payment from people who have medicare or medicaid in addition to all other forms of payment AND zero payment in situations when someone has no ability to pay. I am paid from whatever money they take in through the process. Most years we operate at a LOSS, and members of the local community, make donations to support our community based agency which has roots in our small town going back 30 years.
I get that we have political differences about state services for american citizens with less economic means. Great. But I’m neither sent by the government, nor working for the government, nor paid by the government. My agency will accept people’s insurance, including medicare and medicaid. Just like it accepts others, or individual payment, or no payment at all when someone can’t afford it. If the government stopped funding medicaid or medicare tomorrow, I would still be paid. Why? Because I don’t get paid by the government. Most social workers don’t. There are certainly those who work for the state. That’s not something I would personally do, it’s not what my organization does, and its not what most organizations in our county do. But some to work for the state, its true. But I’m still not ready to write off every individual that does so because I don’t know them and I’d sound like an idiot if I made such a sweeping generalization. I’d need to know what kind of values they brought to whatever work they were doing first.
“Government now negates religion and sends social workers to “help” people. Unlike what happens with religious workers -whose help you can politely refuse-, you cannot refuse the help of a “government sent” social worker who comes comes with a court order that directs him/her to “help you’.”
I cannot not be ordered by any court to do anything. I don’t work for the government. None of us do. I completely understand that this does happen. It’s wrong. And me and my friends are screaming loudly about the fact that it is wrong. You are overgeneralizing and being needlessly antagonistic and reductionist. The community at MIA is filled with all kinds – survivors, activist and psychiatrists (gasp!), psychologists (gasp!), social workers (wtf who let those jerks in?), medical doctors (gasp!) and the like. Then it gets even worse (for purists anyway) because a whole bunch of psychiatrists, social workers, doctors and the like are ALSO peers with their own lived experiences of mental and emotional distress and their own histories with both the negatives and positives of the mental health system. It makes it quite a nightmare for dogmatic reductionistic thinkers.
What unites us is shared agreement on some core values. What destroys community is stupid sweeping generalizations and part-whole logical fallacies. The point is not to have some sort of cave man style reasoning “GRR. SOCIL WERK BAD. GRR.” But instead to talk about the values that unite us.
I actually WANT there to be practicing psychiatrists who hold values I share and challenge the norms of that institution. So thank you very much, all you MIA community psychiatrists who are doing exactly that and taking lots of heat for it. Bless you. I actually want practicing social workers who share my values practicing within the system and standing for those values in the work they do. Thank you very much MIA community social workers for doing exactly that. And I want peers (I am a peer) and survivors who share my values speaking up and speaking out, both against the institutional failures of psychiatry, social work, and hopefully other organizations and movements that feel the distortion of power and move away from values we hold. I also want them inside agencies and institutions if and when they feel that they could engage in meaningful activity consistent with their values. So thank you very much MIA community peers and survivors for doing exactly that.
Values is what unites community. Sweeping generalization and dismissive evidence-absent or factually incorrect dogma destroys it.
So, it kind of feels like, restoring to complaining about long answers is just kind of a dodgy way to avoid answering questions. Serious subjects take serious engagement, not pat answers and reductionistic (but admittedly shorter) rhetoric. Of course you don’t have to engage or reply. But if you’re going to, but don’t choose to read, that sort of leave us stuck. Because basically you are saying, “I want to respond to you, but I don’t want to listen to you.”
“Why I see CBT as “social control”. CBT is about altering behavior in some way that doesn’t come naturally to you.”
So, that’s categorically false. And just because you had an experience in which that happened to you means that you had someone practicing inappropriately. That can happen with anything. Any human activity can be coopted, misused, or abused by someone. But CBT has a concrete definition, and its not what you are saying it is. It’s really that simple.
“To be more precise, my “therapy” consisted of going to gay districts and places like that to “please” my ex wife.”
Not at all part of CBT, which has nothing to do with any sort of “exposure.” You’ll find no literature describing that as a core concept of CBT, nor will if you find any tools or resources that suggest that immersion or exposure is part of a CBT model.
“Take the Justina Pelletier case. It was social workers that received the call from Boston Children’s Hospital psychiatrists/psychologists to apply for the custody of Justina. ”
Except, I don’t work for the government. And you are making a part-whole logical fallacy again. Basically, I feel like you keep using words without having any idea what they actually mean. This happens a lot here, and it is unbelievably frustrating.
All collies are dogs. Not all dogs are collies. So, some individual with a social work degree may chose to go work for the government and take someone’s kids away. That’s a choice they make to go work for the government. But that’s different that acting as though social work itself is about working for the government. That’s simply a provable factual error.
“I am sorry, but the issue of helping other human beings is not the prerogative of social workers. ”
I guess I might be more inclined to be persuaded by your statement if it seemed as though you had any idea what social work is. Once again you are making a part-whole error. Individuals can certainly do bad things in the name of science, psychiatry, social work, religion, and even the psychiatric survivor movement. That doesn’t make (a) individuals in any of those fields bad or (b) prove that anyone associated with any of those fields is automatically bad or part of a problem.
I am paid by a nonprofit. Our non profit accepts payment from both private and public insurance, it also uses a sliding scale for anyone with limited ability to pay and also sees people for free in many cases. I don’t work for the government. Neither does any of my colleges. The government cannot order me to do something. And I would refuse any order that conflicted with my values.
This entire exchange could have been better summed up by Inigo Montoya: “You keep using that word…. I do not think it means what you think it means.” But the level of dogma you are delivering is more than I can take. I don’t like it when it comes from the APA. I definitely don’t like it when it comes from here. Just saying something is true doesn’t make it so. It takes evidence, of which you have none for your “definition” of CBT which is demonstrably incorrect. Or for your “definition” of social work, also demonstrably incorrect.
You can definitely cite examples in which CBT, social work or other things have been coopted and abused either by individuals or government. Which is totally different than saying CBT itself is brainwashing, or that social work is foundationally about values of social control – both statements which are as evidence-absent as the claim that mental “illness” is a brain disease. No evidence, just a lot of bombastic rhetoric.
The fact that a tool can be abused and distorted (CBT) or that an individual in an institution can engage in bad behavior, or alternatively, an institution can engage in bad behavior while individuals resist that behavior – this is a problem that can happen to any individual and ANY institution or movement. It is a problem that no individual or group, including the psychiatric survivor movement, is immune to.
I’d be pretty stupid to say that the psychiatric survivor movement is a form of social control because my dad had a bad experience in which psychiatric survivors tried to “intervene” and coerce him into doing things that felt wrong to him (stopping a medication, stopping seeing a veteran counselor through the va that dad really liked, telling him that he was part of the program for making his own choice in the matter, basically acting pretty much like the stereotype of a Psychiatrist) My dad had a bad experience with people not at all speaking for the community at large, or for other individuals within the community. He had the experience of encountering a couple of jerks, nothing more.
But if I let me anger at that cloud all judgment, then I suppose I could have turned into a person who wrote rants about the survivor movement, and reacted negatively the first time I met anyone who claimed that label all knee-jerk and without an intelligent understanding of what principles and values actually underlie the movement. Glad I didn’t do that. Wish other people wouldn’t to the same.
A bunch of people have already made a similar comment. But because it was very frustrating to read a pretty serious mischaracterization, I guess I’ll add my voice to the mix.
Before I do I want to acknowledge some things so that it does not seem like I’m throwing the baby out with the bathwater. First, I’m not surprised in the slightest that Big Pharma is coopting the language of MI and then totally distorting its foundational principles to suit its own purposes. I’ve shouted obscenities into the air as Big Pharma has done the same with the word “Recovery” and all sorts of other things.
The spirit of the message in this article is extremely important. Exposing how Pharma seeks to manipulate and twist people into drug use is crucial to creating change. So I’m not ignoring the broader point here.
However, I also believe in accuracy, and in this case the article has a fatal flaw. The article conflates motivational interviewing with Pharma’s twisted bastardization of motivational interviewing. I have had extensive training with the approach, which is only a resource that may or may not be helpful in a specific context. I’ve also provided training for other practitioners several times.
Here’s some things you may not know, but need to:
1. The root aim of motivational interviewing is to explore ambivalence. Ambivalence is when someone feels two different or opposite things strongly. If a person is literally experiencing no ambivalence at all, then motivational interviewing stops there.
2. Motivational interviewing is about the exploration of ambivalence…..toward a persons OWN change desires. NOT the change desires of a practitioner. Not some sort of manipulative tool to get someone to comply with someone else’s agenda. Someone who says, “I’ve decided that part of me really wants to make x change, but then again another part of me really doesn’t” may find that tools that facilitate his or her exploration of ambivalence (what MI does) are really useful. Or not. But either way, its up to the individual to drive the process.
3. An absolute core principle of MI from its origin is this: you the practitioner should never make the mistake of being the one to advocate a change as you define it. Instead, through a process of exploring ambivalence and rolling through resistances, the individual can come to clarify whether or not they want to change, what that change will look like, and what steps they decide they will make to facilitate the change. If someone concludes that they do not want to change something, and they have no ambivalence about that, then MI is done. There is no pressure or manipulative advocacy about it.
4. One of the pioneers of MI, William Miller wrote an article that was published in the Psychology of Addictive Behaviors journal in 2000 called “Rediscovering Fire.” In it, he argued that the single most important factor in a positive outcome (as the individual receiving service defines it) is not the type of service or “treatment” but rather the ability of the practitioner to demonstrate unconditional love toward the person being served. Now maybe that sounds like crazy woo-woo talk to someone reading this. But its pretty hard to suggest that from that foundation Miller and Rolnick somehow then build a set of tools called Motivational Interviewing for the purpose of manipulating and tricking people into doing what they want. That, and the fact that over and over and over again the consistently emphasis that manipulation, coercion or trickery is not at all consistent with MI, or ethical.
As MI began to be applied in substance addiction treatment, there was – I admit – a bit of a learning process. Early models did feel manipulative, which promoted miller, rolnick and others to produce an absolute slew of materials arguing that this was wrongheaded, unhelpful, and not consistent with their intentions.
Today, an MI support approach is taught in very specific ways. It is client focused, not practitioner agenda focused, it is aimed at assisting someone in exloring their own ambivalence toward their own desires and resolving that ambivalence, either toward a change they were considering or away from that change – whatever the feel is best for them.
MI, like every single other thing out there in the wide wide world CAN be perverted, distorted, abused, misused, or poorly practiced. But there is a big difference between saying “these are the premises of MI” and saying “these people are abusing the premises of MI.” Big difference.
Thanks for your reply. I feel like I may not be communicating my questions well enough, because I didn’t feel like your response answered that I’m trying to ask. So bear with me, I’ll try to do better this time…
One thing that might help, is you skipped a question of mine, which was to define CBT as you understand it. I need to figure out if we’re talking about the same thing. It does not seem like we are, because you wrote:
“Some people might be unhappy with their own thoughts and might be seeking help to be “brainwashed” as to make those thoughts go away.”
