Kostić utilizes his extensive training and traditional research methods to question the fundamental assumptions of his field. For example, Kostić critiques the flawed premises of genetics research in depression, arguing that it overlooks the heterogeneity of human experience. He uses analogies to illustrate how psychiatry often pathologizes normal human emotions, drawing parallels to how medical conditions are misunderstood when the context is ignored, like trying to treat the lungs alone in a society overrun by air pollution.

We will also discuss his latest study, which emphasizes the benefits of de-medicalizing experiences of depression rather than quickly resorting to diagnoses and subsequent treatments with medication or psychotherapy. His research also sheds light on the effects of biological narratives on patient perspectives, the complexities of drug dependency, and the profound impact of psychiatric diagnoses on individual identity.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Karter: To get us started, can you tell our listeners about your story? How did you train in psychiatry and traditional biological psychiatry, and how did you eventually come to see yourself more as a critical psychiatrist?

Kostić: I trained in medical school, where the focus was entirely on the biological aspects of medicine. The humanistic, social, and philosophical dimensions were on the margins, almost exceptional. We were taught to think in a straightforward cause-and-effect manner: this causes that, and this is treated by that, with very little emphasis on critical thinking. For instance, I find it fascinating that during my six years of medical school, I never heard about randomized controlled trials until my doctoral studies. We were simply told, “This is good, use this.” But how did they know? I had to pursue a doctoral degree to learn the methodology behind such assertions.

Medical school was all about the major exams: anatomy, physiology, pathology, histology, etc. The focus was always on what’s happening in the body. Naturally, when I started psychiatry, it felt like an extension of this focus: understanding what’s wrong with the brain, the emotions, the thoughts. During my psychiatry residency, I simultaneously pursued my doctoral studies, focusing on imaging and genetics in depression, trying to identify subgroups through polymorphisms to better understand these conditions. This defined my first seven years of psychiatry training and even continued after I became a specialist.

During my doctoral studies, it was hard to switch off. You’re in the zone, focused on your thesis and the goal of obtaining your degree. This intense focus often suppresses critical thinking. My first international conference was a turning point. It was in Barcelona, where I attended various sessions and browsed through books on psychiatry. One of the books I bought was “The Loss of Sadness” by Wakefield and Horowitz, which critiques the DSM diagnosis.

After finishing my doctoral thesis, I experienced a sense of loss and confusion. I had completed my residency and started a family, so I thought I should continue my work in genetics. I even began forming a genetic biobank at my institute and establishing connections with other genetic research institutes. However, my heart wasn’t in it. I was trying to push myself, but I felt empty.

Over time, I recognized that reading about genetics and psychiatry bored and irritated me, despite being the focus of my doctoral thesis. On the other hand, reading about the social and political aspects of psychiatry excited me and made my blood boil. This transformation was gradual, taking about a year. Slowly, I made a complete switch, relearning many things. I started several studies aligned with my new perspective, which felt more personally fulfilling because they were more truthful and made more sense to me. The more time I spent in biological psychiatry, the more it felt like a house of cards with no solid foundation.

Karter: Thank you. I do want to get to your recent studies. But just to dig into the genetics of depression a little bit further, from your perspective, having been deeply involved in that field, do you think the main problem with looking for genetic polymorphisms underlying depression is due to the heterogeneity of depression—like the construct is too broad and includes too many people with too many different symptoms—or do you think there are more fundamental issues with even looking for underlying genetic causes of depression?

Kostić: There are a variety of problems, each one complex enough to discuss for hours. My main issue is that the starting premise is wrong. When your premise is flawed, no matter how excellent your studies are, you’ll end up with gibberish. We’re comparing apples and oranges here, and this is often called the heterogeneity of depression. However, I prefer not to use that term because it implies that depression is just a set of different types of the same disorder. Instead, I think it’s more accurate to talk about the heterogeneity of human experience. Words carry weight. When we say “depression,” we typically mean “major depressive disorder,” and when we say “disorder,” it implies something is wrong with the brain.

Medical philosophers and psychiatry philosophers often engage in complex debates, arguing that a condition doesn’t have to be a medical disorder to be significant. But this is Ivory Tower academics. In practice, when a psychiatrist, perceived as a figure of authority, tells a patient they have a disorder, it often leads the patient to believe something is fundamentally wrong with their brain, serotonin levels, or genetics. While there might be some truth to this in certain cases, it’s like saying there might be a problem with anything else—it’s uncertain, and we really have no clear idea.

The problem starts with the premise. We’re just lumping together people with symptoms and asking, “Why are they coughing?” It’s like taking everyone who coughs and putting them in an MRI to figure out why. But some people cough because of asthma, others because of cancer, a bacterial infection, or a tic. Some cough because the air is polluted. In that case, there’s nothing wrong with their lungs—the problem is the air.

We keep seeing a rise in diagnoses, especially with conditions like anxiety, depression, and adult ADHD, which exist on a continuum of normality. How focused should I be? How sad or anxious should I be? There’s a push for mental health awareness, but no one is asking what’s in the air. Why are more and more people coughing? It’s like everything is blamed on the brain. This is the biological basis of medicine, and it’s fundamentally problematic.

When you group together people who are sad for different reasons and try to find a genetic cause, you end up with nothing. It’s useless. There was a huge study in genetics and neuroimaging with a million controls. The abstract sounded fantastic, but when you read the fine print, you see the flaws. They asked participants one vague question: “Have you ever been to a psychiatrist or psychologist for nerves or something in your lifetime?” This was the depression group, even though the question could mean anything. Those who said no were in the control group. They compared apples and oranges. Even with such a large sample, they found meager positive results, explaining only up to 3% of the variance. I think even those 3% are just artifacts, false positives.

But even if they found that 3%, it’s nothing. Yet it makes an amazing headline in a top journal. You see how this clinical aspect is flawed—needing a million sample size, using the best genetics and the best statistics—and it’s still worthless. It’s hard to tell people that all of this is worthless. It’s worth less than a Cosmopolitan magazine you buy on the street, but it has so much power in the discourse that it’s ridiculous.

Karter: This is a great jumping-off point because not only is this way of thinking about depression scientifically worthless, but it’s actually potentially harmful when people start to understand their experiences through this lens. I want to pick up on that because both of your recent studies address this issue. Let’s start with the medical students’ perception study. Can you tell us a little bit about that study, why you conceived it, and how it played out?

Kostić: Sure. We created a vignette with patients showing symptoms of depression but also included some social circumstances. For example, one vignette had a patient with depression whose mother and daughter had also seen a psychiatrist. We wanted to see how these added details would influence the students’ views on treatment.

From this study, the most important result, in my opinion, came from a basic question we asked: “How effective do you think antidepressants are?” We analyzed the responses by year of study, from first to sixth-year medical students.

When we asked first-year students about the effectiveness of antidepressants, they rated it just above no effect, essentially saying the effect was modest. This aligns with the most positive meta-analyses, like the Cipriani study, which also describes the effect as modest. So, the first-year students basically got it right.

However, by the second year, the perceived effectiveness started to rise. By the fourth year, their perception had increased significantly, rating antidepressants between moderate and high effectiveness. This change highlights how education can shape and sometimes distort perceptions over time.

From the very beginning of medical studies, we’re driven to trust medicine and the drugs we prescribe. We’re taught that what we do is inherently good. I think this was the most interesting part of our findings because it shows that we need a complete overhaul—not just in psychiatry, but at the root. We need to address the culture, the media, and the education system to help people understand that things aren’t always as they’re presented. We need to start in medical schools.

For instance, as you mentioned, I’m here on a Fulbright scholarship. In my proposal to the American Embassy, they asked about my future plans. One of the things I wrote was that I want to introduce a topic in medical schools about overtreatment and overdiagnosis. Unfortunately, by the time students get to internal medicine, psychiatry, or neurology, the focus is mostly on what you should and can do. There’s almost no emphasis on what you shouldn’t do. It’s just assumed that you have to do something. This mindset has contributed to the current state of psychiatry.

Karter: When you spoke about your own training at the outset of the interview, you mentioned that the way issues are framed as part of the medical school curriculum leads one to naturally assume that we’re working on correcting some underlying pathology with tools we think might help. This framing makes the issue seem concrete, but it can be really misleading. It’s interesting that your study shows students actually get less accurate reads of the research the more they learn.

Kostić: Yes, but they’re not. They’re not reading research, and that’s a big problem. Research should inform evidence-based medicine. Instead, we’re getting our information from textbooks that simplify the message.

It’s going to be so hard to counter that because the alternative is much more complicated. It’s much easier for a doctor to think, “This patient has these symptoms, so I’ll prescribe this medication.” It’s simple, and patients like it too. They feel reassured, thinking, “This doctor knows what he’s doing. He’s in control.” It’s nice for both the patient and the doctor, but it’s not necessarily good.

Karter: This is a great bridge to the next study, the watchful waiting and depathologization study. Getting indoctrinated into this way of thinking about depression has consequences, as you said, for patients. They come in and, because they screened positive—maybe with their GP using a PHQ-9 or something like that, which has its own issues—they potentially meet the criteria for a depression diagnosis. They hear they have a disorder and that treatments are available. This significantly impacts how patients think about and understand their experiences. Your study looks at an alternative approach, using a model you’d typically see in treatment design studies. Can you walk us through how you conceived this study, how it ran, and what you found?

Kostić: Initially, the study was conceived as a longitudinal study of patients with depression to see what happens when you don’t treat it. There aren’t many studies on this. But it quickly became clear that you can’t just not treat someone who comes to you for help. So, we changed our approach and decided to first tell them, “Maybe you don’t have a disorder.” Many people think that to validate their suffering, they need to be diagnosed with a disorder. But I don’t think a single one of my patients isn’t suffering. The fact that I don’t believe many of them have a disorder has nothing to do with their suffering.

Quite the opposite, I think that to really help them, we need to understand them as social beings. In cognitive behavioral therapy (CBT), which is used in psychiatric settings and is considered evidence-based for some conditions, there’s the concept of learned helplessness. This can be true and useful for some people. Some get stuck in these helpless models of thinking, but then we turn around and tell a patient they have a depressive disorder, which can actually cause hopelessness. So, we’re treating hopelessness on one hand but causing it on the other.

Our approach was to tell the patient, “There’s a chance you don’t have a disorder. We don’t know, and we’re not trying to diagnose you. Maybe there is depression, maybe some people have a brain disorder. What I know is that I don’t know who has a brain disorder, and I know no one else knows because I know what the science says—we don’t know. There’s a chance you don’t have a brain disorder, and there’s a chance things will get better.” This is the basis of depathologization.

But then again, they came because they’re suffering. They didn’t come because they were bored. They came to me because something was wrong. Let’s give them some advice. It doesn’t have to be psychotherapy. You don’t have to be a psychotherapist to give advice. Often, the best psychotherapists are a parent, a spouse, or a friend. If you can get support from them, it’s the best psychotherapy in the world. Sometimes, you do need professional therapy, but it doesn’t have to be complex. It can just be empathy. It can be someone hearing you. It can be someone alleviating your fear that you have a disorder, which I’ve seen happen a lot in my practice.

I’ve seen people who look really depressed and anxious, and when I tell them, “Maybe it is, maybe it isn’t. Let’s wait and see. Think about what you can change in your life, what the problems are,” they come back after a week and say, “I’m still unhappy about these things, but it’s so much more manageable now. I don’t think there’s something wrong with me; I just have to figure out how to deal with these things. I don’t need to come here anymore; I just have to work on my whole life.” This is a powerful thing.

The second aspect was to give them advice. The third thing was that we didn’t impose anything. We said, “You might have depression, or you might not. We can give you advice, but you don’t have to take it. You have options. If you want medication, you can have it. If you want to wait and see, that’s fine too. Drugs have risks and adverse effects, so we can wait and see.”

Some patients said, “Doctor, you’re great, but I came here for antidepressants. I didn’t come here to chat.” That’s valid. If I refused them the medication, it would only increase their anxiety. This aspect needs to be addressed in the public sphere because they’re already so entrenched in the message that medication is the answer. We respected their wishes.

Shared decision-making is extremely important. We didn’t do a randomized controlled trial (RCT) because I think it would be impossible. I’m considering ways to do it because it would be the best approach. But it’s extremely hard to do an RCT for a psychological intervention like watchful waiting. People think watchful waiting means doing nothing, but that’s not the case. This type of watchful waiting is impossible in today’s world.

Maybe it was possible 50 or 100 years ago when someone might come in and say, “I feel sad,” and you could say, “Let’s watch.” Now, they come in saying, “Doctor, I have depression.” Seventy percent of the patients come in saying, “I have depression.” We have to first depathologize.

I love evidence-based medicine. I think it’s extremely important to implement it as much as possible, as often as possible. But some people misunderstand its aspects and limitations, thinking it always gives us true answers. That’s not the case. In internal medicine, you can measure efficacy theoretically. In psychiatry, with all the cultural impacts, I’m not even sure we can do that validly.

I remember two patients who came to me on antidepressants. I didn’t prescribe them. I do prescribe sometimes, but very rarely and usually only when patients ask. These two had been prescribed by other physicians. One said, “Doctor, I’m having problems with impotence.” I said, “Yeah, it’s probably because of the antidepressant. We can start tapering it off.” He replied, “No, please don’t take it away. I feel awesome. I don’t want to go back to how I felt before. I just wanted to know if this is because of that, and if so, I’m fine with it.”

The second patient came in with the same issue, saying, “Doctor, I have a problem with impotence.” I said, “It’s probably because of this medication.” He responded, “Please, we must stop the medication. I can’t live with this.” Both were right for themselves; both had their own truth. There is no objective truth in these cases. This is the problem with evidence-based medicine. When we analyze benefits, they are true for the individual. Saying someone should or shouldn’t take a drug leads us into a paternalistic model where we claim to know what’s best.

It’s good for a person if they believe it’s good after analyzing the risks and benefits. That’s why we didn’t need a randomized controlled trial (RCT) for watchful waiting. Just presenting the option can work. In our sample, two-thirds of the patients were better after three months without drugs using our model. That’s a pretty good number.

Karter: Following up on presenting the risks and benefits of antidepressants to patients, you mentioned sexual dysfunction as one of the potential harms people aren’t always aware of. Another issue that’s gotten more attention in recent years is withdrawal effects from long-term use. I saw that you published on suicidality emerging from rapid Venlafaxine discontinuation. Could you tell our listeners a little bit about how you discuss withdrawal or discontinuation effects with patients when they’re considering starting an antidepressant?

Kostić: In clinical settings, it’s often unclear why a patient is getting worse. The automatic assumption is that the depression is returning. That’s what I was taught in residency, and it’s what residents are still often taught. This is also what many patients think because they’ve been told there’s something wrong with their brain, and if they stop taking the drug, things will get worse.