So I accept that it may be the case that there are people out there who might want this, but it has not connection at all to CBT as I understand it.
Here’s a “CBT” experience of mine that happened in my own life. I had a situation in which I acted (really reacted) in ways I didn’t like. My actions weren’t consistent with the way I want to live, the way that feels right to me, most authentic if you will. I didn’t like it. As I reflected on my actions, I had to accept that this was sort of a pattern. Certainly I was getting in situations where I was acting/reacting in ways that really didn’t feel good to me.
So I began to ask myself, what was I feeling and thinking in the moment when this happened. And it wasn’t too difficult, I was able to articulate for myself exactly what I was thinking (and feeling, as at least for me these are really inseparable things) that contributed to my action/reaction.
Then I asked myself, now that I’m out of the heat of the moment, having had some time and distance to reflect, what do I about the same situation now? And out of the moment, with less immediate urgency and emotion, I was able to think on, what felt to me, like a slightly deeper level. At least a level of thoughts and feelings that felt more consistent with the things I really value. I found myself saying, “wow in the heat of the moment I really wish I could have thought of, remembered these larger thoughts, these thoughts that feel more in line with the kind of person I want to be.”
I continued to have the feeling of wishing I could remember these “deeper” things in the heat of the moment, but that seemed so hard! How do I do that? In the moment, it felt like I was just acting/reacting almost before I even had a chance to connect to any more “thoughtful” place of mind. It’s like it happened before I even knew what was happening.
I didn’t feel like I had a great answer on how to make a shift, but I knew that I really wanted to find some way to remember the thoughts and feelings I was having with some space and distance and connect with them in the moment. Notice that this wasn’t about “replacement” thoughts. I had different thoughts going on that were all really thoughts of mine — the first set were ones coming from a more emotional, reactionary place focused on short term perspective, while the latter set of thoughts were the ones that reflected a more long term perspective, ones that were connected to my own sense of values and the kinds of things that were important to me about how I live my life.
It would only be “brainwashing” if somehow I was trying to eliminate thoughts I have or replace thoughts I have with some other set of thoughts. Instead, what I wanted to do was access the deeper, more contemplative thinking of mine IN THE MOMENT, so that I was better able to really make the kinds of choices and take the kinds of actions that feel good to me. Not to be “rid” of my other, more reactionary thoughts. But rather to make room for ALL my thoughts and feelings, so that I had the best perspective from which to make choices, rather than feel like I was impulsively reacting.
I certainly didn’t have a perfect set of activities or actions to help me get to a place where I could remember these deeper thoughts of mine in the moment. But I decided that I wouldn’t give up on reflecting on these things, and making time to think about the kind of person I wanted to be and the sorts of things I wanted to remember in the heat of the moment.
At first what happened was I would still find myself in situations where I was reacting implusively and felt like my actions weren’t really a product of thoughtful, careful choice making – BUT I also started to more quickly be able to access the other thoughts that I would have too, that used to only come in hindsight. With a little more time, I started to see myself heading down a path toward rash actions/reactions that really didn’t reflect the kind of person I wanted to be, and remember other thoughts and feelings that used to only come with hindsight quickly enough to change directions in my actions and choices. And then, with even more time, I started to notice myself NOT reacting in the ways I used to, and more frequently making thoughtful actions and choices that were far more consistent with the kind of person I wanted to be.
That is, essentially an object lesson in CBT. Calling it brainwashing is a categorical error.
But clearly you disagree. So a completely legitimate question for me to ask you is to define CBT as you understand it. Because if I don’t hear that definition, I can’t possibly understand why you would call it brainwashing. Also, its more than fair for me to assume that you can provide a substantive definition for a thing you are criticizing. And I need that definition, to understand what we are even talking about. So will you do that for me?
Moving on from that, a little more about your dictionary definition of brainwashing you provided: any tactic that can be seen as subverting one’s control over their own thinking. Cool. CBT, by definition, doesn’t have anything to do with that. The individual identifies for themselves what their thinking is. They decide for themselves what patterns of thinking are most helpful or unhelpful to them in a given situation. They choose how to prioritize that thinking and choose to find ways to make more room for more of their thinking as THEY define it. They may decide that the have thinking errors, and if they do they may decide that they’ve come to new thinking that feels more accurate and consistent with who they want to be and what they want to be about. If they do, great. If they don’t, fine. But I’ll be pretty skeptical if you seek to claim to me that you’ve never changed your mind, discarded old ideas about things in favor of ones that feel more right and accurate to you. That’s part of the human experience of every person I’ve ever met so far. It’s a wonderful process we call growth and learning. It’s one of the best parts of being alive.
If YOU decide what thinking is accurate for you and helpful to you, if YOU decide how to incorporate all your thoughts and prioritize them in the ways that serve the beliefs and values you’ve chosen autonomously, and if YOU make the decisions about what – if any – thinking you’ve concluded to be in error, or that you’ve chosen to replace with other ideas that feel more accurate to your values and experience, as long as YOU are the one doing that, then by your OWN dictionary definition, that’s not “brainwashing.”
Now about social control. You define social control as “self-appointed, unaccountable, mind guardians dictating behavioral orthodoxy.” Cool. So that’s not what I do. It’s not what my peers do. It’s not why I left a lucrative job at Hewlett Packard to go back to school to make less money and work ten times as hard so that I could be a servant to other human beings. Those aren’t the values I was taught as a social worker. Those aren’t the values shared by my peers.
On the other hand, I’ve seen those values in play. I’ve interacted with psychiatrists who represented those values. I’ve seen the same “research” and “papers” and talks by the so-called “experts” that match all those descriptions you gave to the letter. I’ve stood with more than a few survivors as they shared their harrowing stories of abuse. I’ve walked out on a job, without having any idea how I was going to eat or pay rent or where my next job would come from, because I did not agree with their treatment of people they worked with.
I’ve also had my own experience of partnering with a wonderful counselor when I had absolutely no one else to turn to. Essentially all she really did was listen to me with compassion and empathy and, as human beings do, periodically gently offer some reflections for me to accept or reject as I saw fit. Few human encounters have been more touching or powerful. And with all due respect, its simply the height of arrogance for you to decree that that experience is somehow “invalid” – just brainwashing and social control. Neither you nor anyone else is qualified to make that judgement. I am.
Me and my colleagues – other social workers and counselors, not Psychiatrists, make just a little bit above a living wage, or the minimum wage in some states. I don’t get any fame, or any authority or prestige. I work ten times as hard as I ever did in the corporate world making way the hell more money. It is emotionally exhausting and incredibly demanding.
I do it because I wanted to SERVE other human beings. And not only do I have to fight institutional psychiatry and the pharamceutical industry and all of the injustices therein, I ALSO have to put up with sweeping, reductionistic, ill-informed generalizations and one-size-its all rhetoric from the very people whose core values I share.
So as you keep delivering vague generalities I am going to continue to ask for concrete specifics. Define CBT for me. Tell me what it is. Then connect that to the dictionary definition of brainwashing you provided. Your definition of social control seems wholly unapplicable to my situation, or the situation of any of my colleagues. So, yeah I’m with you – that’s social control as I understand, and that experience is a REAL one that pervades far too much of psychiatric, pharmacueticals and even broader “mental health” industry at large…
But still not enough for you to legitimately lump everyone into the same boat. Grabbing up the banner of “No one should see a counselor” is the wrong fight. I get that you don’t want to pay taxes for people to receive support services. That sounds super except for the fact that poor people often have less supports than rich people do, and frequently have less natural supports. So where are people without income and without friends or family they feel safe enough to talk to supposed to go? Human beings need other human beings for support. No one I have ever met does it entirely alone, or at least they don’t do it very well. So what then?
Thank you so much for both sharing your journey and for your advocacy efforts. They are much appreciated.
So first, I need to restate your position as I understand it, to make sure you agree I am stating it correctly and not distorting anything. So I as I hear it these are the main declarative statements that I take away:
1. CBT is brainwashing.
2. CBT is a form of social control.
3. Any instance in which an individual sees another person for assistance a form of social control. Did I overstate that, or is your position that universal?
4. You do not wish to have your tax dollars go to pay for others to see a person for support, because any and all forms of support in which one person sees another person who is paid to provide support is a form of social control. Did I overstate that?
Let’s go ahead and assume I’m pretty close to accurate, since I basically just repeated the exact sentences you wrote. I feel like 1-3 are their own issues while 4 is a separate issue. So, rather than talk about what kinds of things we should or shouldn’t pay taxes for, I’d rather ask some questions about the underlying assumptions – the question of “brainwashing” and “social control.”
So, I start with a very simple, but extremely reasonable question: if CBT is brainwashing, tell me how that is the case? I don’t want to be involved in brainwashing anymore than I want to be an agent of social control. So tell me how CBT is brainwashing. Anyone can make hyperbolic statements. Those have no accountability. It’s far more significant and meaningful to give reasoning for the statements we make. I might learn something important. So two questions:
1.) Define CBT as you understand it
2.) How is CBT brainwashing?
The second question is the one I have the most interest in. I’m not interested in bombastic rhetoric from this community any more than I would accept it from the President of the APA. The expectation needs to be that people explain their claims and give reasons to support them. That would help me and others, because then I’d be better able to understand something potentially important.
Next I have a question about the phrase “social control.” How is talking with someone who is voluntarily choosing to talk to me, who freely chooses what kinds of support to receive, or none at all, social control? Actually, define “social control.” When I saw a counselor voluntarily because I had no natural supports and felt like I wanted to die, she saw me for free – never charged me or the taxpayer a cent. Is that still “social control?”
So to summarize:
1) Define social control. What does that mean to you?
2) How is me talking to someone who asks to talk to me, who comes to talk to me voluntarily, who chooses exactly what they want to talk about, what they want back from me, and whether or not to continue or end as they see fit – how is that an example of “social control” in action?
3) When my counselor saw me for free, without my paying or without the taxpayer or any insurance company or anyone else paying a cent, is that still a form of “social control?”
Possibly because CBT, unless done in a categorically inappropriate, immoral and unethical way completely opposite of his framework or guiding principles, can not an any way be likened to brainwashing.
Sounds like you had an experience of something done to you that was unethical and reportable. For example, I am accountable to a licensing board, and I can tell you, when it comes to clinical social work, the Social Work Licensing Board doesn’t kid around.
CBT isn’t a one size fits all thing, and its not even my preferred modality to work with. I do it when that’s what someone requesting support for me ASKS for, and work through the ideas with them for as long as they continue to believe that it is beneficial to them. If and when they tell me it isn’t, we stop. CBT is supposed to be something one tries if the person self-identifies actions in their life that they are not satisfied with or that create problems for them (as they define it.) Then, if the person feels like thinking patterns is what most gets them hooked up, you can start to evaluate thinking going on along side actions that the person doesn’t like and ask, is this thinking helpful to me, relative to my values and goals, or unhelpful to me? Not “right” or “wrong.” But rather, consistent with my values or not consistent.
If someone starts to identify habitual patterns of thinking that THEY feel are not consistent with THEIR values as THEY define them, and if they are interested, then I might be able to be a partner in suggesting some ways to build some new thinking patterns more consistent with their values and goals. The work comes from them, the change if any comes from them, and I simply offer some feedback and some suggestions along the way. If they want it.
CBT was not personally helpful for me. Know what my therapist did when I shared with her that I did not feel that CBT is what I needed?
She stopped. It’s more common than you might think once you get outside capital “P” psychiatry. Social Workers, Family Therapists, Spiritual Guides, etc. don’t prescribe meds, don’t generally work with involuntary clients, don’t force any sort of “treatment” and don’t typically dictate what counseling or “therapy” should look like.
Right work for an agency that employs about 80 people, including peed advocates. Not one of them is a psychiatrist. There is not one single service that is in anyway forced or involuntary. Not one counselor “sends” people to the hospital. The agency core values are built on a often-discussion foundation of rogerian spirit, client autonomy, voluntary services and individually directed support.
Most importantly, we serve poor people. We offer services to people who frequently have few to no natural supports, friends, family or other connections and who have little or in many cases zero income. People who are marginalized and ignored by society at large. Sure, for people of privilege there may be no need to see someone connected to an organization who is paid to provide support services. But what I know, both from my own direct lived experience and my experience of working with the bottom 1 percent in America is a lot of people don’t have the luxury.
So that’s just one fringe organization, you say? My agency is the exception to the rule? Well, let’s expand out to the full county level in my state: and there I can tell you that the overwhelming majority of organizations offering individual counseling or “therapy” services are exactly the same. They have no psychiatrists. They prescribe no medications. The people who request services are completely voluntary and not “forced” to do anything.
In fact, I couldn’t tell you were to find an outpatient psychiatrist in my county. I’m sure they exist, but its not my friends in the lowest economic class that are going to them. Only when you get caught up in the hospital, in the emergency rooms where you get held involuntarily and sent to a psych hospital – only then do the people I work with most meet the Psychiatrists.
And that friends, is a huge problem – involuntary treatment is where the medical model cronies come on the scene. It’s where everything falls apart. But we need to stop conflating every sort of mental/emotional support service provision under the name (small p) psychiatry, because they are not even remotely the same and as a social worker, it is offensive to say that they are.
I hear people making sweeping generalizations about what “mental health professionals” are taught in school. For me graduate school was one of the many profound and positive epochs of my life. I was NOT taught a medical model of mental “illness.” I was not taught the DSM as a bible. In fact, I had only one single class covering the DSM and the only reason it was covered, according to my professor, was because anyone ever billing Medicare would have to know it. When we discussed it it was from a lens of critical scrutiny. Gender theory critiques were offered. Critical and conflict therory critiques were offered. Feminist criticisms were explored. I was taught how to think about the political nature of the book and the medical model. I was taught to think about the power struggles that are behind the “professionalization” of helping professions.
I was taught that a core value of a social worker ought to be challenging unquestioned assumptions about “normacy” and “illness.” Beyond that, I studied public policy from the perspective of radical activism. I was spend days and nights reading Malcom X and studying Saul Alinsky and reading criticisms of Social Work that argued it was drifting away from its radical roots and toward a profession that simply reified social/system norms without asking the question of whether not they were legitimate or just. My professors and cohort pressed me to grapple with these questions. They urged me to be someone that cherished he dignity of other people and their freedom to choose. They drilled into me the belief that I am only ever a support at best – never the one with the “answer.” They urged me never to fall into the trap of believing that I could expertly diagnosis an “illness” OR “prescribe” a fix. I don’t fix people. I ask them what I might be able to do to compassionately assist them in their journey, I offer to share with them insights I have learned about human experience and human development if they wish it, and mostly I just stand along side them and listen and love.
This wasn’t some unique experience of mine. These were the values that defined MY graduate program, my cohort of fellow students and the professors who helped me shape my values of human interaction. I’m not remotely alone in this.
So…. while we are correctly and appropriately challenging the extreme abuse of persons with lived experiences that differ from those in positions of power, while we are correctly and appropriately listening to the horror stories of abuse victims at the hands of either capital P Psychiatry or the mental health system at large with a combination of righteous indignation and heartache….
While we’re doing all that, we have GOT to find a way not to paint with absurd broad brushes. We have got to do a better job if trying to minimize the amount of either/or all-or-nothing binary type thinking and language from our discussions. They world does not fit neatly in a clean little box. There are both people who have experienced severe abuse AND people, like myself, who have experienced deep and life-changing healing in partnership with professional support persons. There’s room to honor both. I’ve come to believe it is a waste of time to debate what percentage of people are abused and what percentage of people are helped. That completely, totally missed the point in spectacular fashion. The point SHOULD BE THAT EVERYONE IS FREE TO CHOOSE.
That’s what we as a community ought to be striving for in my opinion. We miss the point when we get sucked into debates over whether or all counseling is bad or good. Not the point. The point is, ripping choice away from people (either the choice TO take meds or NOT to take meds, TO see a therapist or NOT to see a therapist) is a social and moral wrong. That’s what should unite us: We should be freedom advocates.
(end rant, lol)
This entire debate is a colossal distraction.
I prefer to imagine a world where choice isn’t taken away, including an individual person’s choice to see someone else for whatever kind of support they feel like they desire, or none at all. I prefer to work toward a day when the role of anyone who chooses to devote their working life providing service to others were pure advocates, with no power over others and no desire to reach for such power.
I’m glad that I had the choice to partner with a counselor that was right for me. It was one part of a whole that was part of my path to some deep healing. But it was also completely voluntary, and my counselor prescribed no meds, and had no connecting to a system of forced treatment. I could come, or not come as I felt was best for me. That’s the kind of freedom and choice we all deserve.
There have been people in roles of “counselors,” “guides,” any anything else you want to call them through out much of history. People who devote the bulk of their life energy to trying to serve other people and be a comfort and support to them in difficult emotional times. But in our society, that has all been distorted and contorted by power, profit and a culture of paternalism and bigotry toward persons with differing lived experiences. That’s what I care about changing. They’re can still be counselors for as long as the world lasts for all I care. Or not if no one ever wants or needs that sort of thing. But I am a defender of individual choice. If someone wants to see me, I’m not going to say no.
I agree with you B, and also appreciate the wonderful post you are responding to.
I try to avoid the term “most.” I can’t claim that, I don’t have knowledge of every counselor and therapist out there. Instead what I can comfortably say is that there are “some” and there needs to be “more.”
I wonder if one of the many dividing lines is the difference between forced and voluntary services.
I know a great many people who speak highly of their experiences talking with a counselor (they come in all sorts of flavors, but none of them have power to force a person into doing things and none of them prescribe psychiatric medications). Conversely, the experiences in which someone feels forced to work with a psychiatrist or someone else with institutional authority and power are almost always bad at best, abusive at worst.
Even when it comes to choices about medications, I’ve met a host of incredible community-based prescribers. But they sure as heck don’t work in hospitals, psych facilities, or other places where coercive “treatment” is the model.
I really like the yin/yang metaphor! Polemics are important. They can help clarify values and, more importantly rally together people who have been marginalized. They are critical in rallying like minded people by stirring passions, clarifying shared opposition, creating a sense of unity against the injustice of a system that usually so powerful and dominant that it can sometimes seem unassailable.
So the “Yin” might be the act of rallying together, an act in which passion and even “righteous” anger are powerful and galvanizing tools. I would suggest that the “Yang” comes into play the moment a person seeks to advocate or persuade an individual who is skeptical or has doubts about the position you are advocating. In other words there’s a big difference between the task of rallying and the task of persuading and they are both really important.
If someone is unsure or thinks they might disagree, then the “rallying” message has no traction in most cases. This is because I think we have a tendency to forget one simple reality: no one has to listen to you. Ever. Oh, they may be in some setting where they are required to sit there what you talk at them. But no one has to actually, genuinely listen.
It has been my experience that when we bring powerful emotions, righteous anger and an impatient tone to conversations with people who are not sure they agree with us, or have never considered the questions we are asking them to consider, or are just uncertain – people either shut down, or back away, or become defensive and entrenched in a position they didn’t even feel so strongly about before they felt assaulted by our intensity.
I am only talking about situations in which we are talking to another person who has questions or uncertainties about whether or not they agree with what we are saying, but who are still thinking about it…
In situations where someone agrees with us, or is looking for a voice that reflects their own values or experiences, then deeply passionate no-nonsense intense declarations of our values and our dissent against the things we believe to be unjust or oppressive can feel like a breath of fresh air, and be incredibly powerful and meaningful.
But movements require the changing of attitudes and minds of people who have never thought about these issues before, or have thought about these issues before and come to conclusions we believe to be irrational and oppressive. You can’t walk into a room full of people who are unsure and have questions about your position and yell and them and call them all stupid. Why? Because no one actually has to listen to another person.
This is why I think its really important to find peace with our own traumatic experiences rather than bring deep open wounds of unaddressed trauma into our public dialog without a conscious awareness that we are doing so. It’s one thing to directly talk about experiences of oppression, injustice or abuse at the hands of an institution. It’s another thing not to be aware how those experience trigger us and then react in discussion with others in aggressive ways or with totally unregulated emotional energy.
When people are primarily talking or responding to others from their own pain, it is been my experience that it usually doesn’t lead anywhere good. Engaging with people with anger, snark or flippancy when they are are asking questions or finding their own way but are not certain they see things eye to eye – is a no win for everyone.
High emotion, dogmatic, polemics are outstanding for rallying the base. They completely fail and enlarging a movement, and fail any time you are attempting to persuade someone who is unsure where they stand. They just tune you out. That’s been my experience.
A small point of order to the community. Multiple times across several different articles as well as in comments left in other discussions, people keeps saying things to me like “what a nice young man,” which feels creepily patronizing. I keep getting phrases similar to “you seem like a nice kid, decent young man” and occasionally the less friendly accusatory statements that have the tone of “what can you know, kid? ”
So for the record, not that it’s anyone’s actual business, I am thirty-seven years old. I’d only ask that you keep things like this in mind, and I will try to do the same. The less assumptions we make about people, the better.
Thanks for the comment. I appreciate your quibble! In my article, you’ll notice that I prefer to talk about my own experience as “healing” from suffering. Though in truth I don’t have strong negative feelings about the term “recovery.” Recovery is not exclusively associated with illness. People recover from fatigue, recover from grief, recover from pain, recover something that was lost.