One patient came to me with a story that stood out. She had never had suicidal ideations before. Then, the pharmacy ran out of her medication, and she missed it for two or three days. Suddenly, for the first time in her life, she had suicidal thoughts, which went away when she resumed the drug. Six months later, she had no problems, gained some weight, and her doctor decided to adjust her medication.

What I found interesting is that her previous psychiatrist knew about the risks but not enough. She told the patient, who was on 225 milligrams of Venlafaxine, to take three days of 150 milligrams, three days of 75 milligrams, one day without any, and then start the new medication the next day. This was too rapid. People often don’t realize it can take months, sometimes even years, to safely taper off these medications. This is all new data that many clinicians and patients aren’t fully aware of yet.

Right when she started tapering off her antidepressant, her depression seemed to return, and she had a suicide attempt, which she thankfully survived. Now we’re going much, much slower with the tapering. There was polypharmacy involved, but Venlafaxine was the only change during this period. One of my co-authors, Martin Plöderl, suggested calling it a Challenge-Dechallenge-Rechallenge paradigm.

What’s also interesting, and a bit historical but important, is that the first time I heard about withdrawal in SSRIs was in 2019. This was when Davies and Read’s systematic review came out, showing that around 50% of patients experience withdrawal effects, and a quarter have severe withdrawal effects. This was almost 30 years after Fluoxetine hit the market. Why? Because the drug manufacturers have no monetary incentive to study this.

In ’94, Professor Giovanni Fava published on the possibility of chronicity of depression using antidepressants, but researching this area requires money and people. It often relies on a small number of enthusiastic individuals searching for the truth, like those at Mad in America, while the other side is a machinery of thousands of people and billions of dollars. This is one reason why it took so long for major attention to come to this topic. Thankfully, in the last five years, more is known about it.

I find it fascinating how willfully blind we physicians and psychiatrists can be. I now make it a prerogative to always discuss the possibility of starting without antidepressants with my patients. I think doing less is often better than doing something unnecessary. But I present the options to my patients and respect their decisions. When they want to try medication, I say, “Okay, but know this: it may cause addiction or withdrawal. If we get into that, keep it in mind so we don’t use it for too long if it’s not necessary. If you decide to stop and negative feelings return, it might be withdrawal rather than depression coming back.”

This all takes time, which is a problem when you have 30 patients waiting. It’s much easier and quicker to say, “Here’s the drug; take it three times a day.” But that approach is worse. We have to make things more complicated, and this is never easy.

Karter: I’ve heard it expressed—perhaps a rather cynical position—from some psychiatrists, especially on Twitter and elsewhere, that providing fully informed consent about the limited efficacy of antidepressants and the potential for harm could reduce the placebo effect and, therefore, the healing potential for the patient. I would like to hear your response to that perspective.

Kostić: As you said, it’s a cynical view, and it aligns with the practice of undervaluing harms and overvaluing benefits. When we think about shared decision-making, we consider whether a drug is good, bad, or how it will heal. If I tell a patient they have a disorder, of course, they’ll think they need a drug. But this initial premise is potentially very wrong.

If you keep the patient in the dark to preserve the placebo effect, you’re treating them based on a potentially false premise. If you tell the patient they might not have a disorder, the healing potential or placebo effect becomes less crucial because you’re not pathologizing them unnecessarily. This is a moral issue. Do I have the right to tell my patient that their carcinoma is malignant when it might be benign? No. I have to tell them the possibilities. We don’t tell patients they will die if they might not; we present the odds.

We’ve decided to treat symptoms as disorders, but you may not have a disorder. Maybe you’re just sad or afraid because life is complicated.

I understand the challenges in extreme cases, like psychosis or dementia, where shared decision-making can be difficult. These are often discussed on platforms like Mad in America, and while I don’t always agree, I respect the need for these conversations. We must remember the dangers of too quickly deciding that someone can’t make decisions for themselves. However, there are cases where patients struggle with decision-making, and we should focus more on compliance. In these specific cases or diagnoses, I have some understanding of the concept.

Karter: I want to finish up our time here by spending a little time on what’s coming in the future for you. I wonder if you could share a bit about what you and Dr. Cosgrove are working on for your Fulbright. You mentioned earlier what you hope to achieve with that, but could you share a little more about where you see your work headed in the next few years?

Kostić: Well, one of my goals is to write a book. Using my shared decision-making approach with patients, I’ve gained a lot of practice explaining complex matters in understandable terms. I get wound up, as you can see, and talk a lot, but I try to keep it comprehensible so that more or less anyone can understand it. I want to use this skill—or talent, or whatever you want to call it—to write a book for the masses about the connection between identity and disorder.

When we tell a patient they have a disorder, it changes their identity and how they perceive themselves. I want to explore this using several examples: depression and anxiety, adult ADHD and autism, addiction, and gender dysphoria. Each of these carries different aspects of the interplay between identity and disorder.

With depression and anxiety, it’s a top-down process. The message comes from pharmaceutical companies, the media, and the medical establishment, telling patients they have a disorder, leading them to believe they have a faulty brain. With adult ADHD and autism, it’s fascinating because it’s more bottom-up, originating from social media and philosophical circles of neurodiversity. These concepts gain traction in the public sphere, putting pressure on the medical guilds to adapt. And, of course, the guilds and pharmaceutical companies are eager to comply because there’s monetary gain involved.

In addiction, we see the direct forming of identity. You stand up in front of a group and say, “I am Kostić, and I am a sugar addict,” and this becomes part of your identity to help you understand and fight the problem. I think this approach has its merits. I’m not saying it’s always bad; I’m trying to understand it from all angles.

The fourth topic is gender dysphoria, previously known as gender identity disorder. Along with dissociative identity disorder, it’s one of the few disorders where identity itself is in question. This raises entirely different questions and answers. This is a subject I’m deeply into, and I’m nearing the end of my work on it. I’m looking forward to possibly getting it published, but I felt compelled to write it and get it out there myself.

With Lisa, we’re working on several things. I mentioned Zuranolone, a new drug for postpartum depression. There are some obvious flaws in how it’s presented and marketed, and we want to tackle this issue. We’ve also finished a critique of prolonged grief disorder and the pathologization of grief.

As I mentioned, I’m delving into shared decision-making, not just about drug choices but about the disorder itself. One without the other is useless. I also plan to write about the physiology gap, a theoretical concept questioning the utility of biological research in psychiatry.

In traditional medicine, we know how physiologically normal lungs function and can compare that to pathological lungs. But in psychiatry, we compare people labeled as “depressed” to those without problems, which is illogical. To understand pathology, we should compare depression to sadness. But we don’t know the physiological basis of sadness, so any differences we find are claimed to be pathological markers of depression, which isn’t accurate. This oversight in reasoning is astonishing.

When I get back to Serbia, I plan to do a study with Lisa on our notions of drugs based on their designation as medicine. This is important because many drugs like psychedelics, marijuana, and MDMA, which were street drugs 20 years ago, are now becoming medicines. We have some ideas for questionnaires to understand people’s relationship to this change. I think this is massively important.

Personally, I’m for the legalization of all drugs. I believe it’s a moral position. Politically, examples show it shouldn’t have massive negative societal effects. But this doesn’t mean I think drugs are good. Every drug can be harmful. Alcohol is a legal drug, and it can be harmful. We recognize this with age limits, etc. It’s important for people to understand the risks and have a healthy fear of the drug.

I think the designation of a substance as medicine lowers this fear because there’s a bias where street drugs are seen as dangerous, but medicine is seen as good. If I take marijuana to get high, that’s my choice. But if I say I’m treating my anxiety with it, I might start using it every day, shifting from wanting it to needing it. This is a dangerous premise. This applies to MDMA and psychedelics too. I believe they should be legal, and people should have the right to decide for themselves. However, I would prefer them to be decriminalized rather than medicalized because the potential for misuse is greater with medicalization. This is another study I’m looking forward to.

***

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The post Demedicalizing Depression: An Interview with Milutin Kostić appeared first on Mad In America.

He is the author of numerous additional works, virtually all of which, in one way or another, speak to the emerging field of the psychological humanities. These include Rewriting the Self: History, Memory, Narrative (Routledge, 1993); Finding the Muse: A Sociopsychological Inquiry into the Conditions of Artistic Creativity (Cambridge, 1994); Hindsight: The Promise and Peril of Looking Backward (Oxford, 2010); The Priority of the Other: Thinking and Living Beyond the Self (Oxford, 2014); and Do I Look at You with Love? Reimagining the Story of Dementia (Brill | Sense). Along with David Goodman, he has also co-edited Psychology and the Other (Oxford, 2015) and, with Hanna Meretoja, has co-edited the recently published The Use and Abuse of Stories: New Directions in Narrative Hermeneutics (Oxford, 2023). He also serves as Editor for the Oxford University Press series “Explorations in Narrative Psychology.”

In this interview, we’ll explore his personal journey toward the psychological humanities, delve into his work in narrative psychology, and discuss his approach to the concepts of ‘self’ and the ‘Other.’ We’ll also touch upon how his perspectives guided him as he navigated his mother’s journey through dementia, a deeply personal narrative shared in his book.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: Could you start by sharing what inspired your journey toward the psychological humanities and how this path has shaped your career?

Mark Freeman: I could go back as far as junior high and high school when I was a singer in a rock and roll band, but I’ll leap ahead instead to when I was an undergraduate at Binghamton University.

That was in the 1970s, like a lot of people who pursue psychology, I was interested in big ideas, deep issues, you know, plumbing the depths of the human condition, and that really wasn’t what was happening at that point. On some level, it’s still not happening. But back then, things were predominantly behavioral in orientation, and I was kind of shocked by the whole thing. I had just imagined that psychology was something really rather different than what it was, and that’s partly because I got my images of what psychological understanding was through places like literature and film and the arts and so on.

As luck would have it, I stumbled upon two courses, and it really was luck. I took a course in Phenomenological Psychology in the Philosophy Department, and I won’t pretend to have known at the time what phenomenological psychology was, but I read the course description, and it sounded kind of cool, and it was way closer to what I thought psychology was and also might be. So I was really turned on to that.

I also took a course in the Psychology Department where the main text was called Visual Thinking by Rudolf Arnheim, who was one of the most prominent psychologists of art for many, many years. That, too, really turned me on, and I wound up doing a term paper on Gestalt psychology and art, and just found like I was beginning to find myself, and to find my way into at least some version of the discipline.

The question, of course, after that is what to do. Okay, so I have these funky new ideas about what psychology might be. I was eager to pursue them in some way, but of course, there aren’t many places where you can do that. I took off for several years, did some extensive traveling in the States and around Europe, and eventually had the great good fortune of finding a place that really seemed to suit me, and that was the University of Chicago. I enrolled in the Committee on Human Development, which was a mixture basically of the social sciences and for me, philosophy. It was a kind of do-it-yourself program. I would say most of the people who got their PhDs in the committee turned out to be psychologists, but some became anthropologists, some became sociologists, and so on. So, it was a very heady place to be.

There were a couple of things that I just would call attention to, and it might seem like I’m going into too much detail about this, but it’s actually relevant. In the Committee on Human Development, the main focus was to study human lives in as comprehensive, multifaceted a way as possible. So, we were required to take courses in things like developmental psychology, you know, that sort of thing. But also courses in sociology, cross-cultural human development, and other things. At that point, there was a big focus, especially on the idea of life history and how to understand it, right? How do we understand the movement of a human life? What kind of methods are appropriate to it? So, that’s what was going on in the Committee on Human Development.

But I also went to Chicago because I was interested in learning more about the work of the philosopher Paul Ricoeur, and I saw that he was teaching a two-semester seminar in the Phenomenology of Time Consciousness. It was risky territory for me. I had some philosophy, but not a whole lot, and we had to read in the first semester Plato and Plotinus and Aristotle and St. Augustine, and all of that was new to me. Second semester Husserl, Heidegger, all that, but it was amazing.

Ricoeur, at that point, was also really doing a deep dive into the idea of history and historiography and their relation to narrative, and in fact, he wound up teaching another course that I also had the great privilege of taking called Historicity, History, and Narrative. It was precisely about the kinds of issues that I was pursuing in human development, but on a much broader plane, and we were reading literature, we were reading history, we were reading historiography, we were reading psychoanalysis, and more.

So, there was a kind of amazing confluence between what was going on in my home department and what was going on in philosophy at the time, especially through the work of Ricoeur. So that just sent me to a really quite extraordinary place. You know, the very first piece I ever did was when I was a grad student; it was a very audacious piece called “History, Narrative, and Lifespan Developmental Knowledge,” which I published in the journal Human Development. It was back in 1984 because I just had to figure out some way of integrating and synthesizing all the stuff that I was learning. Otherwise, I would have exploded, so to speak.

The other thing I did was engage in some empirical research, broadly speaking. I became involved in what was known then as the Artist Project, which was led by Mihaly—Mike—Csikszentmihalyi, the person who’s best known for the idea of flow.

He had a research project that studied a group of aspiring painters and sculptors who’d been schooled at the Art Institute of Chicago in the mid-60s, and the goal was to find out what they had and hadn’t been doing some two decades later. So I got to travel to all kinds of funky places, you know, ranging from the Hamptons to Soho, and also outside of New York, to have very extensive talks with some of these people, and so that kind of threw me headlong into the art world and what was happening in the art world, what was happening in the world of culture more generally, what kinds of work had currency and cachet, what kinds of work didn’t, and so on.

So, I basically had two large streams of work. My dissertation was on the Artist Project, but at the same time, I was doing all of this narrative work.

All of that really was going well. I was getting a lot of stuff in print. I had these incredible mentors who were helping me along and so on. And then the question was, well, where do I go with that? Quite honestly, there are some people who are casualties of the University of Chicago because they might have been terrific scholars, thoroughly interdisciplinary, innovative, creative, and more. But that’s not what most departments are looking for, especially psychology departments, who are generally looking for people whose work is much more specialized, who fit into the journals that are generally considered to be the best, which often aren’t.

But again, in a real stroke of luck, I saw an ad. It was 1985 or 1986. The College of the Holy Cross wanted somebody to teach phenomenological psychology and just about anything else I wanted to do. So, I was lucky to land there, and I’ve been there ever since.  This is now my 38th year.

For the first two books I did, one was tied to the artist’s project and was called Finding the Muse, A Sociopsychological Inquiry into the Conditions of Artistic Creativity, and the other was called Rewriting the Self, subtitled History, Memory, Narrative. Of the two, it’s actually the latter book that was more of a precursor to what would eventually become known as the psychological humanities, and it was and remains kind of an odd book in some ways, especially in relation to what was going on at the time. It’s a book in which each chapter focuses on a literary text. Five of those texts are non-fictional, and one is fictional. The non-fictional texts range from St. Augustine’s Confessions all the way to Philip Roth’s “autobiography” called The Facts. The one work of fiction that I explored was Jean-Paul Sartre’s Nausea.