Because of that, I’m not sure the word it self is much of a problem as long as you know what the person using it thinks you are recovering FROM. I don’t see the term as exclusively attached to a medical model. Other words might be restoration, reclamation, remembering, rediscovering, or just plain old emotional healing.
Therapy is also a word that is loaded, and I definitely am not particularly attached to it. However, in referring to my own experience as the person participating in the process, I don’t mind describing it as therapy – it was very therapeutic for me. That doesn’t feel like it had any association with illness. Sitting at the beach is also therapeutic.
But like you, this is only a small thing. If there was a broad based consensus on other terms less triggering or less associated with a disease model I have no qualms about adjusting language.
I really want to be an advocate at MIA for shifting discussion away from “survivors” vs. “psychiatry” or “peer” vs. “professional” or even “biological psychiatry” vs. “psychiatry” and toward definition and clarification of core values of the community.
What are the values we stand for? If you and I broadly share values, then we are allies. It does not matter whether you are a practicing psychiatrist or a psychiatric survivor (or BOTH as is sometimes the case) or neither.
We need to steer away from “purity tests” and not worry so much about what background people have.
There are plenty of psychiatrists right in this community. There are plenty of individual psychiatrists challenging the institution of Psychiatry. In fact I keep a binder for of journal articles and editorials from psychiatrists challenging and criticizing the institution of Psychiatry and demanding change.
There are also Psychiatrists who are peers.
And there are survivors, psychiatrists, psychologists, counselors, social workers and everything in between standing up to challenge the Mental Health System’s anti-science, profit & power driven, bigoted and classist institution every day.
What if we spent less time creating false divides by demonizing all individual psychiatrists or treating it as though stereotypes and generalizations are appropriate or applicable to individuals. What if we didn’t care what motivates someone who is a critic of the institution of psychiatry to remain a psychiatrist. What if it was none of our business, actually?
What if…… what if it were SHARED VALUES that united us rather than purity tests? What if it does not actually matter if you are a psychiatrist or a peer or a psychiatrist & peer or something else or nothing else. What if all the matters is whether or not you share some core values?
What are the core values of the MIA community?
Because I’ll be honest with you, I’m getting pretty tired of the “us vs. them” back and forth and feel like it dissevers the power this community could actually have. While he can be very cathartic to speak in all or nothing absolutes about utterly complicated and nuanced realities, it is every bit as irrational as anti-science psychiatrists are. And while the community is very well versed in criticizing the dogmas that are pervasive at an institutional level in Psychiatry, I believe we are far too comfortable in making our own dogmatic, blanket statements that are no more responsible or rationally defensible.
Values. We need to be talking about the values that make us a community? What are the essential values that bind us together? If anyone – no matter what their profession, or background, or disposition, shares those values, then they are one of US. They are not “those people,” the term I so often hear used here that makes me cringe.
One possibility is that you could start by accepting that the MIA community is made up all sorts, including psychiatrists. Plenty of opportunity to have open dialogue there.
Another possibility is a lot more difficult to say out loud sometimes. But perhaps its time to talk more frequently about the fact that personal pain isn’t usually the best vantage point for reflective dialog.
There are a lot of people who seem to be interested in dialog about the complexity of human suffering and the complexity of social service vs institutional failures. There also seem to be a lot of people who want catharsis, who are angry and hurting by abuse and not exactly well situated to tackle “nuance.” The world feels artificially black and white when you’ve been violated. That seems like an unavoidable effect of abuse.
A lot of what I read on MIA mirrors my own history with religion. I was severely abused by my own experience with religion when I was a child. And for a long time afterward and I was angry and emotional toward any mention of religion in any context. People who tried to say that not all spiritual experience is the same, or not all religious communities are the same only made me more angry – because I just couldn’t hear that, it felt like it was invalidating my experience of abuse.
I mostly felt angry, bitter and resentful and anytime someone would point out all of the situations or different ways that the subject was far more complex than my black and white thinking, I would shut them down and just be more dissmissive and upset.
You know what changed? I continued to heal from the pain of my own experience at the hands of my religious community. I began to see other people who had very different experiences where religious community was a big positive part of their path. I began to see that once size didn’t fit all, and simply saying “Religion” as though it was all the same just wasn’t fair or accurate enough.
So now, I have a much more nuanced critique of the dangers and pitfalls of religion as well as an ability to recognize the potential power and positives for some people in some situations some of the time.
I see that hole journey of mine mirrored here. Different subject, same exact process.
A client of mine was detained by police who transported him to the emergency room where he was then involuntarily hospitalized after he publicly threatened to set his neighbors house on fire and burn it to the ground with them inside, then proceeded to get a gasoline can and start heading toward the house.
He did this because at that time he believed that spirits/aliens have kidnapped real persons and replaced them with clones controlled by the government, and that spirits/aliens live under the ground in his house and collude with other people to steal the five million dollars he made by being a famous rock star and writing every song we’ve heard for the last two decades.
What disturbs me is that a frequent sentiment I hear at MIA is that this person should have simply been sent to prison. That somehow that’s the better, more just and humane response. That seems morally abhorrent to me. I believe someone has to be able to understand the implications of their actions and understand what is happening to them (i.e. they are standing trial for a crime, and facing consequences) in order to be justly convicted and sentenced.
At the same time, I find it to be equally morally irresponsible to ignore a sense of responsibility to protect innocent people in the community. So, in this case, simply ignoring the actions of this person until he actually set his neighbors on fire under the pretense that “coercive intervention is wrong” is not acceptable. He stated what he intended to do, AND was in the process of carrying that intention out.
I happen to know that this particular person, a client of mine, also holds very opposite attitudes and intentions when he is not so immediately experiencing such extreme cognitive/emotional states. In those times, he is a kind and empathetic person, who cares about other people and is fearful of the times when he feels like he is “not in control of my own mind.”
So, I am not able to see how sending him to prison is the moral choice. Maybe prisons are different elsewhere but here in the United States there is no institution, including psychiatry, more abusive and broken than the prison system. I am also not able to see how simply releasing him from the hospital back to his neighbors where there lives were in danger is a moral choice. Once we are aware of his stated intentions, and see those intentions backed up by action, there’s no reasonable way to excuse doing nothing to protect that family from the threat of immanent harm.
I would like involuntary hospitalization to be (a) safe and (b) rare. I would also like involuntary hospitalizations to follow the mantra of “the least amount of intervention necessary for the briefest duration possible.” And I will continue to speak about about the abuses and failures of hospitalization, pharmacology, psychiatry and the like….
But I don’t have the luxury of speaking from a place of abstraction on these issues. I have first hand, direct experience with times when it is far more immoral and reprehensible not to intervene than it is to do so, even with the failings and limitations of the system as it stands today. And until someone has a better answer that satisfies my own moral and ethical convictions, I’m not particularly moved by all-or-nothing sweeping generalizations about this subject that frequently get made here.
It’s very easy to say, “this should never happen period,” from the sidelines. It looks a little different if you are the family that is about to be burned alive, or if you are the individual about to be sent to prison without understanding what is happening to you or why you are there.
There has to be another option.
I think what I’m really trying to get at is this: what should unify the movement is agreement in VALUES. If there is agreement in values, then everyone is welcome – from psychiatric survivor to psychiatrist and everyone in between.
When we envision a better world, my dream is one in which people with shared values come together from all backgrounds and professions and build healing, empowering community services in which people who are hurting can come and participate in a community of compassion and wisdom.
It’ the values that are the litmus test, not the titles, or someones background, educational, professional or otherwise. Individual’s aren’t institutions. Institutional analysis is important. In fact its critical. But individuals still have educational background and practical expertise that they can and will contribute to the greater community in powerful and positive ways.
My “professional” education and practice are voluntary partnerships with individuals who desire to meet together with me, who are not required, forced or obligated to do anything, who choose to continue returning to the relationship because it has value to them. That’s not slavery. Thats human interaction at its finest.
So that’s the individual professional. But you and I stand in agreement, that there is this “institution” called “mental health” that primarily impacts poor people, but occasionally ensnares those from other social classes. The main institution however, is the one that is providing State funded “services” to the “undesirable class” i.e. poor people. In part because of attitudes about so-called mental illness, and in part because of attitudes toward class, that system is authoritarian, coercive at its best and involuntary at its worst.
State-run Mental Health is a disastrous mess of injustice and abuse. But that kind of definition of “professional” is not the same as simply anyone who went to school and studied human behavior, development, perspectives on healing counseling and therapeutic relationships, etc.
(And if you are a social worker, also studied class conflict, poverty and inequality, social justice advocacy and public policy and the like.)
We need to talk about unity in values, and not get bogged down in false divides about who has what professional background. Having an MSW and a couple different professional certs after my name does not make me either more OR less a part of a movement for transformation and change in how we approach mental “health.” The values that I hold are what make me either a part of a powerful community movement or apart from it.
That’s the litmus test. Not whether or not I have CSWA, QMHP after my name.
Unless I don’t understand what you mean by mental health “detention,” then the criteria is not the presence or absence of a mental health diagnosis. The criteria is the presence or absence of immanent danger of harm to self or others. Then, the difference between being involuntarily being sent to jail and involuntarily being sent to a psychiatric facility depends on whether or not a judge things there are extenuating circumstances to the behavior, namely cognitive or emotional distress severe enough that a person can not be said to be “rationally aware” of the consequences of his or her actions/behaviors.
Before thirty people reply and start attacking me, I am NOT endorsing this. I am however, telling you how it works at least in my State. Because I think if we are going to argue against something, we need to at least be sure we accurately describe it as it really is, and accurately argue against it as it really works.
You might be right. It might not be an important distinction. Perhaps it is just semantics.
But what I see from my vantage point are front line “professionals” working with individuals because the individuals voluntarily come and seek that kind of partnership. Of the approximately 80 people that work in our agency, a grand total of zero are psychiatrists. Clinical Social Workers, LPCs, Marriage and Family Therapists are the people working with people who feel they need that kind of support.
This is a huge percentage of the “mental health system” and my experiences has been that a significant number of “professionals” from these disciplines are not adversaries, but allies to the cause of responsible science and social justice for persons with lived experiences.
I don’t believe there will ever be a point in human history in which human beings won’t benefit from reaching out and accessing support from other people, and people who decide to try and devote their working time to understanding human experiences, emotions and training in how to relational possible in helpful ways, unlikely to ever go away. The place for persons who choose to make that duty of service their lifes work will also probably not go away.
Think of all the allies right here at MIA – frequent authors who are clinical psychologists, social workers, family therapists. I sort of feel like when you speak of “your profession” it really comes without clarity about what that “profession” even means. My world doesn’t look anything like the simple stereotype world where there are all good guys on one side in the consumer movement and all bad guys the moment they make helping and service their life’s work.
Instead, I suspect that we need to continue oppose institutions that have made it clear they are anti-science, anti-justice filled with bigotry toward persons with lived experience. But I think we also need to spend a little less time drawing arbitrary lines in the sand based on someone’s credentials or lack thereof and instead start looking for people who hold certain values.
Do our values align? Then we’re all allies. And each of us can probably contribute in powerful ways, including those of us who made a choice to pretty much spend our lives studying human experience and matching that up with compassionate practice and social activism.
“No professionals” shouldn’t even be a goal. The goal should be no bigotry, no oppression, no coercion, no dehumanization. Anyone can participate in those goals, and we probably need everyone. Including the social workers, professional counselors, family therapists and others already living these values out, as direct feedback from the people voluntarily choosing to see them attests.
Laura, you are an incredible inspiration and I admire you deeply and stand with you in this struggle. But I want to make a comment for thought. When you write that you dream of a place “with no professional” in sight, I understand the reason you write this. Yet, it makes me sad, because it excludes me, and says that my desire to serve and a compassionate, gentle, affirming and (hopefully) empowering way isn’t welcome. It makes me sad because I was never looking to be labeled a “professional” though these days I am. I am also a peer, with my own direct lived experiences and interactions with the system. I devoted my life to what I see to be a duty to serve, going head over heels in debt in the process, because I believed that understanding the human processes of emotions, responses to trauma, and processes by which meaningful relationships can be rediscovered were the kinds of things I wanted to know, and know as fully and as “professionally” as I possibly could.
I am not a psychiatrist. I am a social worker, engaged most often in individual counseling directed by the individual, not by my agenda. I’m not able to write and say that my education was a waste, because it wasn’t. Never in school was I indoctrinated in a medical model. In fact there was little at odds with the very passions and missions that drive the community here at MIA. Maybe “social work” is vastly different that psychiatry or psychology in its education or professionalism. But I feel left out when I am written off by my label as a “professional.” I need you and every other member of this community and the consumer movement as partners and allies. But I also think you need professionals like me. I don’t believe in coercive, or directive, or authoritarian structures of interactions with other people, and I carry those values out in the small agency I work for, celebrating the ways in which the agency upholds those values and challenging and pushing the agency in the instances where it does not.
I could not agree more with the vision of a total transformation in how we provide positive, relational community to all persons experiencing deep emotional struggles (not illness.) But I hope that there can be room not only for peer experiences, such as yours and mine and others, but also for hearts that burn for social justice for those branded as “mentally ill” and castigated to the fringe of society who also happen to be “professionals.”
Thank you so much for this open letter. It breaks my heart that these false narratives are still being propagated through our culture. Of course, I am angry at the professional institutions that perpetuate false information. But I am equally angered by the state of our media, which regularly colludes with big, powerful institutions rather than maintaining the skepticism and spirit if critical inquire essential to an informed public.
In simpler language, its bad enough that doctors and psychiatrists regularly lie or regurgitate ignorance misinformation. It’s worse that our entire info-tainment culture consistently lets them get away with it. Thank you for calling that out.
I think the way the term “psychotherapy” is used in this article is imprecise. So, as a practicing therapist, when I read the perspective of others I always have to look around me and see if the author’s assumed definitions of how things are actually match my direct experience of doing the work. There are a lot of statements about what psychotherapy would say or do, or what its professional obligations are that simply don’t match my experience.
So first things first, can we define psychotherapy? Because virtually no one conflates all human experiences to “Oedipal issues” and hasn’t in my lifetime. I don’t know of any fellow counselor or therapist who, in response to a woman’s deep trauma over the fate of her son, would say what you have written. Is there someone out there who might do that? Maybe. But I work in the field and don’t know of anyone around me who would respond like that. So how do I hold that experience and let it inform how we frame issues?
“Psychotherapy” today is often a blanket term to mean any kind of “talk therapy.” It’s no longer synonymous with the stereotypical idea of a stuff old man in a lab coat talking to a “patient” on a couch about his mother. That’s a stereotype that hasn’t been close to accurate in a generation or more. These days, “talk therapy” is a catch-all term that really means, anything that isn’t rooted in the biomedical or behavior modification schools of thinking.
Today, “psychotherapy” is often the term used to described compassionate interactions with people seeking support that start from the fundamental question “what happened to you” rather than the medical/behavioralistic question, “what’s wrong with you.” In response to the mother who is living every day holding her breath out of love and worry for her son, the question “what happened to you” is probably critically important. “What happened to you” doesn’t mean the answer lies in someone’s childhood or in their unconscious, though it can. And I certainly wouldn’t make those assumptions when I entered into dialog with another person.
I work for a small agency that serves a community of under ten thousand people as well as the surrounding area in the county. I work along side numerous therapists, all engaging in psychotherapy as the term is used to that. What is how the service is documented officially, and it has nothing to do with Oedipal complexes or all these other stereotypes from Freud and the 1920s. I may be blessed to work in a small community and not experience the same pressures that often corrupt institutions as they become ever-larger. But my experience is that there’s not a single therapist here who would read your descriptions of what “psychotherapists” do and think it was anything other than absurd.
Now with that said, I definitely agree with the spirit of the article that says what is needed are people who are “human experience specialists” or, as I said, committed to the question of “what happens (or is happening) to you” rather than “what is wrong with you.” But when you suggest that its a violation of license or and oaths to do this, well, that’s not at all true for me, or any counselor or therapist I know under any licensing board I am aware of.
LCSWs, MTFs, LPCs and others have all been practicing “talk therapy” identified as “psychotherapy” for decades along with clinical psychologists and a very small number of psychiatrists. What you are advocating in your article is not new or revolutionary to me, or anyone I work with here. We’ve been saying this for years. We’ve been practicing this as best we can within a system that does not prioritize or value experience-based support.
I feel like talking about psychiatry and psychotherapy as though they are similar or equivalent is an error. Psychiatry is an institution. Psychotherapy is a very broad term that encompasses talk-therapy oriented processes, that are experience based, that grapple with the questions of meaning-making through questions like “what has happened to you, what is happening to you, how do these things influence who you are and how do you create meaning and identify values in your life?” Many people from different professional disciplines engage in such talk-therapy processes. And none of them that I know would ever walk up to a woman who’s son was in harms way and suggest she had some sort of “Oedipal” issues.
My experience as a clinical social work associate is that a lot of people people voluntarily seeking traditional “talk-therapy” see clinical social workers, licensed professional counselors (LPCs) or Marriage and Family Therapists (MFTs). Often they see these folks (including me and other counselors through my community agency) as a self-referral, walk-in, etc. The bulk of the people I’ve worked with either don’t see a psychiatrist or do see one but we certainly don’t “report” to them or pass any information whatsoever without direct consent.
Of course the scenario you describe where someone sees a clinical psychologist, and that psychologist coordinates closely with a psychiatrist is something I’m sure happens. I’m just trying to figure out who it happens too. Perhaps, since I work primarily with individuals and families with low-income, this is something more common in a different economic bracket.
As for psychology being a “less damaging fraud,” well I think the potential exists for that criticism to be levied against any profession that claims more certainty than it actually has. So we social workers, or LPCs or MFTs could be guilty of this just as much as anyone else. But it is also not necessarily the case that this is true, simply be definition of being some kind of a counselor.
When you’re honest about the limits of what you know, honest about the realities of non-objectivity in the term “mental illness,” the evidence about medications, and so on, then there remains a whole lot of room for positive, healing, collaborative partnership between people. In my own life, finding my way to a caring, open, gentle counselor who never tried to coopt my own processes was an invaluable support in my own healing and recovery from significant trauma. She was a big reason why I wanted to try and do something similar with my own career.
These are good things, and can be really positive relationships (as was the case in my own life) so I want to make sure I don’t paint everything (even “Psychology” or “all psychologists”) with the same broad brush.
Whenever I hear the privileged talk about this stuff, they always do it with a tone and language that feels eerily similar to other historic bigotry. They talk about persons experiencing economic distress and persons experiencing emotional distress about like people used to talk about “the coloreds.”
It’s “those people” this and “those people” that. It’s talking ABOUT others from a position of privilege rather than listening to and talking WITH other human beings about what their needs are and how to be compassionate human partners that is at the root of the problem.
As long as Dr. Torrey and those like him continue to justify their own bigotry, and as long as the public continues to allow and accept it, very little good can happen. The attitude that persons in the working class are stupid while persons in the privilege class are wise and learned is as much a root cause of the these ills as anything else.
We rightfully talk about all of the injusticies of psychiatry and the mental health system towards persons labeled “mentally ill.” But we don’t talk enough (in my opinion) about the fact that it is really poor people labeled “mentally ill” who experience the bulk of the coercive treatment and abuse. If you are rich, you are far more likely to only ever be known as “eccentric” rather than “sick.” And even if you are ever labeled with a “mental illness,” if you are rich then you get to CHOOSE your “treatment.” Don’t like what a psychiatrist is telling you? You fire that psychiatrist and go pay to see someone who will give you the designer “therapy” you want. Rich people don’t end up civilly committed, generally speaking. It’s not rich people who are filling state hospitals or locked down in secure treatment centers. During the year I spent working in an involuntary psychiatric center (before I quit in protest) – there was only ONE person in the entire time who came there who did not receive public economic assistance and have income below the poverty line. That one person was only there because he had committed a felony and was mandated by the criminal justice system. Short of committing a crime, the wealthy just aren’t subject to this system.
So when we talking about abuses in psychiatry and mental health that’s important, and we should all keep doing that. But there is another issue that is even more foundational – class. Not all persons experiencing emotional distress have the same horror stories in mental health, and the difference between horror stories and healing stories can usually be determined by no other factor than how much money you have. Sad, but true.
On the other hand, if you are poor your experiences with “mental health” are overwhelmingly bad. Our society is completely comfortable with the most paternalistic and bigoted attitudes imaginable when it comes to the poorest members of our society. So it should be a shock to no one that homelessness is used as an excuse to justify paternalistic, coercive treatment because the problem as seen by the privileged is a disgusting, ignorant, less-than-human underclass that inconveniences or threatens the day to day of privileged people – that is the problem that people like Torrey try to “solve” from their privileged vantage point.
Bruce your articles are some of my favorites, and they have been such a profound influence on my own development personally and professionally. I thank you very much for this new contribution.
I agree with Richard Lewis when he rights that the article reads like a sad lament for a return to the “good ole days.”
Given what we now know empirically about the extreme costs and profoundly limited benefit offered by psychiatric drugs, particularly when prescribed under a “first, frequently and forever” model of practice – I don’t believe any attitude other than the utmost sobriety is morally appropriate to the subject.
“When I’m at my best, I’m both prescribing meds and helping people work through their suffering.”