So, I was interested in issues that are arguably, though maybe not in the eyes of some psychologists, called psychology—memory, identity, history, narrative—but I was moving into the humanities and into literature as a prime vehicle for doing it.

So, that was a focus for quite a while, and eventually, I expanded that focus because I didn’t only want to write about books. I also wanted to write about people, and eventually, those people would include my father, one of my daughters, my mother, and, on some level, myself.

It’s challenging work to do. You never want it to be too self-indulgent or confessional, but I did want to explore the lives of people I knew and cared about, and that led me to think more deeply still about what it means to be human. So that’s a start.

Justin Karter: You begin your book, “Toward the Psychological Humanities,” by sharing how conflicted you felt as you delivered your presidential address for the Society for Theoretical and Philosophical Psychology at the America Psychological Association Meeting in 2015. First, I want to say that I was actually in the room for this address – as a Master’s student new to the field trying to find my way – and was really inspired by your approach. So, I owe you a thank you for articulating a version of psychology that I felt I could get on board with. Second, can you bring our listeners into the conflict you felt at the time? What is so “weird–and, at times, positively wrongheaded and deplorable” about the discipline of psychology?

Freeman: It was a very, very difficult time for me to be president of the division, and the reason actually had to do with what was going on in the APA at large. I don’t know if you recall, but one of the main topics was what they referred to as “enhanced interrogation techniques,” otherwise known as torture, and that was one of my take-off points, and it occupied a lot of my time and thought.

The word “deplorable” is a strong word, maybe too strong. I wouldn’t want to use that word to characterize the whole of psychology, but I could certainly use it to characterize some of what was going on at the time. But there were lots of other things that I had seen throughout my entire career that I also thought were wrong-headed in some ways, or if we want a somewhat more charitable version, just radically incomplete.

I continued to see methodological narrowness, and while there were some efforts afoot to change that, for instance, in the Society for Qualitative Inquiry in Psychology—which, as you know, I also became heavily involved in—psychology still had delimited its focus methodologically in a remarkably parochial way, focusing especially on the kinds of phenomena that could readily be encapsulated, objectified, measured, and so forth.

I have no particular interest in knocking that. There is certainly a realm of phenomena for which that kind of approach is appropriate and valuable, but there are so many other ways of exploring the human realm; the human experience and qualitative work were part of it, but I was also interested in pushing it even farther in some ways. There’s some qualitative work that is fairly standard social science that’s just not quantitative. But as I say, I wanted to push things even farther, and not just for the sake of pushing things farther, but for the sake of expanding the field of possibility in psychology as an arena of inquiry.

What else did I see that led me to think some of it was and remains wrong-headed? A lot of the work in psychology is hermetic. People are speaking to one another about a relatively narrow band of phenomena and are often developing highly sophisticated and technical procedures, both in order to study those phenomena and to begin to explain them. That results in a lot of very, very technical jargon that’s often only accessible to those within that particular subfield, and so on.

So this is why I wanted to move further in the direction of the psychological humanities. As I say in the book, if I really want to read something or experience something that plumbs the depth of the human experience and allows me not only to think about it in some intellectualized way but maybe to feel it and to engage in some imaginative flight, I’m much more likely to read a good work of literature or go to the theater or go to a concert or whatever. And so by degrees, I also came to ask a very basic question: Why can’t a portion of psychology have the kind of expressive, living, evocative power and passion that works outside the discipline sometimes have?

Karter: I’m wondering if, as somebody who’s deeply attentive to narrative, you can say something about the type of language and narratives that are produced by mainstream psychology and how you see them working in the world around you, with students that you work with, and even in the broader political discourse. I’m thinking both of sort of our diagnostic nomenclature and how it’s being widely used, but also the phenomena of a lot of young people increasingly using psychological concepts to understand themselves and other people.

Freeman: We are surrounded by narratives, and they occur, of course, in sites ranging from the confines, so to speak, of our own lives to what’s going on in the wider world, culturally, politically, and so forth.

One of the things that I’ve done for a very long time as a teacher is give students the time and the space to be able to explore their own lives through narrative, and not just for the sake of introspection but to begin also to understand some of the discourses and forces that have led them to lead the lives that they have, in terms of the expectations that have been put upon them, in terms of the desires that they have, in terms of what it is that they see as being a meaningful and valid life.

I’ve had students engage in some considered narrative work. I’ve sometimes called them narrative self-analyses. I’ve sometimes called them mini-memoirs. They have to really work hard at those. They have to do multiple drafts. They have to get some feedback, and as I tell them oftentimes, these stories need to be both about you and not about you. Right? You need to be able to tell a story that addresses some feature of psychological life that exists beyond you as a self, and that’s actually quite a hard thing to do.

Karter: I am also thinking about “the hermetic” discipline of mainstream psychology, as you described it. When the hermetic seal is broken, and these concepts that are forged in increasingly specialized and experimental settings become part of the popular discourse, they or become part of the ways that people are making sense of themselves and their relationships with other people. As a narrative psychologist, how do you see this sort of increased psychologization working against the sort of poetic, humanities, or literary approach to understanding our lives?

Freeman: Psychologization is part of the fabric of contemporary culture and has even become more visibly so in recent years, as people talk about, for example, the anxiety that derived from COVID. Meanwhile, students are taking courses in psychology departments where they are being exposed to the DSM and the jargon of psychology and diagnostic categories and, on some level, applying them to their own lives. You’re probably familiar with the looping effect. So, you know, that certainly happens. I mean, on some level, we become the selves that we’re reading about and studying about and that are circulating through contemporary culture.

Some of that’s fine, in its way. So, my goal would never be to say, nor would it be possible, to disregard all of that. Stand apart from all of those discourses and categories that are circulating, and see if you can move into the depths of your own truth. You know, that would be “un-hermeneutical.” It would assume the possibility that we could extricate ourselves from all that surrounds us and somehow encounter and behold ourselves nakedly. And as you well know, that’s not possible.

What is possible is to provide some resources that can allow students to interrogate things to become aware, more aware, at least of the way in which they are constituted and formed, and perhaps on some level, deformed as modern selves.

So, there’s a limit to what can be done in the span of a semester or a year. I have no illusions about being some magical transformative force. But I hope to be able to have students acquire some critical consciousness toward the way that we’re talking about ourselves, and some historical consciousness, in the sense of being more aware of the formative factors that have culminated in their way of thinking about themselves.

One has to be very cautious in doing these things. If I’m going to write about my mother, or my father, or myself, and I’m going to try to do it with some measure of honesty and integrity and depth, it’s not only going to be risky, but it’s almost certainly bound to be painful in some way.

Karter: And I know that you say this as somebody who has written both about “the self” in general, and yourself and your mother, as you mentioned, so let me pick up on “the self” first. One of the intriguing aspects of your work is the idea of transcending the ‘self.’ Could you discuss how these experiences, as exemplified in music and other forms of art, as well as mystical or religious encounters, contribute to our understanding of the human condition and the possible interplay between the human and the divine? How does this concept of transcendence challenge and expand our conventional notions of selfhood and psychological experience?

Freeman: How did I develop this interest? I certainly developed an interest through some of the things I was reading. Like St. Augustine’s Confessions, and people like Martin Buber and Emmanuel Levinas, and so on. I also, by virtue of being at the College of the Holy Cross, was engaged in dialogue with really smart people who were interested in things like religious experience. Being in dialogue with those people allowed me to see, in some ways, the poverty of some of my previous education because a lot of those issues were kind of ruled out of bounds as being either too religious or just too freaky for psychology. So that’s part of it.

But also, there was experience as such. And, for me, probably the best inroad into my moving in this direction was my own experience of music as both a listener and a player. I mentioned earlier that I’d been a singer in a band many, many years ago; I had played guitar, although not particularly well, for some 40 years and decided to finally take lessons when I was around 60. And I also just had some extraordinarily moving experiences, singing in choirs, and listening to classical music, and jazz and blues, and so on. And it led me relatively early on to ask,  What is this? What is this? And, initially, how can I begin to understand it? And so, I moved back and forth between my own experience and also encountering some texts that really helped me think differently about these phenomena.

One text that really allowed me to think differently was William James’s book, The Varieties of Religious Experience, which is not only about religion, but it is about things like the experience of nature, the experience of art, the experience of music, and so on.

It’s an extraordinary compendium of experiences of people who are describing a kind of ecstatic oneness with the world. And, James discusses the central characteristics of mystical experience; people have the conviction that they’re discovering new dimensions of knowledge and reality and selfhood, and they also describe themselves as encountering some sphere of reality and being that is outside the perimeter of the self.

In classic James fashion, towards the end of the book, he basically asks, so what is all of this? Are these just really cool and interesting, deep and provocative experiences that, finally, can be understood in a purely psychological way—which is to say, naturalistically? Well, maybe it’s unconscious, or subconscious, cerebration, as he calls it. Or maybe it’s some kind of biochemical phenomenon. He’s also interested in the issue of why it is that so many people who have these experiences also have significant elements of psychopathology, including religious virtuosos, mystics, great writers, painters, and all the rest.

So he wants to answer the question. Can all of this be understood in the basic terms that psychology has formulated? Or might it be the case that there’s something else at work? He doesn’t know exactly what that is. He doesn’t know what to call it. He refers, at one point, to spiritual energies.

He offers us an answer in the final pages. He says, Look, I can’t possibly answer this question in any definitive way. All I can tell you is that what experience has revealed to me in multiple ways, throughout the course of my life, and what I’ve learned from other people’s lives, is that there may be more to human beings than a purely naturalistic, wholly secular, so to speak, account can give.

I find that to be a courageous and very provocative move. And I’m not especially religious, so I should kind of get that out of the way. As I said to one psychologist of religion, probably 20 years ago, I said, Look, you need to understand this. I’m a Jewish guy from New York. My wife is a Lutheran who’s basically become a Buddhist, and my kids are confused Unitarians. So, I’m not trying to smuggle in religious dogma through the back door.

What I am trying to do is practice fidelity, radical fidelity, to what experience seems to tell us. There are so many ways in which we can explain things away; we can explain things away biochemically and neurologically. Any one of a number of ways. But at times, I think it’s important to really listen to what experience seems to say.

It also becomes important to find a language to be able to speak to experiences that are not readily articulable, explainable, and so on. And that also means moving into a different register of language, and maybe even moving beyond language altogether, for some of what we do in psychology.

Karter: Part of what I’m hearing, in the answers that you’ve given so far, is that this whole project of the psychological humanities is not just a supplement to psychology. It is, instead, a necessary approach for students, for people learning psychology, to be able to think about how to put the constructs and the narratives that they’re learning together–how to make sense of them, how to hold them lightly, how to make sense of themselves, through different lenses–and then also to be able to sit with others whose experiences seem unknowable or uncharacterizable, or where our language fails us.

I think you demonstrate in your work how this way of thinking about psychology prepares you for witnessing this kind of ineffability. In particular, in your book “Do I Look at You with Love?” you explore your mother’s journey through dementia. Could you share how your background in narrative psychology and the psychological humanities influenced your perception and experience of this deeply personal journey?

Freeman: So there I am as a student of memory, identity, self, and so on, and it was clear that my mother was falling victim to some mild cognitive impairment. That was painful and disturbing, of course, to her and to me and my brothers and our families. But I won’t deny that it also became fascinating. So, relatively early on, I began writing, and I wound up basically writing four or five pieces that paralleled the trajectory of her disease across the dozen or so years of her dementia. And I will say in, in many ways, I see it as a real psychological humanities endeavor. In fact, I go so far as to say that it was probably that book, more than anything, that allowed me to move more from promising the psychological humanities or talking about it in an abstract way to actually doing it.

One decision I made relatively early on was, and some people might find fault with this, I decided not to read very much about dementia at all. I wanted my own understanding to grow out of what it was that I was seeing, what it was that I was observing, and what it was that I was understanding.

So, how do you find the language to do that? I mean, it’s another challenge. It’s not unrelated to the one we just talked about. How do you find language to talk about phenomena that are in some fundamental way ungraspable? But there was another thing I wanted to do in the book. And that is, so much of what I had read was almost exclusively tragic. And understandably so; it’s a tragic disease. And in some cases of dementia, it seems as if there’s no story to tell except a tragic one of deterioration and demise. But that’s not the only thing that I saw in my mother’s experience.

Yes, of course, I saw deterioration and demise, and protest and rage and confusion, and what I call dislocation and lots of other horrifying, painful things. And I also saw beauty and joy and connection of a sort that I wouldn’t have seen had she remained healthy. That’s such a strange thing to say, but it’s true. It’s partly because I spent lots of time with her. And it was time also spent being attentive and being there for her. I’m not trying to portray myself as a caregiver hero; there were times when I left to do other things, and there were times when she would piss me off, or I’d find it annoying or frustrating, whatever. So all that’s part of the story.

But I also, to use the language of the philosopher Levinas, was called out of myself, by the face, by her, by what she demanded of me. And that was an extraordinary process. In some ways, I would consider it a process of my own maturation–being able to set aside one’s own preoccupations, and on some level interests, because somebody is really drawing you outward.

Let me mention one other dimension that really gets to the psychological humanities. I’ve been involved in an enterprise, or at least I was involved in an enterprise for a number of years, called Art Transcending Borders at Holy Cross. The goal of the project was basically to infuse the arts more visibly into the life of the College, and we decided early on that we would have a special class that was devoted to that, and it was called CreateLab.

In the first year of CreateLab, eight faculty were in a theater space together for the entire semester with about 70 students. There was a composer and novelist, a sculptor, two people from theater, somebody from economic sociology, and myself. The theme for that year was “Time, Memory, and Identity,” and the goal was to bring together all of our interests, knowledge, and skills as thinkers, artists, and so forth to shed light on this trio of ideas.

Another year, we had the theme “Looking Backward, Moving Forward,” and it had a special focus on dementia. We had about 40 students that year. They read my book [on my mother]. Another person who was teaching in the class, his mother, is a well-known poet, and she was writing about dementia, partly because this fellow’s father was in the throes of it. There was a photographer who taught at a nearby college whose father also had fallen prey to dementia. And he had done extraordinary kinds of photodocumentary work.

So, we have a work of psychological literature, we have photography, we have music, we have poetry. The goal is for students not just to have the most comprehensive intellectual understanding of this difficult phenomenon that they can possibly have but to also be able to approach it from a myriad of perspectives, all of which can serve to illuminate it and deepen their own understanding of it but also their feel for it in some way.

Karter: So the psychological humanities is an approach that offers a way out of using one way of seeing and understanding the person. A goal is to incorporate different ways of understanding, and it opened up possibilities for you to see other elements of your mother’s dementia, other elements of her person, that otherwise, you might not have been open to.

Certainly, here at Mad in America, we have been focused for a long time on critique of the psy-disciplines broadly, and psychology as well, through critical psychology. So I want to pick up on your final principle, in your book on the psychological humanities, which is Tear Down the Walls (in the Name of Love). You argue that any critique of mainstream psychology should come from a place of love. And so my question, and maybe to end our set here with a love ballad, is “What’s Love Got to Do with It?”

Freeman: You know, for a long time, the kind of rap that I would share with my students took the following form. I would often say to them, my problem really isn’t so much with what psychology does as it is with what it doesn’t do.

So I had no interest in, you know, knocking down this or knocking down that, and for the most part, I still don’t. But I do think that there are aspects of the edifice, so to speak, that really need to be dismantled.

There’s no way to really move ahead, constructively and productively, without a moment of destruction, without a moment of negation, without a moment of critique. But the last thing I would want as a psychologist, and this I do mean, is to simply remain at the level of critique.

Early on in the book, I actually say that if I had to make the choice of being a psychologist again, there’s a good chance that I would do it. Why? Because psychology, at its best — and I know other people have entirely different images of what “at its best” means – is about getting to know other people; getting to really interrogate and explore the human experience imaginatively is a good and wonderful and even potentially noble thing to do.

So I don’t want my work, especially as I move into the closing years of my career, to be animated primarily by hostility, or for that matter, even critique. I want to do it with a sense of what the discipline might be, or at least a portion of it, what it could be, what I believe it should be. And that requires care. It requires patience. And, on some level, it requires love. But I really don’t mean love in a kind of mushy way.

I make some mention of Iris Murdoch towards the end of the book, and she has some remarkable things to say about love and about Eros more generally. It has a lot to do with being attentive enough to the world to see it, or at least come close to seeing it, as it is.

There are all kinds of ways that we could criticize that point of view; we could say, well, we never get to see it as it is. It’s always informed by our prejudices, and all the rest, and she undoubtedly knows that. Yet, there are ways in which we can become terribly clouded by our understanding of things.

One of the faults of academic psychology is that through its vast arsenal of methods and techniques, scales, and measures, it has beclouded our own encounter with elements of human reality that precede all of that arsenal of instruments. The ability to see human reality and the reality beyond the human clearly, attentively, and with true care for what is other, she suggests, is another way of speaking about love.

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Featured image provided by Mark Freeman: Sculpture of Leonard Cohen in Vilnius, Lithuania

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The post The Psychological Humanities Manifesto: An Interview with Mark Freeman appeared first on Mad In America.

Lewis earned degrees in psychiatry (MD) and Interdisciplinary Humanities (PhD) from George Washington University, and he currently holds an associate professorship at New York University’s Gallatin School of Individualized Study. He also has affiliations with NYU’s Department of Social and Cultural Analysis, the Department of Psychiatry, and the Disability Studies Minor. Additionally, he serves on the editorial board of the Journal of Medical Humanities.

His books include Moving Beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry, Narrative Psychiatry: How Stories Shape Clinical Practice, and Depression: Integrating Science, Culture, and Humanities. He has two books forthcoming: Experiencing Epiphanies in Literature and Cinema and a co-edited Mad Studies Reader. His writing offers unique insights into the hegemonic foundations of mental health and champions the role of narrative in therapy.

His work also actively bridges the gap between academia and on-the-ground initiatives. A founding member of the Institute for the Development of Human Arts (IDHA), Lewis champions a paradigm shift in mental health by facilitating collaboration between advocates, service users, and clinicians.

His profound appreciation for the humanities guides his exploration of mental health, often through the lens of art and literature. By analyzing the lives of figures like Vincent Van Gogh or dissecting Chekhov’s narratives, Lewis encourages us to rethink and expand our understanding of psychological experiences.

Join us as we explore the philosophical foundations, practical implications, and transformative potential of his work.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: You live at a pretty unique intersection with medicine and psychiatry on the one hand and the humanities, philosophy, and disability studies on the other. How did you find yourself walking these two roads simultaneously?

Bradley Lewis: Well, I guess it goes back to — I originally trained in medicine and psychiatry. I did my residency in psychiatry in the 1980s. It was a time when psychiatry was toggling back and forth between the biomedical model and the psychoanalytic model. I was at George Washington University, and our department had the last standing psychoanalytic chair.

I was very impressed with how the two worlds of bio-psychiatry and psychoanalysis created wholly different ways of understanding. In one, you look for causal, mechanical understandings and then apply biological interventions. The other is much more about humans, more meaning-oriented, and it’s through talking.

I found this dichotomy so fascinating, and it seemed nobody in psychiatry was really discussing it. So, I ventured across the campus and began taking classes in philosophy, literature, the arts, and anthropology. I wanted to grasp what it meant that these two distinct ways of making sense existed in psychiatry. I believed that by turning to the arts and humanities, we could expand our understanding of this range of possibilities. As a result, I pursued a PhD in Interdisciplinary Arts and Humanities.

I felt a problem with psychiatry was that it was over-disciplined. Even psychoanalysis, it seemed, was narrow. People mainly referenced other psychoanalysts. It was a world where there were clear foundational figures, and most of the readings in psychoanalytic classes were from other psychoanalysts. I wanted to step outside those confines. Hence, I pursued this Interdisciplinary PhD, and I’ve been bridging these domains ever since.

Interestingly, there are a few interdisciplinary academic programs out there. New York University has one called the Gallatin School of Individualized Study. It’s for people who feel that while depth of discipline is crucial, we have many specialists and not enough individuals connecting the dots across fields. Gallatin is a place that values this. I joined their faculty, and on one day of the week, I practice psychiatry.

Karter: It seems that one of the clear benefits of your interdisciplinary training, as evident in your work, is the ability to view psychiatry through the lens of other disciplines. This approach situates the diverse ways of thinking in psychiatry within broader ideological and political movements. I’m particularly drawn to your work on post-psychiatry. Could you expand on how you’ve come to conceptualize what post-psychiatry is? Furthermore, how does this interdisciplinary and philosophical approach allow us to perceive psychiatry and the mental health fields from a unique perspective?

Lewis: During my PhD in Interdisciplinary Arts and Humanities, post-structural theory and postmodern philosophy were very much the common languages. Interdisciplinary thinkers like Foucault, Derrida, Lyotard, and Julia Kristeva were seen as having insights relevant to many disciplines. I felt that their perspectives were incredibly pertinent to psychiatry.

Rather than viewing psychiatry as a modernist discourse, striving continuously towards an objective truth, postmodern theory encourages us to perceive psychiatry as a means of formulating useful meanings to navigate the world. This perspective emphasizes not just the meanings themselves, but also the individuals involved in creating them. It raises questions about power dynamics: Who gets to participate in this meaning-making process?

This is evident at the point of service, when a patient might be asked if they prefer electroshock therapy, psychoanalysis, or family therapy. Moreover, it probes deeper, asking who has a voice in shaping the foundational knowledge of psychiatry. I believed that postmodern theory could broaden psychiatry’s vision, allowing it to transition from a singular viewpoint to a multi-lensed perspective. Thus, post-psychiatry aims to establish the foundation for such an interdisciplinary approach.

Karter: From this perspective, psychiatry is not just seeking the truth about the cause of mental illness; it’s actively engaged in the process of interpreting mental distress and determining who gets a say in that interpretation. Post-psychiatry introduces these questions to the field. So, when we view psychiatry through this lens, what answers emerge? What do we discern about psychiatry and the mental health fields when we question the nature of the meanings they produce and for whose benefit?

Lewis: Well, I think the first thing that becomes apparent is the tremendous diversity of perspectives and how the modernist logic – that one view is correct while all others are mistaken, or one holds the truth while others are myths – doesn’t quite stand up. Once you acknowledge that no single perspective is inherently superior, you’re forced to consider how decisions are made.

Currently, these decisions often rest with those in positions of power. This insight fundamentally challenges the established structure of psychiatry, arguing for the inclusion of a broader range of voices. However, post-psychiatry doesn’t necessarily dictate where psychiatry should head or its final form. It doesn’t claim the mainstream is the wrong path, but rather that it isn’t the only valid one. It doesn’t denounce checkers as a game but argues it’s not the ultimate game. The emphasis shifts to inclusivity and ensuring fairness within this diversity.

Karter: One challenge I’ve encountered in my work is balancing a critical, overarching viewpoint of the role mental health fields play with the tangible impact on individual client interactions. Your work on narrative psychiatry intrigued me, particularly how you’ve bridged post-psychiatry and critical psychiatry with your actual practice of psychotherapy. Could you elaborate on this? How does narrative psychiatry shape your clinical practice? And how might your approach differ from someone not influenced by narrative theory or a post-psychiatry perspective?

Lewis: Indeed, I find narrative theory immensely helpful. It distills complex philosophical issues like language and power, grounding them in the tangible realm of available language options we use to narrate our stories.

When confronted with a mental difference or distress, we lean on narrative tools to articulate our experiences. Key among these tools are metaphor, plot, character, and point of view.

Metaphors, in particular, are intriguing. Many models describing mental differences hinge on foundational metaphors. Terms like “broken brain,” “childhood trauma,” “unresolved grief,” and “family dysfunction” come to mind. Then there are also the more celebratory metaphors, likening someone to an artist with heightened sensitivity, attuned to nuances others might miss. These metaphors help us frame our past, interpret our present, and envision our future.

In mainstream settings, there’s often an unconscious reliance on these metaphors to guide understanding. For instance, the prevalent “chemical imbalance” narrative might lead to recommendations like medication. It becomes a default narrative, often adopted without deeper reflection.

By incorporating narrative theory, the therapeutic process becomes markedly collaborative. The individual, whose life and story are central, assumes a pivotal role in shaping their narrative. This approach delves into the specifics of an individual’s life, juxtaposed against broader philosophical frameworks of post-psychiatry. It’s about discerning how best to structure one’s life journey.

Karter: I’m curious. When you’re working with a client who has latched onto a metaphor, like the “broken brain” metaphor — which holds considerable cultural sway and is often endorsed by the psychiatric establishment and even pharmaceutical companies — how do you approach it? If you believe their adherence to this metaphor is hindering their progress, how do you introduce alternative metaphors or suggest a more nuanced understanding, especially when such a metaphor has become integral to their self-conception? How do you handle this in practice?

It really comes down to a dialogue, a conversation. Often, the key decision is choosing between a pathological metaphor and a more celebratory one. Mainstream perspectives, whether they’re biological, psychoanalytic, or cognitive-behavioral, usually imply something is ‘wrong’ or ‘broken’ that requires fixing. But a celebratory or affirmative model views these deviations from the norm more as gifts than dysfunctions. These ‘gifts’ often revolve around heightened sensitivity or profound yearning.

Such sensitive individuals frequently clash with societal norms, leading to advice like “see a therapist” or “take medication.” However, we don’t advise figures like Martin Luther King to be less sensitive to injustice, nor would we tell spiritual leaders to suppress their profound insights. Artists, too, are celebrated for their heightened sensitivity.

The fundamental question then becomes: Are we overly pathologizing this trait? Or is it a form of sensitivity that, though not always comfortable, offers a depth of understanding and perception that many might overlook? Recognizing this sensitivity or yearning doesn’t invalidate the challenges they bring, but it reframes them, moving from seeing them as purely negative to potentially insightful and transformative.

Karter: From this viewpoint, it seems that the biomedical metaphor in psychiatry could marginalize or even pathologize political dissent. Your work in madness studies suggests it holds political implications, challenging psychiatry to be more receptive to critiques from service users, peer specialists, social activists, and journalists, like those of us at Mad In America. Could you elaborate on the role of madness studies and how it might pave the way for more democratic practices within psychiatry?

Lewis: Absolutely. Mainstream psychiatry, as illustrated by platforms like Mad In America, has often been a point of contention. Many individuals have felt harmed by traditional psychiatric practices and have organized as activists to challenge or modify its influence. If you attend an American Psychiatric Association event, you’d often witness a protest movement outside. If these protests are only interpreted through a pathological lens, we risk missing the deeper insights these activists offer on how psychiatry could evolve.

This shift can be better understood when aligned with other societal difference issues like racism, sexism, homophobia, ableism, and sanism. While sanism might not yet be as widely recognized, it mirrors the same insidious othering and subordination based on prejudice.

Mad studies, much like gender or disability studies, aims to improve conditions for those marginalized because of their differences. Rather than focusing on changing the individual, the emphasis is on transforming society to be more inclusive and appreciative of diverse perspectives. This also fosters a coalition between activists seeking psychiatric reform and academics, who, through intersectionality, have been considering issues of race, sex, gender, and ability. Incorporating sanism into this intersectional understanding is a logical progression.

Given the rise of disability studies, which now encompasses mental and cognitive differences, the momentum for mad studies continues to grow. It’s about channeling already established understandings of ‘difference’ in academia towards areas that have yet to receive as much attention.

Karter: You’ve alluded to the protests outside the American Psychiatric Association meetings. This leads me to wonder, instead of a divide between protestors and psychiatrists, is there a way for dissenting voices to have an influential seat at the table and help shape the future of psychiatry? What might an American Psychiatric Association meeting look like under a more democratic framework in psychiatry?

Lewis: As it stands now, psychiatry hasn’t been particularly open to that idea. Ideally, there’d be more organized democracy, inviting different stakeholders. The individuals impacted by the knowledge base of psychiatry span much wider than just psychiatrists.

Taking from the disability studies mantra, “nothing about us without us,” those who are affected by the knowledge – be it service users, family members, or even community members – should have a say in how that knowledge is created. But, traditionally, psychiatry hasn’t been open to this democratic approach. Philosophically, psychiatry holds the view that good knowledge is tested through empirical methods, not necessarily shaped by democratic consensus.

So, democratizing knowledge might come through alternative means. Maybe through grassroots organizing, platforms like Mad In America, or even the arts, which provides a vast and rich exploration of the human experience. While there currently isn’t a structure in place to invite such diverse stakeholders into the process, it’s a vision worth pursuing.

Karter: That’s an excellent segue. I wanted to ask you about the Institute for the Development of Human Arts (IDHA). It’s an alternative outside of the medical model, addressing mental health and distress by aiming to bring a new discourse through democratic collaboration among advocates, service users, and clinicians. As a co-founder, could you tell us how this organization began? What’s the vision there?

Lewis: Certainly. IDHA represents a shift in the activist community from just critique to reimagining in many ways. Critique has its place and remains a significant part of various protests. However, as time has passed, many critics began to ponder the potential—what services might they prefer? How might Mutual Aid tactics be applied more broadly?