No, sir. When you or anyone else in your position of power are “at your best,” you are listening and responding to the needs and requests of the person before you, you are not assuming that either medication or no-medication is the way to go, before you’ve have even bothered to hear and understand the person-in-context. When you are at your best, you are not ignoring empirical evidence that suggest long term use of psych medications is contra-indicated. And when you are at your best, you are not ignoring the empirical evidence which now documents, in exhaustive detail, the extremely limited usefulness and extremely severe dangers of psychiatric medications. When you are at your best, you follow the now formally evidence-based practice of limiting the role of psychiatric drugging in “treatment,” adopting a selective use model and discouraging reliance on dangerous medications whenever possible.
That would be you at your best.
It’s true I am not “anti-medication.” Which is to say that, I believe that if an individual believes that short term, selective use of certain psychiatric medications is the right option for them, I defend their right to make that choice just as much as I would defend the right of someone not to be pressured or coerced into taking medications against their will.
But given the fact that I know how to read, and have chosen to read empirical data, neither can I possibly be “pro-medication” given what we know.
Everything has meaning, that is to say no thoughts, feelings, beliefs or perceptions are “empty static” or “gibberish.” Not everything is *literal* however, as I know full well from my own individual experience.
And without question, as I have written about repeatedly, I am convinced that listening and understanding other human beings’ lived experience is one of the most important things that can be done.
I’m a little embarassed by the mass posting, but I am doing some heavy seeking on this issue right now – I also want to ask for even more discussion about alternatives.
What are some better ways of doing ER crisis work that I should be advocating? Here are some random thoughts of mine and I would appreciate the thoughts of others….
— the increasing availability of peer-run voluntary crisis respite programs that follow a relational/social model of offering compassionate support. If there were safe alternatives to a medical hospital, perhaps more people would feel safe in voluntarily accessing those alternatives when experiencing serious distress
— the total elimination of forced drugging as an option, i.e. making it illegal. I don’t believe I will see this happen in my lifetime, but I imagine that if it did, the system would be forced to come up with more creative alternatives for “support,” and that would mean at least the possibility that those alternatives be more relationally appropriate and morally responsible.
— the total elimination of “civil commitments” where a judge takes your rights away and hands you over to the state for six months at a time, with the ongoing option to “recommit” after each six months indefinitely. I know this goes beyond the things that happen in the ER (at least in my ER) but I just believe these are utterly abusive. I don’t believe anything I can imagine can justify a six month time period of stripping someone’s rights away. I’ve worked with persons who were civilly committed because they yelled at a cop, and an 18 year old who was civilly committed because he had a “problem with authority.” These are intrinsic tools of systemic abuse and NO ONE should wield that much power over someone else.
– the replacement of force/restraint response models to dangerous or aggressive situations with non-force/non-restraint models of crisis deescalation. The latter models are focused on safety, avoidance of danger and deescalation rather than behavior control. I have attended trainings for something called PRO-ACT (Professional Assault Crisis Training) which based itself on the triangle of: Safety, Dignity and Respect. It focused on how to get out of assaultive situations, how to avoid conflict, and how to attempt to deescalate critical situations with a combination of calm talking and body language. It also talked about planning ahead on how to evacutate staff from a dangerous situation or areas, how to avoid and escape aggression so that physical force was avoided. In situations where all attempts to avoid physical assault have failed, the principles taught to a person were, “the absolute least amount of force required to escape the situation applied for the absolute least amount of time possible.
I’ve heard that PRO-ACT includes a whole different section on restraint training, under the idea that sometimes it may be necessary, which I oppose. So I’m not ready to specifically endorse PRO-ACT wholesale, because I don’t know enough about it. But where I had the training, restraint was not acceptable and the training only focused on deescalation and avoidance training. What if ER’s were trained like this?
EDIT – I need to correct this because it totally changes the meaning.
My post above includes a statement that says, “I know that because our people work in this ER, far less people are not hospitalized, and fewer people experience coercive force.”
That should read, “far less people are hospitalized” NOT more people are hospitalized.
Thank you so, so much for this article!
I have been deeply wrestling with this issue recently. I’ve participated in a couple discussion comment threads on this topic which, despite the understandable emotional intensity around the issue, have been really helpful to me.
I’m hoping that your feedback (and that of others) can help me further my own understanding. Forgive me because I am going to provide some lengthy background on my present situation, because I feel like when it comes to a topic like this one, the devil is in the details. So I ask for your patience as I want to ask you some questions after I give this background:
Actually first, let me state something: I oppose forced “treatment.” I’m not confused as to whether I support or oppose that. But I haves some questions about the implications of that conviction to which I don’t think there are easy answers…
My background is that one of my two jobs presently is on-call to the local Emergency Room as a “Mental Health Crisis Worker.” My job is to meet with persons who come to the ER and are identified as possibly experiencing non-physical cognitive or emotional distress, determine whether or not they are an immediate danger to themselves or to others in the community, and then recommend to the doctor what the response should be.
Now, if this was the end of it, I’ll concede to you that I wouldn’t have accepted this job, because I feel it would too often conflict with my own sense of ethical values when it comes to how we treat other people. The description I just gave sounds cold, paternalistic, hierarchical and fought with the potential for abuse. The ER can be a place where people are restrained, secluded, forcibly drugged, sent into longer term involuntary hospitalization, and a sea of other harmful and traumatizing practices. Many if not most members in this community have personal ER horror stories.
In the interest of full disclosure, I was offered a full-time position working in the same role at a different, larger hospital and at the last minute I turned it down. I was out of work at the time, and I had tried to rationalize away my ability to do that job and not lose my soul in the process because I needed to put food on my table. But in the 11th hour my courage won out – and I accepted that I knew a great deal about how this particular hospital operated, and their predisposition toward force and dehumanization in response to persons experiencing emotional distress was not something I could willingly participate in.
However, the ER where I work now is different. First, it does NOT hire its own “mental health” workers. Instead, it partners with a local community counseling and “mental health” agency – the only one in this small community, that was built directly from the community started over thirty years ago by a group of volunteers. So I don’t work for the hospital directly. Instead I work for an organization that has a social community mission of proving non-coercive, compassionate support services to the local small town community regardless of anyone’s ability to pay. These services include counseling, case management for persons trying to navigate the complexity of the disability system or the healthcare system or the benefits system, and voluntary psychiatric prescribing services (if requested by the individual) in which the individual makes decisions about what if any supplemental medication support may or may not be right for them.
Because I work for this agency and not the hospital directly, my role in the Emergency Room is a little different. My mission is to keep people out of involuntary psychiatric hospitals and to avoid hospitalization altogether unless it becomes absolutely clear that an individual is insisting that they want a voluntary admission and convince me that they are fully informed about the risks of such an option. It is the expectation of me in my position that I be an advocate for the person that I see in the ER, and it is my job to hear from then what they feel they might need in terms of support in the face of whatever crisis brought them to the ER and do everything in my power to meet those needs as they define them.
To this end, my agency takes a financial loss in order to offer any person that I see in the ER up to 10 free visits to our community clinic for any service the individual feels would be of benefit to them. I am also able to schedule them to be able to meet with someone to receive those supports within 24-48 hours of the time they are seen in the ER. Further, with the individuals permission, I am able to offer to contact them in follow-up after they have visited with me in the ER just to check-in and offer a kind and listening ear if they continue to feel they are struggling or just want someone to talk to. If a person gets to the end of 10 free visits and has no ability to pay, then the agency continues to find ways to work with them. One of the core missions of the small community-based agency is “support regardless of ability to pay.” Any person I see in the ER my of course decline any of these options.
To me this entirely changes the “flavor” of working in an ER. My job is to AVOID forced treatment options and assist someone in connecting to the relational supports that make sense to the individual. There have been many nights I have been called to the ER because the ER doc thinks a person needs to be hospitalized. But after talking to the person I discover that they do not want to be hospitalized and we are successfully able to form a partnership in which I provide a wider array of non-coercive support options and the individual decides what makes sense to them. I then go back to the doctor explain that I don’t support hospitalization and describe the alternative support plan. In every case so far, the doctor has accepted that plan and the person was discharged from the ER freely.
I feel like I am doing something very positive for both individuals I get to work with who come into the ER often experiencing a lot of suffering. It does not take too long for my heart to break/melt in the face of someone else’s tears of distress and requests to be listened to. I consider it an honor to be able to offer non-coercive options for relational support because I believe that most human beings can benefit from not going through distress alone, and benefit form finding people who genuinely want to listen to them and believe that they can indeed “make it” through even the darkest of spots they find themselves in.
But I’ve ALSO had the more rare experience of working with someone who adamantly insisted on being admitted to a psychiatric unit of the hospital. Obviously my knowledge of the abuses and shortcomings of psychiatric hospitals mean that I really dislike this option. But after having done my very best to mare certain this person understood that even if s/he went voluntarily, the hospital could turn that into an involuntary stay, that s/he could be medicated by the hospital forcibly, and all the other risks that come with it, this person remained adamant. So, I helped them be hospitalized.
The one experience I have NOT yet had is the one I am most afraid of: it is the experience where someone comes to the ER because they have severely hurt themselves or because they have hurt someone else, and they express their clear intent to continue hurting themselves or someone else with they leave, and they are not willing to collaborate on any sort of alternative support plan that would decrease their risk of harm to themselves of someone else.
In those cases, the hospital is REQUIRED to keep the person against their will. If the hospital releases the person who has clearly indicated their intention to immediately (immediately is defined as, “can be reasonably expected to do this within the next 24 hours”) hurt themselves or someone else, and then they make good on that threat, the hospital CAN be held liable, be sued and would lose. Hospitals have lost this suit in the past. Worse still, the ER doctor on duty can also be held personally liable, and sued and lose. Depending on the finding of “negligence” that doctor could be sanctioned or fired or even lose the ability to practice. And I personally could be found liable, and civilly sued. I complaint can also be filed with my licensing board, which would be investigated, and I could potentially be found “negligent” and lose my status as a CSWA (which is like “residency” for social workers, means I’m acquiring clinical hours under supervision toward independent licensure.
For those reasons, if a person has expressed thoughts to harm themselves or someone else and they then try to leave the ER before a plan has been put together, the ER will prevent them from leaving OR require the police to detain them and bring them back. I’m not saying this is right; I’m saying the reasons it happens are, in part, because of legal liability.
What I’m trying to do is figure out what I do when I finally have the situation where someone is being detained in the hospital against their wishes and the ER doctor does not consent to any other plan apart from involuntary psychiatric admission? Do I just quit? I have had so many opportunities for deeply positive interactions with people who have come to the ER. In several cases, persons have come to our community office later to seek me out in order to thank me for being willing to listen to them and care enough about them to come up with a plan that made sense. I know that because our people work in this ER, far less people are not hospitalized, and fewer people experience coercive force. I know that I am empowered to disagree with the doctor and advocate for non-coercive alternative plans and I know that in every case so far I’ve been successful with that advocacy…..