Even SAMSA began to realize the value of incorporating those with lived experience into hospitals and clinics. The idea is that without these firsthand perspectives, there’s a risk of alienating certain individuals.

IDHA’s aim is to curate curriculums that address what’s been overlooked or what stakeholders believe should be discussed more. And it’s not just about including those with lived experiences. The goal is to make them well-informed. If we train peer workers only in the mainstream, then their perspectives won’t differ from it. So, the question becomes: what kind of foundational education would benefit both the mainstream and peer workers?

IDHA’s inception involved activists. Jazmine Russell, with her educational background at NYU and her personal experiences in community mental health, teamed up with Peter Stastny, a long-time reform-minded psychiatrist. The Icarus Project, which was evolving to be more proactive in building knowledge bases, had many members get involved.

So now, it’s more than just protests. It’s about presenting new ideas and methods, promoting democratic procedures, and understanding the essence of Mutual Aid.

They employ a mix of strategies to stay operational. Some content might come with fees, others are offered free, and some are backed by grants. They’re not aiming for exclusive knowledge or profit. The goal is to disseminate information as widely as possible.

Karter: At the Institute for Development of the Human Arts, there’s an emphasis on how the arts and humanities can reshape the mental health field. Similarly, you’ve recently discussed the mental health humanities or the psychological humanities as potential ways forward. I’ve also noticed you referencing Vincent van Gogh as an illustration of how art and history might challenge our perceptions of mental difference and disability. Can you share more about that case and what insights Van Gogh provides regarding mental health?

Lewis: Indeed, the arts, broadly speaking, represent an interdisciplinary space that encapsulates the vast range of the human experience. It contrasts with my training where, even though I was exposed to varied perspectives like psychoanalysis and bio-psychiatry, the narratives often fell short of capturing the holistic nature of individuals’ lives. When people share their struggles, they don’t confine their stories to a single discipline. Their stories blend biology with spirituality, childhood memories with current political events, and so much more. The arts have always provided a platform for such multifaceted narratives, outside of academic silos.

From the arts, we can both learn and find therapeutic avenues for ourselves and our communities. Taking Van Gogh as an example: no matter how you interpret his life, his profound sensitivity stands out.

If you visit the library and research books on Van Gogh, roughly half might pathologize him, offering various potential pathologies. The remaining books often celebrate him, suggesting we can learn from Van Gogh, seeing him as a beacon in our lives. He isn’t necessarily broken, but rather, someone who can heal. Many aspects he was sensitive about resonate with topics we discuss today.

Early in his life, Van Gogh was drawn to religion, influenced by his father’s religious vocation. He harbored deep sympathy for the poor and suffering, aspiring to elevate their spiritual consciousness. Over time, his focus shifted more toward a spiritual and natural connection than a strictly theological one. Still, his art emanates an indescribable spiritual connection.

I attended a Van Gogh retrospective at MASS MoCA a few years ago. The atmosphere was electric. Attendees were captivated by his work, especially those iconic swirls. Moreover, Van Gogh was acutely sensitive to issues of inequality and oppression. His artwork often features the downtrodden or marginalized. He belonged to a post-French Revolution era where artists believed that to instill dignity in every individual, change needed to be channeled through the arts as well as politics.

For us to truly value and dignify every individual, our perception must change. Van Gogh’s work aids in recognizing the intrinsic worth of all, regardless of social status.

Of course, another aspect he was deeply sensitive to was the transformative power of art. Art has the potential to reach and profoundly touch people, serving as a medium to convey deep understanding. While his sensitivity was undoubtedly a gift, Van Gogh also faced considerable suffering and challenges. So, how do we interpret Van Gogh? Do we pathologize him or celebrate him? Which lens do we choose? His life presents a myriad of interpretative possibilities.

We can’t truly know how Van Gogh would want his life to be understood. If we consider the Van Gogh within each of us, how would we wish our stories to be told? Different individuals will have varying perspectives. It’s not about pinpointing a singular “truth” of Van Gogh as a celebration or pathology. There are numerous interpretations, and the ones we embrace influence how we view life. These aren’t merely philosophical considerations but also decisions about our personal identities and how we choose to navigate our lives.

Karter: It seems like the depth and complexity of Van Gogh’s work sort of confounds our ability to impose a readymade model on him to understand who he was as a person. We can examine his biography, viewing it through various lenses, but then we also have to wrestle with his art, which encourages us to perceive the world differently—perhaps even as he did for a time. The way of seeing and being that his work invites us to makes plain the utter futility of simply applying a diagnostic label or some sort of shallow metaphor to make sense of his life. It pushes us to think beyond the immediate frameworks we typically use to interpret the world.

Lewis: Yes, and I think that’s right. I believe it’s largely because Van Gogh had a distinct voice. I mean, as Foucault said, the history of psychiatry is framed as the “monologue of reason.” And Foucault highlighted that once experts begin to give their verdicts, other voices are muted. But with Van Gogh, you hear him through his art. It’s not just the expert’s voice that prevails; with his art, there’s a powerful dialogue. His work has such weight that you simply can’t dismiss it.

Karter: In addition to Van Gogh, you’ve offered analyses of several of Chekhov’s short stories to call for a deeper appreciation of the complexities of the lived realities of depression and melancholia. Is there a particular story you can present for us to illustrate your point?

Well, when considering medicine and psychiatry, Chekhov emerges as a profoundly useful model. In him, there’s a rich interdisciplinarity. On one side, he’s a medical physician, trained, practiced, and deeply rooted in the medical realm. Conversely, he’s an acclaimed short story writer and playwright, revered nearly to the level of Shakespeare in terms of his influence on theatre arts and short stories. This duality allowed him to perceive the world through the lens of medicine while simultaneously viewing it through the language of art.

Indeed, Chekhov’s work features many doctors, each with their own unique perspective. They don’t represent a monolithic voice. In Chekhov, we find someone deeply invested in medicine, yet he understands that it represents just one viewpoint among many. A doctor’s narrative isn’t necessarily an unfiltered reflection of reality.

Moreover, Chekhov himself faced significant hardships. He grappled with personal despair and sadness and succumbed to tuberculosis at a young age. His writings hint at a spiritual depth that’s rare in a secular world. He was keenly aware of societal injustices, and his stories often highlight humans striving amidst overwhelming challenges.

In a recent paper that Jussi Valtonen and I wrote, we analyzed Chekhov’s story “A Nervous Breakdown.” The story centers around a young law student who is acutely sensitive to oppression. More so than his peers, which include a medical student and an art student. As they spend an evening at a brothel, he becomes deeply disturbed by the blatant oppression in the sex worker trade. This heightened awareness leads him to a breakdown. But should we view this heightened sensitivity as a negative trait? As we’ve discussed, while such sensitivity can be admirable, it can also be overwhelming.

And when he consults a clinician, the approach is solely scientific. This overlooks the depth of his despair and offers him a rather superficial treatment, neglecting the complexity of his experience. This is highly relevant to today’s context.

Karter: And specifically, in your recent book, you explore depression and melancholia through the lens of the humanities. How does the depiction of depression differ from the clinical perspective when you delve into the works of Chekhov for insights on melancholia, or study Van Gogh’s pieces to understand suffering? How would you define or describe depression? I’m hesitant to even use that term, but what alternative understanding of that experience do you present?

Well, when we ask, “What is depression?” we must remember that it’s essentially a term. History offers a lens to challenge our current understanding. Examining the historical record reveals diverse interpretations of what we now refer to as melancholia or depression. Notably, it’s not always the same concept, even though the name changes. Each label slightly shifts its definition. For example, the term “melancholia” originates from the idea of black bile, rooted in the ancient humoral system. Today, the notion of bile seems foreign and nonsensical to us. It was thought to make people sluggish and heavy. But did we label people as sluggish because we believed they had an excess of black bile? Or did the theory of humors lead us to categorize individuals based on observable traits, such as that which matched our concept of black bile? It appears that we often categorized people based on these theories as much as the theories were based on observed behaviors.

We all have unique belly buttons and ears, but we don’t use these differences to segregate spaces like bathrooms. There are myriad ways we could categorize ourselves. Terms like “melancholia” appear to originate and then evolve, shifting over time.

Considering history, cultural diversity, subcultural nuances, and the arts provide diverse lenses to challenge a monolithic interpretation. The question then arises: How can both our mental health system and individuals striving to understand themselves do justice to these varied perspectives?

Karter: I’m intrigued by your perspective on the future trajectory of psychiatry and mental health fields. With the rise of social media and organized movements, we’re seeing a diversification of narratives. These range from neurodiversity and psychoanalytic concepts to biomedical terminology. People are shaping their self-perceptions and forming communities around these narratives. Do you think these emerging perspectives challenge traditional psychiatry? Is there potential for a more democratic inclusion of these diverse voices? How optimistic are you that the field will genuinely welcome these perspectives?

Lewis: I’m genuinely optimistic. The dominance of the biomedical model seems to be waning. Entities like Mad in America, academic contributions, and protest movements have all played roles in this shift. The lived experiences of many underscore its limitations. Additionally, the financial incentives behind this model are changing, especially as fewer products remain under patent. It feels like we’re entering a phase where the conversation is broadening. There’s a renewed interest in psychotherapy. Moreover, with the emergence of fields like Disability Studies and now, Mad Studies, more individuals are becoming aware of the diverse perspectives available.

I’m drawn to the concept of mental health humanities. Similarly, psychology is exploring areas like psychological humanities. Throughout my career, I’ve engaged in interdisciplinary areas such as medical and health humanities. These fields question how medicine and broader healthcare can harness the arts and humanities to enhance clinical empathy, understanding, and narrative competency. The appealing aspect is that this integration doesn’t necessitate a complete overhaul. You don’t need to entirely replace the biomedical model. In medicine, it might be a matter of supplementing the existing model with fresh perspectives and offering additional certifications, courses, and programs. Essentially, it’s about infusing an appreciation for the arts and humanities within the healthcare community. Moreover, considering the prevalent burnout and emotional fatigue among healthcare professionals, the arts and humanities could play a role in rejuvenating their sense of purpose and meaning.

I appreciate the concept of integrating the arts and humanities into the realm of mental health. It would be beneficial for psychology, social work, and psychiatry departments to incorporate aspects of the arts and humanities. Some faculty members should have ties with these disciplines and specific classes should be dedicated to them. This would foster a more diverse and less monological perspective.

Karter: Thank you. Before we conclude today, are there any final thoughts or anything else you’d like to share with our readers or listeners?

Lewis: Actually, I believe we’ve covered a lot. Justin, I’d be interested in interviewing you someday. I genuinely admire what Mad in America is accomplishing, and I appreciate your initiative in amplifying diverse voices. This, in my eyes, is truly a form of democracy—making sure multiple perspectives are heard. Overall, I feel more celebratory than anything.

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MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.

The post How Mad Studies and the Psychological Humanities are Changing Mental Health: An Interview with Narrative Psychiatrist Bradley Lewis appeared first on Mad In America.

A columnist for the Independent, and a former editor with the Guardian and gal-dem, she also founded Blueprint, a magazine exclusively dedicated to mental health issues. Frazer-Carroll has emerged as a formidable voice in challenging the orthodox, often apolitical, interpretations that pervade psychology and psychiatry.

Her new book, “Mad World: The Politics of Mental Health,” released by Pluto Press, is a rigorous dissection of mental health as a profoundly political issue. In its pages, she situates our understanding of mental health within the larger constellations of capitalism, systemic racism, disability justice, and queer liberation, among other frameworks.

“Mad World” is a revolutionary manifesto, probing into the possibilities of empathic care and a reimagining of what we mean by mental well-being. Critics have lauded it as a “radical antidote” to the prevailing paradigms that dictate our attitudes toward mental health. It serves as an indispensable primer for those seeking to subvert the status quo in their respective fields.

In this interview, we engage with the intricacies of “The Radical Politics of Madness” and explore what it means to reframe mental health as an urgent political concern. We discuss the potential of radical political thought to liberate us from the restrictive lexicon and institutional constraints that often encase our understanding of mental health.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: I think it is helpful to begin by discussing what we mean when we talk about the politics of mental health. Many attempts to connect mental health, mental distress, and madness to political realities connect the material effects of poverty, oppression, and dislocation to the development of psychological disturbance. However, you deliberately push beyond this approach. You write that “a truly political approach cannot only look at causes of what we call madness and mental illness. It must also be constructivist – interrogating the very concepts of madness and mental illness themselves…” Can you begin by explaining your approach here and how being constructivist illuminates the political complexities of mental health work?

Micha Frazer-Carroll: Definitely. So I should start by saying that I think it is really crucial, as you mentioned, to situate mental health and our experience of distress within a political context. We must ask how forces like neoliberal capitalism, racism, homophobia, transphobia, and ableism shape who experiences distress and how it is experienced. I believe that’s really important.

But as you mentioned in the book, I try hard to push beyond just asking, “Why are some groups disproportionately likely to experience mental distress?” Instead, I ask, “What is this thing that we call madness or mental illness, and how did we come to think of it this way?” The reason I think this inquiry is necessary for a radical political approach is that when we start to question and examine the history of when certain things became categorized as madness or mental illness, we see that political forces, explicitly capitalism, play a significant role in defining who is seen as mentally well or ill, and who is seen as mad or sane.

Unless we examine these political conditions and explore how we came to define the things we call madness and mental illness as such, I think we can’t truly take a political approach. We must unpack and ask, “Could it look a different way in a different world?” and “Is the way all of the people that are usually categorized societally into these groups consensual, and is it actually good for them?” That’s why I believe a political approach demands this focus on the social construction of these concepts.

Karter: So you’re pointing out the fact that the very language we use, the words like “madness,” “mental distress,” in the mental health fields, each contain within them a lot of ideological, philosophical, and historical baggage. In the book, I see you both working within the existing language—because that’s what we have—but also trying to challenge it and create new ways of talking and thinking. For example, you make a point of talking about “bodyminds” as one word. Can you tell us what this means and how it challenges our usual discourse and our ways of thinking about the mind in mental health?

Frazer-Carroll: As you say, language is so potent in this area, and I really agonized over the use of certain terminology. Much like “Mad In America,” my book is called “Mad World,” and “madness” is right there in the title. But to some people, that’s seen as controversial. At the same time, “mental illness” comes with a lot of baggage and ideology that’s woven into that concept. I use the term “bodyminds,” which you point out, and it’s another one that I agonized over. At first, I thought it might sound too jargony, but then I decided to go with it. The use of the word “bodyminds” unites “body” and “mind” in one word, trying to gesture towards the idea that we often think of the mind as a completely separate domain from our physical bodies. This separation is rooted in Mind-Body dualism, the idea that they’re not intertwined. I wanted to push against this for several reasons.