…but there is going to come a time where the doctor refuses to do anything other that hospitalize someone against their will. So do I just stand on principle and quit, losing every opportunity to be a tiny ray of hope for so many other people within a system that is so often oppressive?
What about when I am faced with a situation like that of my colleague who met with a guy who had cut open his shoulder with a kitchen knife to the point that he severed an artery and was bleeding out. When he stabilized, he told my colleague that he was “doing surgery to remove the microchip” that he believed had been implanted by aliens. He apparently had no understanding that he nearly killed himself and was adamant that the hospital couldn’t be trusted to take it out for him and that one he was released he was going to go right back to finish the job. What do I do then?
Recently, as I talk with the community at MIA I’ve entertained the idea that the most appropriate thing to do would be to simply let him go and do whatever it is he is going to do. He can then go “die with his rights on.” Certainly he is not presently thinking clearly, and I think its reasonable to say that its possible that if he was able to come to a place of more rational clarity he would likely not want to do something that would kill himself anymore. But hey, at least I didn’t infringe on his rights while he went off and died, right?
Even if this was truly the best choice, its not an option for hospitals. There is no AMA (Against Medical Advice) procedure for hospitals (that I’m aware of, and not for our hospital) when it comes to “mental health” issues. And maybe that’s the answer – maybe their should be. But would my moral responsibility really be absolved by a piece of paper that says I’m not liable when I can be almost certain that I’m sending someone out the door who is not thinking clearly and is absolutely going to go accidentally kill themselves in the midst of their emotional distress? How am I not morally complicit in not trying to do something to prevent that?
And then again, I don’t want my other question to get overlooked – what should I do the first time the doctor wants to force someone into treatment over my objection? Am I a reprehensible slug to work there, despite all of the opportunities to do genuine relational non-coercive compassionate work together with persons who are (by their own accounts) deeply suffering? (Not everyone who comes to the ER is “deeply suffering” and I get that. But many are, I know from direct experience of listening to their own statements on the matter.)
It’s 4:15am here, but I had to get back up because I couldn’t sleep while still thinking about this. In my previous comment, I said at one point that, because of my sense of right to protect myself from the threat of immanent violence and my belief in a moral obligation to protect others from the threat of immanent violence that I could not say that I can’t say that restaint, forced drugging, or involuntary hospitalization is always wrong.
Then I couldn’t sleep…
Look I don’t know what the answers are to all of this. But I can’t go to sleep tonight and leave that the way I stated it.
Forced drugging is wrong. I want to START there, and then discuss the complexities from that starting point. When I said earlier that when responding to the threat of immanent violence I believe in the principle of the least amount of force required (so, if none is required because there are real alternatives then none should be applied) for the least amount of time required I’m not sure that forced drugging *ever* meets those standards.
Is it possible that there is usually (or always?) a viable, accessible alternative that can effective protect others from violence and be less coercive?
I get into these comment thread discussions because this is one way through which I learn. I try not to write articles that seek out the most controversial sub-topic because I don’t think that’s helpful, or its at least not where I want to spend my writing energy. But in these discussion threads, I do sometimes try to grapple with the complexities of the particulars.
My posts my not always be perfectly consistent because I am learning, struggling, questioning, thinking. But tonight, so that I can sleep, I want to take a step back and revisit some core principles that I do feel clear about.
(1) The use of coercion, in all its forms, should be understood as both a relational evil as well as a “treatment” failure. I put the words “treatment” in quotes, because I don’t like the word at all. I think its demeaning and hierarchical and comes from a medical disease model that is evidence-lacking. But what I mean is that, there is nothing at all positive about coercive actions toward other human beings.
Is there even a situation in which coercion of another human being might be necessary and justified? I don’t know (honest, yes?) But maybe.
To me, self-defense in response to an immediate (“immediate” means right then and there) danger of violence may be a time where coercive force to prevent violent assault may be justified. I stand by what I said earlier when I said that I feel a sense of obligation to attempt to intervene to protect an innocent person from violent harm. That might mean that I tackle and “restrain” a person who is trying to attack an innocent person – something I might chose to do anywhere in my community and having nothing to do with “mental health,” hospitals or anything else.
One of the major problems with our system right now is that if a person comes to a hospital ER and states their intention to hurt themselves or someone else, and then the ER allows that person to leave the ER when they ask to leave, if that person then kills themselves or someone else the hospital can be successfully sued, and the Doctor on call can be successfully individually sued for failing to “appropriately” respond. Additionally, the Doctor can be found to have been “negligent” and even lose the ability to practice.
Please understand I did not write the above paragraph as a DEFENSE of coercive practices. But I do believe we need to be honest about the barriers created by a system to non-coercive practice. ER Docs do not feel able to make a decision to let a person leave the ER whenever they wish because if they do and that person goes out and hurts someone they can and will be held directly responsible in many cases. That is just as wrong as coercive practices are.
This conversation thread has also conflated the subject of long term involuntary psychiatric incarceration, and acute emergency care lasting no more than 48 hours. For some that is because there is absolutely no difference and context does not matter in this case, because coercive interventions are never acceptable not matter what the situation. For others though, it seems to be more an accidental conflation of two very different situations.
What I am confident tonight that I oppose are long term involuntary actions – long term involuntary psychiatric hospitalizations, and involuntary civil commitments (which are long term by definition, usually for six months with too many options available to the system to recommit someone over and over again against their will.)
As I keep reflecting on things, I also think that I might just oppose forced medications in every circumstance, including the emergency room or any other circumstance. And the reason I think this might be true is because I think its possible that there may always be a less invasive, less “force” alternative available. That’s not the same thing as saying I don’t believe medications can sometimes be helpful. I do believe, and speak from personal experience with psych meds, that in some cases, medications chosen voluntarily and used carefully and selectively MAY be helpful to some people some times….
…but I’m not sure I think forced drugging is ever ok.
I am more confused about letting someone who is expressing immanent threat of violence toward other people leave the Emergency Room the moment they state they want to leave. I worry that this might be recklessly irresponsible to other innocent people. So then the question of law enforcement comes up. Again, many people here have made it quite clear they think that is the appropriate mechanism when coercive force becomes a necessity for the protection of others. Maybe that’s true, but I have grave, grave concerns about just saying “call the cops.”
My experiences with police are worse than my experiences with the mental health system. Much worse. I agree with those who have pointed out that the police are much more likely to escalate bad situations and utilize violence. So is keeping someone in a hospital ER room for 24 hours while crisis workers like myself talk with them and try to offer relational support a worse choice than calling in the police, having them taszed to the ground and carted off to prison? How is that not the more disproportional application of force?
To me there is a big difference between talking about psychiatric hospitals and long term involuntary hospitalization and talking about dealing with an acute and dangerous crisis in the Emergency Room. The questions are still complicated in either case, but I do believe those cases are SO different that the really need to be talked about separately.
I don’t agree with long term psychiatric hospitalization, which is why I left my former job. And I’ve written about why and know that there’s very little disagreement within the community with my perspective when it comes to that. The issue of emergency response to acute crisis when other people are at risk is a different issue altogether for which I don’t have perfect answers tonight.
Thank you for your very thoughtful article on a very difficult and emotionally charged subject. More important than agreeing on every point is someone making clear effort to wrestle with the extremely complicated questions of how we interact and relate socially to other human beings without lapsing into either sweeping generalizations or dismissive dogmas that end up not serving any person well.
I work in a hospital too. Well, that’s one of my two jobs – working as a ER mental health crisis worker. Before this I also worked as something called a “Treatment Team Coordinator” in a secure psychiatric facility. I hope that background will provide some context to what I’m going to say next.
It’s difficult to talk about these issues when many in the community have such direct and extreme trauma histories related to hospitals, doctors, psychiatrists and the like. Myself I managed to avoid what I’m sure would have been involuntary hospitalization during my own “darkest night” because I happened to be lucking enough to have friends with resources who chose to offer me 24-7 private care in their own home for about 36 hours instead of taking me to a hospital. But beyond this, I attribute some of the responsibility for my own fathers traumatic and early death to a mental health system that utterly failed him, loaded him up on medications and sent him out the door without any kind of actual human care.
While everyone’s individual experience is different, one thing many if not most of us bring to the discussion is a lot of emotion and not a small amount of pain around the topics. This is always a tricky environment in which to maintain respectful discussion without becoming overwrought with emotion. I appreciate the tone and thoughtfulness in which you give your perspective.
Generally I find myself in broad-based agreement with your perspectives. But the discussion thread has helped me clarify my points of disagreement.
The person who made the distinction between “force” as treatment tool and “force” as a matter of self-defense really hit the nail on the head. I don’t think “force” is ever therapeutic in any way, and really has not business being talked about as part of treatment even in “extreme cases.” Once you’ve gotten to a situation where you are doing things to another person against their consent, you’ve left the domain of “treatment” and gone somewhere else. That might be a place you have no choice to go, but its not treatment anymore, or therapeutic. “Treatment” can resume when the people involve can find their way back to a collaborative space.
Having said that, if someone is violent I believe that I not only have the right to protect myself by whatever means required but I also believe I have the moral responsibility to attempt to protect other innocent people who are the target of violence even if I am not directly targeted myself. If I have the ability and capability to intervene to prevent violence and protect innocent people from violence, its my moral obligation to do so. That’s what I believe, and I won’t be budging in that belief any time soon.
In those situations I believe in the application of the absolute minimum force necessary for the absolute minimum amount of time possible to prevent immanent violence. This isn’t an issue of treatment, as there is nothing therapeutic about the situation at all. It is simply a matter of the response to immanent violence I believe to be necessary in order to live with myself morally.
Here’s the real rub: How do we define immanent violence? I believe that it includes the threat of immanent violence. I don’t believe that we should first let someone be violently assaulted before we intervene.
Verbal threats ARE a form of violence. So if a patient in the emergency room says to the staff, “the first opportunity I get I am going to kill you tonight” I don’t really care how quietly and calmly that violent statement is made, I fully support taking appropriate measures to PROTECT innocent people from the treat of immanent violence.
What would that mean? It would mean that, if that patient was unwilling to collaborate in a non-violent way, we utilize the minimum amount of force required to protect innocent people from the immanent threat of violence for the minimum amount of time required to alleviate that threat. That means I can’t say that restraint is ALWAYS wrong, or that chemical sedation is ALWAYS wrong, or that being held in a hospital involuntarily is ALWAYS wrong. Sometimes, those things may be part of my moral responsibility to defend myself from immanent violence and to defend other innocent people from immanent violence when it is within my power to do so.
Some people I have talked with have suggested that individuals would be better served if persons who make violent threats in the ER were not restrained or involuntarily hospitalized rather than released to the community but were instead simply arrested and sent to jail. The argument being that immanent threats of violence toward others are a criminal matter and that’s the appropriate mechanism for responding.