I think one reason is that even in the critical mental health space, I sometimes see evidence of this dualism popping up when people say things like, “Mental health is constructed, but physical health is real,” or “Diagnosis isn’t valid for mental health, but is for physical health.” I tried to muddy the waters a bit by saying “bodyminds,” and gesture towards the fact that not only psychiatry but also the medical industrial complex, all our ways of thinking about biomedicine and diagnosis, for example, are grounded in a political context. I think when we analyze the mind and the body, or psychiatry versus medicine, we need to acknowledge that there’s a lot of fluidity between the two, and there’s not a hard split between them.

Karter: In the book, there was a quote that stuck out to me where you said that illness—and I think you’re alluding to both physical and mental “bodyminds”—illness is a way of being or an identity necessitated under capitalism. Something to that effect; is that right? Can you elaborate on what you meant by that?

Frazer-Carroll: Yeah, I borrowed this from the Socialist Patients’ Collective, which was a psychiatric survivor and service user collective operating, I believe, in the 1970s in Germany. They have this manifesto called “Turn Illness Into a Weapon,” which has some really intriguing analysis of mental health under capitalism, but also health and illness more broadly. They take this united approach, probably advocates of the body-mind idea, when they talk about mental and physical. They write that illness is unnecessary; it is the only condition that we can have under capitalism, which I think is really apt. 

This theme comes through quite a lot in the book, looking at how, for example, the Industrial Revolution caused not only mass distress, leading to the explosion of the asylum system during this period, but also physical injuries on the production line, people getting sick in crowded city conditions, and so on.

So the concept really is that capitalist work, along with the quest for profit and capital accumulation more broadly, will always harm us; it will always make us sick. How unwell you become, or how much you suffer, is a matter of degree. We’re all experiencing the same forces to an extent.

Karter: You make the compelling case in your book that our current understanding of mental health and madness has been inextricably tied to the demands of capitalist production from the start. For example, you cite laws adopted in the UK in the 1800s that attempted to name and manage the conditions preventing people from living independently and working in factories. Previously, these folks were able to be part of communities and families, contributing in ways no longer seen as employable labor, but now they needed to be named and accounted for. Can you elaborate on how mental health and mental illness have been tied to ideas of productivity under capitalism?

Frazer-Carroll: Definitely. As you mention, I take a U.K. focus in the book, starting with Bethlem Hospital, colloquially named Bedlam, the world’s first known asylum. I examine the fact that in Britain, for the majority of history, people categorized as mad lived in the community, cared for by family or friends. For example, the poor laws were introduced in Britain, stripping funding from families who previously could afford to care for their mad relatives at home. I also consider the dawn of the capitalist economic system and the Industrial Revolution, which coincided with the poor laws, and the shift from community-based production to fast-paced factory conditions.

I explore this emergence of the factory as a key moment in starting to categorize particular people as mad and in starting to institutionalize them. The number of admissions to asylums exploded around this time. A few reasons for this include the stripping of family funding and the need for people to go to factories or workhouses instead of working at home. This shift from a community-based approach to care resulted in many more people being admitted to asylums. In Britain, two asylum acts were passed, mandating the building of what were called Lunatic Asylums in every county.

Many people question why so many were suddenly admitted, and I believe the emergence of capitalism is a key factor. With so many admissions, you see systems of taxonomizing. Initially, there were two main categories, Mania and Melancholia, but over time, narrower and even ridiculous categories emerged, such as politics, novel reading, and immoral life, all considered valid forms of madness. This illustrates who in society was seen as productive.

I argue that those sent to asylums, categorized as mad, were seen as unproductive. They couldn’t work on the production line or be cared for at home. As the book progresses, I extend this argument to how we categorize mental health versus illness today. For instance, Bruce Cohen notes in “Psychiatric Hegemony” that the DSM mentions work 300 times. Work is central to judging what’s considered an illness. The ability to work is a major factor in diagnosis, even to the point where meeting deadlines might negate a diagnosis of depression.

On the flip side, some experiences, such as hearing voices, are pathologized even if they’re not distressing because they’re often associated with a reduced ability to work a traditional job. I try to question whether we could create a world where work isn’t the central metric by which we value people’s bodies and minds. I argue that we should build toward a future that’s more self-directed and less characterized by capitalism.

Karter: You highlight the need to function under specific capitalist conditions that require self-management and hyper-individualism, and you connect this to neoliberalism and the necessity for people to manage their emotions independently. This concept is further tied to how people navigate the world. In your book, you discuss the role of psy-professions in neoliberalism, suggesting that thinking in mental health terms might weaken resistance to capitalism. You note that strike days have dwindled over recent decades while working days lost to stress-related illnesses have surged. You also plainly state that mindfulness is no substitute for a unionized workplace. Can you elaborate on how mental health discourse, psychiatry, and psychology may have played a role in the weakening of labor politics in the U.K. and the U.S.?

Frazer-Carroll: I certainly think it has played a role and intertwined with the diminishing of labor politics. As you mentioned, journalist Tim Adams points to a peak in mass strike action in the UK during the 1970s. This was followed by a dismantling of the labor movement under Margaret Thatcher, and at the same time, the number of days workers lost to “stress-related illness” increased dramatically. Though it’s anecdotal, it illustrates a shift from diagnosing the problem as societal to viewing it as an individual concern. What might have been perceived as a societal disorder becomes an individual one. Cultural theorist Mark Fisher refers to this as the privatization of stress. Under neoliberalism, we see the privatization of many state services and businesses, and Fisher argues that even our perception of stress and political problems has shifted to an individual level.

I do have sympathy for the workers losing days to stress-related illness. This is a very real problem, and policies like those enacted by Margaret Thatcher that targeted the union movement contributed to this situation. However, I also think that we must question our response to these issues. Often, mental health treatment becomes about realigning what are seen as unruly individuals with market demands. This approach is both individualistic and retrospective.

What’s insidious is how this approach has permeated workplaces. Many people can now get free therapy or mindfulness apps through their work, and while these remedies can be helpful to some, they are inherently individual. By beginning and ending our analysis at the individual level, we never reach the political core of the problem. It also leads to blaming individuals for suffering caused by our economic system.

A British service user collective, Recovery in the Bin, aptly named, points this out. They argue that the individual recovery model adopted by services is flawed. They insist that under current conditions, full recovery may be impossible for some, and pretending otherwise places blame on individuals for problems they didn’t create.

Karter: So it appears that mental health discourse – not just mental health treatment itself, but how psychological constructs spread to become a discourse that people use to make sense of themselves – serves two functions under capitalism. One function is to identify and isolate those who can’t function within the system and those who won’t be productive and find a way to move them out of the labor market. The other function is a sort of recovery process that helps cultivate people to be the types of subjects that can continually show up to work the next day, even if it is alienating, extracting, or causing illness, as you say. It thus prepares the labor market to be exploitable under capital. 

This is particularly interesting to think about in light of the global mental health movement, as it seems to spread this discourse globally, preparing subjects from different cultural backgrounds to be used. Could you say more about the global mental health movement and how ways of thinking about ourselves – or even ways of experiencing spiritual practices, as you mention – can be categorized and treated as pathology? How does this impact populations globally when we’re spreading this particular neoliberal Western mental health discourse?

Frazer-Carroll: Yeah, in the book, I draw on the work of Dr. China Mills to critique the Global Mental Health Movement, which essentially exports psychiatric ways of thinking across the world. 

I examine various examples to understand how psychiatry operates cross-culturally. For instance, I look at a proposed diagnostic category in the 19th century called Drapetomania, proposed by a physician named Samuel Cartwright. The symptoms were when enslaved Black people would run away from the plantation, and the prescribed treatment was beating or whipping. We can now see this as ludicrous, but it reveals what was expected of Black people at the time to make them exploitable.

One clear modern-day example comes from my experience with my communities and my family in Antigua and Jamaica. In Antigua, my family was involved in the Pentecostal church. In that context, spiritual experiences like hearing the voice of God or speaking in tongues were not only tolerated but encouraged. This is significant when considering the disproportionate number of Black people diagnosed with schizophrenia. While racism and trauma may play a part, we must also examine the construct of the diagnosis itself and recognize that specific populations may be disproportionately diagnosed.

In the book, I also discuss the stereotyping and construction of schizophrenia in line with ideas of criminality, with terms like “hostile” and “aggressive” in the diagnostic criteria. This can’t be separated from the fact that Black people, and Black men specifically, are disproportionately diagnosed and also stereotyped as hostile, criminal, and aggressive. I try to look at how exporting diagnosis across racialized populations and across the globe leads to marginalized and global majority people being pathologized in unique and disproportionate ways.

Karter: You’ve emphasized the widespread suffering in communities and the need to be cautious with the language used to describe it, avoiding a solely Western, neoliberal view. This leads me to consider the different interpretations of mental distress within various mental health fields and among activist and identity groups. In your book, you propose a more inclusive approach, focusing on the diverse ways people experience and describe suffering. You suggest this could foster solidarity among groups such as those identified as mad, neurodiverse, neurodivergent, psychiatric survivors, or psycho-socially disabled, and others opposing mainstream views. Could you elaborate on this epistemological approach and explain how it might facilitate unity among these different groups?

Frazer-Carroll: The argument I made in the book was indeed risky, as it’s a contentious issue. Questions like “Is it an illness? Is it society? Is it distress? Is it all capitalism?” are personal and often controversial. These topics can become heated in mental health and mad spaces. Like you mentioned, I draw on the work of Jonah Bossewitch from the Fireweed Collective, arguing that the heart of the matter may not be about finding an objective truth, such as whether it’s biological or social. Instead, I believe in many possible realities where people can have autonomy over how they define their experiences without being non-consensually pushed into specific frameworks or languages.

What I find insidious about psychiatric knowledge is how it’s presented as objective, like all medical knowledge. I believe in the validity of lived experience, and survivor knowledge, and that there can be many possible truths. Your suggestion about trying to come together and find solidarity resonates with me. Conflicts can arise, for example, between the neurodiversity movement, which often reclaims psychiatric language, and the psychiatric survivor or mad movement tradition, which generally rejects this terminology. I hope for a future where we can unite these perspectives, creating a coherent politics that resists psychiatric power, allows creativity with language, and emphasizes survivor agency. Whether we use terms like mad, mentally ill, neurodivergent, or psychosocial disabilities, the central principle should be our agency over how we define ourselves.

Karter: This aligns with my research into psychosocial disability, a construct that different activist groups are using to unite, discuss, and resist mental health discourse. One consistent result I found was an agreement not to challenge each individual’s definition of how they became different, neurodiverse, or mad. They recognize that society’s labeling or exclusion based on that difference created the disability, discrimination, or inability to fully participate in life. Despite various understandings of the origin, there was an ability to unite to fight against the conditions that produce disability among those struggling. Do you see psychosocial disability as a potential umbrella term or a philosophy that can unite these different groups?

Frazer-Carroll: Well, firstly, I want to expand on what you just mentioned, because it’s very relevant. It links to the notion that we often feel a need to find the cause or origin of mental differences. This can be seen as a psychiatric, medicalized, or scientific approach—seeking a blood test, brain scan, or objective measure. I’m arguing, like you, that madness, mental illness, or disability operates as a social experience. As for psychosocial disability, I think it could be an effective bridge, recognizing the possibility of both or an interaction between various factors.

Also, I appreciate the use of the word “disability,” as I have a constructivist and social model approach to it. This acknowledges that disability isn’t an inherent biological fact but is instead about societal conditions that hinder participation. I like the term because it leaves space for this approach, recognizing that disability is not inherent but constructed by our living conditions. Simultaneously, I know that for some, the term “disability” might be difficult to claim or reclaim, perhaps due to existing marginalizations or the fear of increased stigma. There are debates around this word, but for me, it’s a term that I find fitting and appealing.

Karter: I’m trying to think about how we can move beyond these terms, a task I find difficult even in this conversation, as we strive to discuss these issues without invoking mental health discourse. It’s always lingering in the background. But you end the book on a hopeful note, outlining several alternatives to the status quo that could revolutionize our approach to madness. Going further, you push us to envision a world beyond the psychiatric discourse we’ve all inherited. So, first, I want to ask you, what alternatives give you hope? What stood out in your reading and research? Secondly, what might a world look like where we can think beyond and without this psychiatric discourse?

Frazer-Carroll: Yeah, I want to emphasize that there isn’t a single answer, project, or example that can solve everything. The future of mental health must be plural, relying on millions of unique, hyperlocal, tailored experiments, rather than a one-size-fits-all approach like psychiatry tries to be.

A few examples that I love include the Hearing Voices Network, which takes a de-pathologizing approach to experiences like hearing or seeing things others don’t. Instead of simply eradicating a symptom, usually with psychiatric medication, they explore engaging with the content of voices, finding different ways to relate to these experiences. It’s not about reframing them as positive or good; there are various ways to approach them.

I also appreciate Mad Pride, which represents a liberating, de-pathologizing way of thinking about madness and distress. The resurgence of Mad Pride in the UK and the campaign for psychiatric abolition show that it’s possible to acknowledge the reality of suffering while also taking pride in madness as an identity.

Furthermore, initiatives like Crisis Houses and peer support, especially non-carceral crisis interventions in the States, excite me. They emphasize community and individualized approaches.

For me, a liberated future also means a world where far fewer people reach a crisis point in the first place. We need to move away from institutions, but that alone is not enough. We must also transform the world and the conditions that produce these institutions, creating an environment where fewer people suffer and communities have the resources to care for one another before they become unwell.

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Cover image credit: Edi McGurk

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MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.

The post The Radical Politics of Madness: An Interview with Micha Frazer-Carroll appeared first on Mad In America.

Luis conducted this conversation in his role as an editor of Mad in Mexico. Established in September 2021, Mad in Mexico is not just an extension but an essential limb of the international initiative of Mad In America. Its mission resonates with the core values of challenging conventional thinking around mental health, focusing on the Spanish-speaking communities of South and Central America as well as the United States.

Luis graduated from Universidad La Salle and is now pursuing a master’s degree in Social Psychology of Groups and Institutions at UAM Xochimilco. He is currently conducting research on “Depsychiatrization of Mental Health,” with an interest in the fields of critical psychology, anti-psychiatry, and anti-speciesism.

Luis is in conversation today with Mad in America’s own Justin M. Karter, whose multidisciplinary work stands at the intersection of psychology, philosophy, mad studies, and global mental health. As a counseling psychologist, an Instructor for the Center for Psychological Humanities & Ethics at Boston College, and the lead research news editor at Mad in America since 2015, Justin’s approach to mental health goes beyond clinical practice.

In the spotlight is Justin’s research titled “Inclusion Toward Transformation: Psychosocial Disability Advocacy and Global Mental Health.” This study, completed in August 2021, addresses pressing concerns in modern mental health discourse. It critiques the prevailing Western notions that shape the Movement for Global Mental Health (MGMH) and champions a rights-based perspective, considering cultural, political, and economic conditions.

This interview explores the crux of Justin’s research, examining the transformative potential of an integrated psychosocial disability framework. By interrogating and deconstructing mainstream discourses, this conversation promises to shed light on how we can better serve those with lived experiences of mental distress, transcending traditional boundaries and embracing a more rights-based, inclusive approach. This conversation aims to redefine the way we approach mental health, madness, psychiatry, and psychological suffering, in a world that desperately needs a compassionate, critical perspective.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Luis Arroyo: So, the idea of this interview or conversation is to discuss your dissertation and other articles you’ve written about Global Mental Health, particularly focusing on the relationship established with the psychosocial disabilities movement and activism. Right now, I’m working on a project exploring how activism is driving significant changes in the way we think about mental health. During my research, however, I find myself getting stuck in situations where mental health and psychiatry discourses seem to exploit these circumstances. They base their own narratives on activism, making them appear progressive but in an almost extractivist way.

 When I began reading your articles and thesis, I was inspired. It’s remarkable work, and I thought to myself, “More people need to know about this, read about it, and be aware of these situations.” So I sent you some topics to discuss, along with specific questions. The idea is to see where the conversation takes us, aiming for something more flexible. But the first topic, the one with which I want to start, is “What is Global Mental Health?” Initially, I thought of it as a discourse established by the WHO, a psychiatric discourse. But in the article “The Poison in the Cure,” you made a distinction between Global Mental Health and the WHO.

Justin Karter: Yeah, first, thanks for your interest in this work. I think it’s an important topic that hasn’t received much attention within the psychological and psychiatric disciplines, particularly in the Global North. I mean, the movements of consumers, survivors, ex-patients, scholarship, and activism have been largely marginalized in our professional disciplines. Now, paying attention to the way psychosocial disability, both as an identity and an advocacy framework, has challenged our fields and hasn’t really been acknowledged or talked about as a transformative discourse. So yeah, I welcome more attention to it.

Also, I’m not a person with a psychosocial disability, and I’m a researcher in the Global North. So there are all these limitations to my own understanding that I want to acknowledge. I hope that it can serve as a bridge to some extent, inviting other professionals to make the effort to start to listen to these voices and engage with the scholarship in a way that I think could be transformational for our discipline. It could also improve conditions of treatment for people worldwide.

Starting with that, what is the Global Mental Health Movement? Well, it’s tough to define, right? Because it’s amorphous, and there are lots of institutions involved. There are lots of different conceptualizations and treatment approaches captured within this larger framework of Global Mental Health. But for most, the movement of Global Mental Health is connected to the Lancet Commission. The Lancet is a leading medical journal, and the Lancet Psychiatry Commission report on Global Mental Health has been led by Vikram Patel and many other well-known psychiatric scholars. From the outset, it was also connected to institutional players like the World Health Organization, the World Bank, and even the United Nations Sustainable Development Goals.

The idea, as you mention in the article with Dr. Cosgrove, “The Poison in the Cure,” was that there’s an economic and political incentive globally for improving mental health treatment. The idea was that the Global South has a large number of people that might be suffering from mental health conditions, and these conditions were preventing people from being productive laborers or citizens. This was hampering the Global South’s attempts to increase GDP and reach the economic productivity of the Global North. There’s a lot that’s problematic about this narrative, and we can pick it apart a bit, but that was the economic framing initially. The global community helped to shape mental health treatments in the Global South that would have helped these countries achieve such an economic standard that could improve their conditions.

Arroyo: I was thinking about a situation that you mentioned regarding your own perspective on the field. Since you’re not a person with a psychosocial disability and you’re also a researcher from the Global North, you identified this as a kind of limitation in discussing counter-discourses and various perspectives. You made it clear that this existing condition might influence your viewpoint. Before we continue with the topics, I was wondering if this specific situation made your research more complicated or if it perhaps gave you some advantages. How do you deal with these kinds of situations when talking about psychosocial disabilities without being seen as part of an extractivist system?

Karter: It’s a complicated question, and I think it cuts both ways. As someone with the privilege of being in academic disciplines in the Global North and being a white researcher, society affords me certain privileges. These allow me to impact the discourse in specific ways. I’m taken seriously as a researcher and granted access to institutions that normally exclude people with psychosocial disabilities, such as psychiatric conferences and events from the American Psychological Association.

To the extent that I’m able to faithfully represent the interests of groups that I’m not a part of, I believe I can be influential. It’s important to have allies that help push the narrative forward. However, the risk lies in how my own interests, both consciously and unconsciously, influence how I represent the work. I also have to work within certain constraints in academia or as a graduate student, whether it’s the pressure to publish quickly or to translate the language of those with lived experience into recognizable academic jargon to be seen as a serious researcher.

All these pressures can distort the message in a way that may co-opt it and make it more digestible to the psychiatric or psychological establishment or may lead me to speak for people when they can speak for themselves. So I think it’s essential to be conscious of both sides of this – the ways I can be helpful and influential and how I can leverage my privilege to make space for this movement in areas where space is not being made. At the same time, I must recognize my limitations and the ways in which I might not always be a faithful ally and be open to feedback when that happens.

I don’t think there’s any clear answer except for acknowledging the tensions on either side and trying to take a stand on shaky ground. I had a professor in my master’s program, Bob McInerney, who gave a great lecture on how all our concepts are constructed on shaky ground, but we still have to decide what matters to us, what our values are, and what we’re willing to fight for. So I try to take a stand for what feels right at the moment, even when caught in the paralysis of questioning my role and influence and remain open to learning from my mistakes.

Arroyo: I was reflecting on the moment when I started to read your dissertation, “Inclusion Toward Transformation.” When you discuss psychosocial disability as a counter-discourse against the psy complex, specifically in the Global South, it made complete sense to me. But simultaneously, I was contemplating the particular difficulty you were navigating, being from the Global North and speaking about the Global South. At least from my perspective, when I read it, I felt that you were genuinely respectful of the discourses of people with lived experience.

 Returning to “Inclusion Toward Transformation,” you describe psychosocial disability as an umbrella term that covers psychiatric survivors, mad persons, and other identities. So, do you think there’s a difference in being referred to in one way or another? Does it imply something different, or is it all part of the same identity?

Karter: I think that there are really important differences, and the language we use to understand ourselves and our experiences is super important. The language itself opens up possibilities for understanding how to respond, and it can also obscure other ways of responding. In my research, I found that psychosocial disability, as a term coming from the Convention on the Rights of People with Disabilities in the UN, offers a new framework. It provides an umbrella term that many different people worldwide, with different advocacy experiences and narratives about their mental distress, have embraced. Many of these groups had previously interacted and debated, but some had not.

Not only does psychosocial disability offer a way for people to advocate against psychiatric discourse and act as a counter-discourse, but it also works to bring people with different counter-discourses together, creating productive friction. Often in political organizing, groups that are resisting may splinter and fight among themselves, preventing a unified front against the oppressor regime they’re fighting against. This could happen under the psychosocial disability framework, but it seems, at least from the participants I was able to work with, that there are core conditions they agree upon. They disagree on many things but agree on letting people come to their own narrative about their experiences. They acknowledge that people may have a strong connection to their own story and believe that people should be allowed to have that and revise it over time.

The reason why there’s such a strong belief in allowing people to come to their own understandings is that they didn’t want to replicate the power dynamics experienced in psychiatric settings, where somebody says, “This is what’s going on with you, this is the true story about your psychotic episode.” They don’t want to replicate that dynamic, so they allow room for disagreement and respect people’s process of doing so.

Specifically, you mentioned psychiatric survivors versus psychosocial disability. I see psychosocial disability as an umbrella term that serves a very pragmatic purpose. It’s an identity for some and a legal category tied to human rights discourse and a disability advocacy framework. It offers a way of speaking back to psychiatric practices worldwide that demands an answer, whereas previous discourses like psychiatric survivors, ex-patient, or mad studies could be ignored or marginalized. Psychosocial disability, with its legal significance and support from organizations like the UN, forces psychiatry to respond.

The term psychiatric survivor started in the United States, and one of my participants pointed out that it still centers on psychiatric discourse. If you come from a community that doesn’t have a strong psychiatric history, with no asylums, etc., there may not be something to be a survivor of. People are hesitant to define themselves in opposition to an institution they never really interacted with, and sometimes they wish for more access to treatment within a human rights framework, without imposition or involuntariness. They would like more access to medication, psychotherapy, and informed, culturally appropriate services.

There was some tension about the term psychiatric survivor in the Global South, as it doesn’t always make sense to people in communities without a long legacy of psychiatry, in the same way that it makes sense in the United States as it developed in the 1970s.

Arroyo: I was thinking that the term “psychiatric survivor” is hard to find, at least in Mexico City. I haven’t encountered it easily, and I think that’s because of what you mentioned: there’s not a background of psychiatric abuse in the same way as in the United States. By saying this, I don’t mean to imply that there’s no abuse by psychiatry in Mexico; of course, there is, but it occurs in a different context and situation than in the United States.

I’m recalling that in the United States, the police are more aligned with psychiatric institutions, allowing police to intervene in certain situations. This is something that doesn’t happen as often in Mexico, so I believe these are some of the distinctions explaining why the concept of “psychiatric survivor” is not as commonly used here in Mexico.

Additionally, with the idea of psychosocial disability serving as both a legal category and an identity and having the background of advocacy for human rights or alignment with the UN and the Convention, it is somewhat forcing psychiatry to acknowledge this concept and respond. I think that Psychiatry isn’t really answering to the people with lived experience but rather to other institutions and “authorities” in this sense. So, in that context, do you think it’s possible to discuss mental health outside of psychiatric discourse, or is psychiatric discourse always implicit when we talk about mental health? 

Karter: It’s a good question, and I wonder—and I’m not answering from a point of expertise but from a point of curiosity—whether, as things have become so globalized and the Global North has played such a role in colonizing not just the institutions of the Global South, but the language and concepts, it is becoming less and less possible to exist outside a baseline discourse that has been influenced by Western psychiatric history. There might still be places where that is more possible than others, but I think that at some level, it might be the case that alternatives are held as alternatives rather than primary treatments because the primary approach seems to be this sort of Western biomedical set of concepts or framework.

It’s sort of like asking, are there ways of experiencing sadness or feeling distraught without implicitly invoking the concept of depression, which is rooted in Western language and psychiatric practice? I think yes, but it’s increasingly more difficult not to have that as part of your implicit framework when you’re trying to understand what is going on with your mood.

Arroyo: With that, I just talked with Tina Minkowitz about a book she wrote, “Re-Imagining Crisis Support: Matrix, Roadmap, and Policy,” and in the conversation, she mentioned, “Well, maybe ‘crisis’ isn’t the best word, as it brings us back to psychiatry.” Distress, sadness, even feelings, affections, and perceptions always lead us back to the idea of “Is it normal or not normal?” and “Should we, or can we, medicate it?”

Karter: The notion of emotions being rooted in the individual is consistent with Western enlightenment philosophy. This view posits that feelings are contained within us and are personal possessions rather than manifestations of complex interactions involving our relationships, the world around us, and the material universe we engage with daily. This individualistic perspective can limit our language and understanding, making it challenging to explore more nuanced concepts. For example, how can we articulate what it means for an emotion to be interpersonal or relational, rather than solely an individual experience? This issue goes beyond mere semantics, touching on profound questions about the interconnectedness of our feelings with others as we speak, our shared history, our ancestry, and the various factors present in our interactions. Such a holistic perspective recognizes emotions as dynamic and emergent phenomena, shaped by complex interplay rather than isolated within individual minds.

Arroyo: With that, I’m going back to “Inclusion Toward Transformation” because I think I remember a part in which you mention that advocacy groups in the Global South are defying the idea of Global Mental Health. They argue that it doesn’t take into account the context and political aspects, seeming to focus only on particular situations, as you mentioned. With that in mind, how can we start to think about mental health outside the psychiatric discourse and approach it from a lived-experience perspective? How can we shift the scenario, and what role are advocacy groups playing in making that change possible?

Karter: It’s a great question, and I wish I had a clear answer. I think I have two different lines of thought. One is sort of philosophical, which means that we need to denaturalize psychiatric concepts. In the sense that we examine them, we must recognize that the plural discourse of psychiatry, when speaking about our mind, is speaking about our essence and our natural brain function, as if it has a scientific basis to it. I think we need to continue to challenge that and to open up space for counter-discourses that question these ideas. This way, culturally, we can be open to thinking differently.

The first step is kind of like shaking things up, so we don’t work with assumptions in the back of our mind, such as “we are really talking about a brain disorder, that it’s purely a chemical imbalance,” or things like that. We need to continue to shake that up, and I think people are doing important work on that front so that we’re open to other ways of thinking.

And then I think there should be the institutional change that guarantees the full and effective inclusion of people with psychosocial disabilities, or however, they are defined, but also offers protections against co-option, marginalization, and discrimination within those spaces.

This change must take into account the importance of having people with specific experiences from the local community, culture, and religious background involved in the research. It’s not like you can pick someone with a psychosocial disability from the Global North and have them be part of a panel on Global Mental Health in your local area, like Mexico City, and assume that they’ll know everything. They must also be able to correct for all the misconceptions that occur when applying a Western psychiatric framework to Central America, right? So we also need to be thoughtful about that, and I think that’s something we can do legally, structurally, and institutionally.

We can put safeguards in place and make guarantees about what needs to happen, who needs to be included, and what boxes need to be checked in order for research to be funded, to be in compliance with the UNCRPD, and to align with the Human Rights framework that’s been endorsed by whatever NGO or foundation that is funding the research or the university institutional review board. There are practical things that have been done and can continue to be done to make those kinds of spaces possible and to challenge the discourse in the places where it’s being constructed and developed.

Arroyo: With what you mention, it’s important to give people the chance to participate in these spaces while being aware of the position that people are taking. As in the example, a person with a psychosocial disability from the Global North won’t be the same as a person from the Global South. And I’m starting to think, how can we avoid individualizing these situations again? Because human rights advocacy and the Convention talk about reasonable adjustments, and all that kind of stuff has to be made specifically for every case and situation. It’s not the same adjustment for one person as for another, but rather it takes into account the social context.

I’m thinking about that scenario in a really superficial way. Maybe someone could say, “It’s the exact same thing; psychiatry says that mental health is an individual situation that requires individual treatment, and the Convention says exactly the same thing, but in other words.” So, I know it’s hard to answer, but what do you think about that situation, and how can we avoid that comparison?