I must admit that to me, this seems like an infinitely worse option as in my opinion, the only institution more broken than the mental health institution is the institution of “law enforcement.” But obviously different people have different viewpoints.
At the end of the day, the main issue boils down to this: some people believe that there is absolutely no situation whatsoever in which it is morally appropriate to intervene on another person’s behalf against their will. I disagree. In fact, I believe that if I really adheared to that idea, I’d end up being more guilty of morally abhorrent behavior more frequently, as I refused to act to defend innocent people against the threat of immanent violence.
The way our system fails right now is that by and large it:
(a) does not accept that any sort of “forced” action is not, by responsible definition, “treatment” or “theraputic.” It may be necessary to prevent violence, but its not a treatment tool.
(b) does not believe that force is a last resort used only in cases of credible threat of impending violence. Instead it is often used casually and as a mechanism of power and control.
(c) does not believe that one should use the absolute minimum amount of force necessary. Instead, often disproportionately applying force far beyond anything appropriate to the level of threat.
(d) does not believe in the the absolute minimum amount of time required. Instead, the system believes in involuntary “treatments” that can last up to six months or longer depending on the civil commitment process. That sort of thing is not any kind of response to an immanent threat. And I don’t support that.
Again, thank you for your article and I want to reiterate that I appreciate the tone in which you right and broadly agree with much of your perspective.
I’m still working in the public mental health system. Only know I work with a group that have historically either been chronically hospitalized or placed in secure pysch facilities or group homes. Instead, in our program, they have their own houses and appartments indepedent and free in the community, and we meet them in their homes or in the community to offer support. That support can range from individual counseling and therapy right down to transportation to medical appointments down to rides to the grocery store.
These service are selected by the individual, not by us. Occasionally there have been times where the program has started to take more control and wanted to dictate services to an individual, but we’ve had open frank conversations about that within our team, where it was safe for that trend to be openly challenged. We made corrections and moved back in the right direction.
There is an expectation that they work with a psychiatric prescribe and then take medications prescribed to them, and regrettable, this expectation comes from the automatic assumption that persons who have had a long history of hospitalizations must be “sick” and must need to be on medications permanently. As you know I have serious, serious objections to this assumption. But I have been supported by my team in advocating for and with individuals concerning their desires around medications, including their desire not to take medications if that is what they wish. I’ve even gone to prescriber appointments with a person to help them advocate for their wishes.
Sadly, I can’t say the outcomes have always been perfect. Interactions with prescribers have been, let’s just say “mixed.” And there are some within our agency who still believe in a “those other people” type mentality toward persons the system has labeled “mentally ill.”
The program I currently work in is getting a lot of things right. And some of the things I think it gets wrong are the subject of active, open, discussions (and sometimes debates!) I would like to be a part of those discussions. So for now, this feels like a good place to be.
Francesca, I added a post in the conversation chain above, but again – I apologize I’ve accidentially got multiple emails/accounts at MIA and I’m working with site admins to fix that and get the old one discontinued.
With that out the way, I very much agree with you on all points I think. But just to clarify terms, you said you don’t object to the emergency psych intervention but only to the forced treatment that follows.
When I use the language of forced treatment, I was including the act of holding someone in the hospital or admitting them into an acute psych ward as forced treatment. And I was saying there seem to be a few extreme situations in which that becomes the least harmful, least inhumane option.
But I’m also curious, if you could see the place for emergency psych intervention, but not forced treatment (and again, i don’t feel like I have any core disagreement here) what should be done for, and in partnership with, persons who have been admitted into the hospital on an emergency basis because they were a danger to someone?
I sense that we basically agree in our objection to the idea that you just shoot them full of drugs they don’t want with the idea that they should then be on these drugs forever because they have a permanent “illness.”
What about a selective use model, in which certain medications were seen as a last resort, and used as minimally as possible for the least amount of time possible, and only in the most rare of extreme situations, with the sole goal of stabilization from the most acute phase of a very severe crisis that has put a person at severe risk? A model that included the expectation that immediately after acute stabilization, a titration OFF any medication administered would be considered the “standard of care” for most cases?
My disposition at present (open to change) is that I am not anti-medication as a blanket absolute. What I object to, is the “drugs first, frequently and forever” model of practice in the West. I think psychiatric medications, possibly even “antipsychotic” medications, have a limited place in a selective use model. What do you think?
Last comment, and side note:
The site administrator is helping me with a screw up in which I have accumulated more than one site log in over the years. I logged in with the wrong (old) account above (alyoder) so I apologize for the confusion, the icon (which I don’t find to be very appropriate to the context here) and the added messiness in this thread. I’ve communicated with site admins and they are helping me fix my mess! Please be patient. 🙂
As I said before, I believe that effective advocacy and activism is about more than being confident you have the “truth.” I also think its about delivering your message in ways that are most likely to be heard and be persusive.
But I also want to restate something else I said before: I’m not about to insist that my sensibilities and ideas on the best advocacy approach be everyone elses. We have to embrace the idea of diversity of tactics because if we don’t, we’ll never have a functional movement — all we will have is infighting.
So, its not for me to tell you what signs you can or can’t hold, and I’ll certainly stand right beside you. But I also think some tactics are more effective than others, and I’ll try to tailor my own advocacy accordingly.
Let me use an example from outside mental health advocacy: I can tell you that an organization like PETA, with its shock-tactic approach to advocacy, doesn’t do anything for me other than turn me off. I’m not even interested in listening to them because they are so obnoxious and ridiculous. Instead, I work with and donate other organizations that make persuasive arguments and foster dialog rather than monologue.
But that opinion simply reflects my own sensibilities. People are different. Am I going to mount some campaign to attack PETA or bring them down? Of course not. Talk about counter productive. But at the same time, my personal assessment is that they are generally more counterproductive than productive to the cause. That’s what I want to avoid with my own advocacy.
The question I ask myself is usually, “why am I doing this? Is what I am about to do really about meeting a personal emotional need of my own? Or its it because I really think this is the best possible way to advocate for change?
I can’t answer that question for anyone else. But I can share my own opinion, then leave room for other people to disagree and do it differently. When that happens, we’re still allies. 🙂
My heart is with you. And I consider myself to be a seeker on this subject, not a “knower.”
So I have the same question as Francesca Allan, help me understand what you feel would be the most compassionate, just response in the situations (real ones I experienced) I described above. This is the question that has kept me up nights, as someone who stands opposed to forced treatment as a principle, but has had direct personal experience with situations that have given me pause. What do you think?
I hope its obvious that I wrote my article as an expression of the beliefs I’ve come to hold – and those include a rejection of coercion as a rule. But does that mean there is never, ever a situation that challenges the general principle, where the more compassionate act might be some short term actions without a person’s immediate consent? Before you say know, help me understand what your response would be to someone whose voice hearing experience has caused him to set himself on fire when left on his own (on his own, by the way, being with few social supports.)
These are the kinds of discussions I need to have, because they’re the questions I don’t have good answers to.
I am always so appreciative of people willing to tackle the reality of this grey life, without many points of clear black or clear white.
One of the most important values for me personally is that I try my best to be committed to accuracy. Not “truth,” because the philosophers will tell you that truth is hard to quantify. But accuracy is not. Accuracy really comes down to: (1) being honest about what you don’t know (2) being honest about the limits of what you do know and (3) accepting the reality that things are complicated.
So, I’ve had a client who heard voices ordering him to set himself on fire. He expressed to me and others that he did not want to set himself on fire. And yet, he had been in the emergency room on more than on occasion. The last time he was in the emergency room he was civilly committed for 180 days. Why? Because he set his hands on fire, and burned the flesh on his hands and fingers all the way down to the bone in certain areas. He suffered major infection, and required both heavy skin grafting and some plastic sugery. Doctors said that it was nothing short of a miracle that he did not destroy all nerves and permanently lose the use of both his hands. This was a 22 year old kid, who nearly lost the use of his hands for the rest of his life.
The commitment said that he was presently a danger to himself such that it wasn’t safe for him to be independent in the community. And you know what, I think I agree. I don’t say that lightly. But nothing about this kids command voices ordering him to set himself on fire had changed. While the kid did not want to be hospitalized (which I can understand) he also was pretty clear that he didn’t want to be setting himself on fire either. That wasn’t a choice he was freely making for himself.
I worked with another person who shot his neighbor to death because this person thought he was receiving orders from the government, and that his neighbor was a child abuser who he was ordered to kill in order to protect children. Premeditated murder. He murdered him, then drug the body out of the house and hid it in a boat in the backyard. It was only after the CIA didn’t pick up the body that he thought something was wrong. When the police questioned him, he told them everything because, again – he thought he was doing what he was supposed to be doing.
He was found not guilty by reason of mental defect (yeah nasty term I get that) and ordered into psychiatric care. He was put on anti-psychotics, and he cleared cognitively. Yes, I know how that sounds, but this is how he described his own experience to me. He started on haldol and said that it was after this medication support that his thoughts began to clear. He was lucky to work with some psychiatrists who treated these meds as selective use and supported downward titration. When I worked with him six years after the crime he was not on haldol anymore. He also had no more voices or thoughts that he describes in his own words as “delusions.” But the meds were a big part of his early stabilization – that’s what he says about his own experience. Now his major struggles are with extreme guilt and shame for what he did.
So what do with do with the really complicated situations where the answers aren’t perhaps always as simple as “you never want to hospitalize someone” or “medications are never the answer” or “involuntary services are never appropriate.”
My own personal sense is that throwing terms like “nazis” or “swastikas” into the mix is a fast way to alienate the very people we are wanting to awaken to the severity of this crisis. Doesn’t really matter how “right” it is or not. Being right is not always the same thing as doing the “wisest” thing.
Having said that, I’m not about to insist that my sensibilities and ideas on the best advocacy approach be everyone elses. We have to embrace the idea of diversity of tactics because if we don’t, we’ll never have a functional movement — all we will have is infighting.
So….. I’ll stand right next to you and your nazi sign and, while I won’t be holding my own, I’ll hopefully bring my distinctive contribution to the cause. 🙂
Tragic, infuriating, heart-wrenching and, for someone working within the public system of mental health – so incredibly discouraging and defeating I don’t even know where to begin.
The task of challenging automatic assumptions made from positions of power for the purpose of maintaining power and control seems so overwhelming I’m left feeling mostly helpless to act.
Thank you for the comments. Mary Anne, I love hearing from other people still actively engaged in the mental health system who are also committed to speaking out and being an advocate for justice.
I can’t say I will work in the public mental health system for the rest of my life, or even for how much longer. But I will say that we should all (I think) be very grateful that there are some people with similar passions who are working in mental health. Because it really doesn’t matter how broken the system is, or how little hope for “change from within there is.” The fact of the matter is, persons are still funneled into this system every single day, and more than anything these human beings will need advocates and partners who stand with them when the resist systemic abuses. So thanks for your dedication and commitment.