Karter: It’s an essential question that underscores a paradox: the human rights framework, though rooted in Western enlightenment and the philosophy of the Global North, has become a powerful tool for advocating rights and inclusion. But like any framework, it reveals certain truths while obscuring others, making some issues clear while leaving others hidden and challenging to advocate for.

Consider the dilemma of harm versus benefit, which might echo psychiatric discourse by asking, “Do the side effects outweigh the benefits?” It’s vital that we continue to interrogate the limitations of the Human Rights framework even as we employ it for advocacy. We may say, “We’re using this framework to improve lives and legal rights,” but we must also recognize that we might be missing critical perspectives within this very approach.

What are the known unknowns? What aspects are we failing to consider because our framework doesn’t even allow us to recognize them? We must actively seek out these blind spots, examining the framework’s edges and asking questions about its limitations, much like you are doing. One notable limitation you’ve identified is the persistent focus on the individual.

The complexity of mental distress requires a multifaceted exploration, considering everything from history, social environment, politics, economics, community, and religious beliefs, to family dynamics. These factors interplay in profound ways, shaping our experiences and perceptions. The existing frameworks, focused on individualistic concepts, struggle to grasp these intricate relationships. We are in desperate need of frameworks that can adequately reflect this complexity, even though they may be messy and difficult to apply.

Prominent thinkers like transcultural psychiatrist Laurence Kirmayer and sociologist Nikolas Rose are already exploring how to develop concepts that embrace this complex interplay. And indeed, these frameworks are often inherent in mad studies and the consumer, survivor, and ex-patient scholarship as well. They are striving to understand the multifaceted influences that shape a person’s unique experience of the world in a specific historical and cultural context.

As we improve our ability to articulate these nuanced frameworks, they have the potential to transform our understanding, even within the constraints of the Human Rights framework, which itself is built on the concept of individual rights. The challenge is vast, but the quest is vital; we must strive to understand the human condition in all its intricate complexity without losing sight of the broader social and cultural landscape that shapes and defines us.

Arroyo: From what you mention, I recall that in the article “The Poison in the Cure,” you discussed the neoliberal system. You emphasized that it’s not merely an economic system, but one that constructs subjectivity, shapes the way we relate to one another, and instills the idea that individuals must take care of themselves. This leads to constant self-monitoring, creating a scenario defined by what could be called biopower.

The pandemic, I believe, has brought this situation to a boiling point. I can’t speak for your experience, but here in Mexico, I was required to fill out a daily report, monitoring my symptoms, such as feverish feelings or other signs of illness, and whether I had received the vaccine or not. This monitoring seems to disguise the underlying notion that the problem lies with the individual rather than society. It promotes the message that if you don’t care for yourself, no one else will, and this thought leads me back to the contemporary emphasis on self-medication.

Currently, we’re witnessing significant discourse on wellness, mindfulness, life coaching, and related concepts that place complete responsibility on the individual. The prevalent message is: “You have the opportunity to change yourself.” Often, this is coupled with the idea of self-fulfillment, productivity, and striving “to be more.” These perspectives have a substantial impact on how we think about our mental health.

In this context, I think that recognizing psychosocial disability allows us to acknowledge and say, “Well, I’m not feeling good right now; I’m feeling stressed, anxious,” etc. It gives us the opportunity to genuinely experience and explore the wide spectrum of emotions that psychiatry often attempts to suppress or manage in some way.

Karter: There are many significant points to consider. First, operating within the neoliberal logic, we see the ideology that fuels capitalism and free markets. This ideology emphasizes individuals who must make rational choices in a market that decides winners and losers. It produces a certain type of person, forms of subjectivity, that permits this ideology to continue to function, allowing societies to “work.” But here, “work” doesn’t necessarily mean producing well-being for people; it means keeping the system running, at least until it destroys enough of the planet that it ceases to function.

When we talk about this individual tendency, it’s essential to recognize that we’re swimming against a potent current. Living in neoliberal societies, it’s challenging to think of ourselves outside of those terms. It’s like escaping history in a way; it’s exceptionally difficult.

The pandemic example is a good illustration of this. One way we can approach a pandemic, or spreading diseases, is through hyper-individualization and hyper-individual responsibility. We’re all required to self-monitor continually, and the government assists us in this by providing systems that enforce this self-monitoring and individual accountability for disease spread.

But we can also envision a world where we think more about the conditions of the environment, the political and community conditions, and the overall health of the community. We might imagine more green spaces, more outdoor environments, and governments providing universal income to prevent people from having to expose themselves to dangerous situations to earn money.

We could think about it differently. The psychosocial disability framework invites us to consider what material and ideological environment produces experiences of disablement for a community or an individual. By articulating these thoughts, they become more susceptible to challenge and change.

If we instead focus on the disability within the individual, thinking about changing what’s inside the person through medication, psychotherapy, or mindfulness, we miss what needs to change ideologically in the community, country, and world. We overlook changes needed in the physically built environment, such as access to green spaces, community areas that lead to healthy relationships, and rights that prevent discrimination, oppression, or bullying.

This shift in perspective, while seemingly simple, can reveal pathways toward challenging and transforming our existing structures.

But we must remember such a transformation is not aligned with the goals of neoliberal ideology. It may create communities that do not fit neatly into existing molds, that challenge rather than comply. And in that challenge, in that willingness to think and act differently, lies the profound opportunity for change.

Arroyo: I remembered a quote you mentioned in both “The Poison in the Cure” and “Inclusion Toward Transformation.” It’s from Rose and asks, “What kind of creatures do we think we should become?” You present this question as one that should challenge us, moving us beyond merely changing ourselves and leading us to consider how we might transform others and effect collective change.

I also wanted to mention an example you used in the article, where you discuss the Syrian refugee situation. You describe it as not merely a “loss of their minds, but a loss of their worlds.” Yet, the only alternatives we offer are medication and therapy, without any effort to change the material situation of the people. It’s as if we’re saying, “The problem isn’t that you had to leave your country because it was being bombed; the problem is that you’re sad, so as long as you’re not sad, everything is okay.” This leads me to ask, do we really want to become creatures that deny these situations and the experiences of others?

Additionally, and I recognize this is a complex question, what role should mental health professionals take in this new scenario and context? Should they participate within these new frameworks and counter-discourses, or should they step aside and let those with psychosocial disabilities and advocates for human rights take full control of the situation?

Karter: Such good questions, and it’s all very thought-provoking. I want to acknowledge that the quote, “It’s not that they lost their minds, but that they lost their worlds,” comes from psychiatrist Derek Summerfield, who’s done really important work in pushing back against the Western conceptualization of depression, particularly in these combat zones.

So much to say: What role should mental health professionals play? In attempting to answer one question among many – what kind of creatures do we want to become, should we become, or would it be ethical for us to become – I wonder if having psychiatrists, psychologists, and psy disciplines involved in such a large way is good. I don’t think it is. I don’t think our disciplines speak to that question with new answers, complexity, or ethical understanding that other disciplines like literature, history, sociology, and anthropology might offer.

Yet, probably because psy disciplines fit so well within the neoliberal worldview, we’ve been afforded a very large megaphone to speak to these questions. Children, youth, and adolescents today are increasingly invoking psychological and psychiatric language to understand themselves and their relationships in a way that was unprecedented even a generation ago. I think the reason for that is because it fits with the prevailing ideology rather than challenging it. If our disciplines are being called to and given that megaphone, I think it’s important to have those within these disciplines think about the problems as loudly as possible and try to influence that discourse.

The question of what kind of people we might become makes us think about the ecological collapse of our planet and the disproportionate impact on humans in different positions. Are we capable of becoming the kind of beings that can face the coming tragedy, the destruction of our planet? If we are, what does that look like, and how do we get there? We must transform our psychological understanding of the self towards a more relational-ecological understanding of the human being.

We must move away from a capitalistic-neoliberal understanding of our role in the world, where we are not just extracting and exploiting for our benefit. We are mutually constituted by one another and our engagement with the world, the animals, and our whole ecological niche.

This transformation would take more than a change in psychological discourse; it would also involve the arts and humanities in articulating a different way of being a person and making those kinds of subjectivities accessible and possible, especially for young people.

In terms of the role of psychological disciplines, psychologists, and psychiatrists in the movements of people with psychological disabilities, I think it’s complicated and fragile. As we talked about earlier, we can agree to come alongside people with the understanding, “I know something; some of those things might be helpful, and some might be harmful.” We need to know more about what they need, how we can join them, and what we should not do. We must be able to form a relationship where they can let us know when we’re getting in the way, and we can let them know when we see something they might not have considered. We must do this from a place of mutual respect and understanding, not assuming that everyone wants that kind of person to come and accompany them. But when it’s welcome, we should think about how we can fill that role.

Arroyo: So, the participation of mental health professionals should always take the form of a question: “What can we add? Should we leave?” We must always try to establish this kind of dialogue when the response is expected to come from the other party.

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MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.

The post Can Psychosocial Disability Transform Mental Health? A Conversation with Luis Arroyo and Justin Karter appeared first on Mad In America.

He has authored or co-authored thirteen books, including the Wiley World Handbook of Existential Therapy, The Spirituality of Awe: Challenges to the Robotic Revolution, The Polarized Mind: Why It’s Killing Us and What We Can Do About It, and, most recently, The Depolarizing of America: A Guidebook for Social Healing. Many trainees in counseling and clinical psychology will recognize Schneider from the APA Psychotherapy Training video series featuring his therapy work.

Schneider is campaigning to serve as President of APA to “to address the existential crises that are now flaring all about us.” As he puts it:

In this interview, Schneider discusses his path into psychology, including his own struggles and growth, his approach to psychotherapy, and his scholarship on the psychology of awe and the polarized mind. Then we turn to his vision for psychology; a “whole-person” approach to healthcare, a “Psychologist General” of the United States, and the development of dialogue groups that address polarization and division.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: I wonder if we can start at the beginning. James Baldwin once said, “History is not the past. It is the present. We carry our history with us. We are our history.” I imagine this may be as true for personal histories as it is for our collective social and political histories. You’ve written about how the early loss of your brother deeply affected you and altered your life trajectory. How did this experience bring you into the world of psychology?

Kirk Schneider: That is a great question. I think of my history almost like a patchwork quilt that has many weaves to it.

Certainly, the loss of my brother when I was about two and a half years old and he was seven, was a huge blow; shattering to me, my family, and my parents, in particular. It was like a rip in the fabric of our day to day lives, our routines, our familiarity with ourselves and the world. I was in quite bad shape as a young kid because of that. But I had very unique parents and that probably should be noted.

Actually my mother just passed away. She was 90 years old and what an inspiration she was and is to me personally. Professionally, she was a leader, a pioneer really, for women. She had a great deal of pluck and she fought her way into becoming a leading spokesperson on radio and television in Cleveland, in the late fifties and early sixties. She always had a very expansive spirit. She believed that if you can do something, do it, you know, go for it, no holds barred. She definitely brought that fire to me. But she went through a very profound struggle and torment after my brother died. As a result, she went into psychoanalysis. She had the wherewithal to do that, which was quite unusual for that time.

She actually referred me to a child analyst who was extremely important, as I look back, in helping me find a footing in life. This was somebody outside my family system who was very seasoned. I don’t remember a word that was exchanged, but I do remember his presence. He brought a very steady, calming, and seasoned presence. I got a sense that he had been there in profound ways in his own life and that was extremely important for me because my mother and dad were having quite a challenge for a period of time.

My father was also a very unusual guy. He was a school teacher and then became a principal. His main field was science and education. He eventually became a professor of education and he did his dissertation on creativity and kids. I spent quite a bit of time with my dad, making up stories and talking into a tape recorder that he had. When I was as young as four years old, I’d be talking about the government and pollution and also stories that I saw, movies or books that I read. He was very encouraging of that.

They were both very supportive of me and helped me in dealing with my emotional life, to the degree possible. As I said, I was in some trouble for a period of time. I would go on long periods of crying and screaming and raging and had a lot of fears and night terrors. I think they did all they could to help and I’m so grateful for that.

We were the only Jewish family in an Italian German Catholic neighborhood. At that time in the early sixties, it was still pretty challenging for Jews in that kind of circumstance. I remember one time when we woke up to see a big black Nazi sign painted on our ping pong table, which was hanging in our garage. There was a neighborhood bully who would call me names, “dirty Jew,” whatever, and beat me up a few times.

I actually, I have no regrets at all about having grown up in that environment. I think it’s been part of a thread in my life, discovering the beauty, the charm, the knowledge of others.

Karter: Your latest works focus on the psychological impacts of racism, marginalization, and oppression. Being a white man in this country, it can be easy to remain in a state of obliviousness or even denial concerning issues of social justice. It sounds like you had the experience of being oppressed, but then also the experience of being the oppressor at times. You carried both of those identities at an early age. Can you talk a little bit about how your eyes came to be opened to these issues?

Schneider: Very much so, Justin. Unfortunately, that was a part of my experience growing up too. I, like many kids, wanted to identify with the crowd, with my peers.

This one time stands out in my memory, in particular, where a group of kids in the neighborhood started chasing after a kid of color in the street. He was also, I think, limited mentally and emotionally, which just added to the prejudices of kids. We were maybe seven years old. And I went along and I followed him too.

It obviously stood out because that wasn’t typical of me. I just got caught up. I remember because my father saw it from the house. He abruptly ran up to me, took me by the shoulder collar, took me back to the house, and spanked me. It was maybe one of two times that he spanked me. But it wasn’t just corporal punishment. He sat me down and he talked to me and the first thing that he conveyed was the seriousness. “Do you understand the seriousness of what you’re doing, Kirk? I mean, what if those guys were chasing you and you were this fellow running away and terrified? And what if they were chasing you because of your skin color? How would you feel? What comes up in your mind about that?” I don’t remember the details of the conversation, but I know we had had a long talk about it and it impressed me profoundly.

That was a part of a kind general upbringing that was conscious and concerned about social issues.

Karter: There you are as a young person, and you’ve lost your older brother at a very young age, and it’s clear that life isn’t guaranteed for anyone forever. You’re trying to make sense of your role and position in your community and in the world. It sounds like your parents set an example for you, and they also connected you to the world of psychology and also the worlds of literature and film. All of that helped you find your place. Not every child is fortunate to have those kinds of outlets. I wonder how it might be different for a child going through some of those same experiences that you had today.

Schneider: I’m sure radically different.

My parents were first-generation from Ukraine, Eastern Europe, but somehow they found these psychologically and psycho-socially enriching paths for themselves. I’d say I’ve been extremely blessed. It is not solely about finances either, in that many wealthy families are not raising these questions with their kids. I see this as a huge problem in our educational system generally. I think the gutting of the arts and humanities has been an extraordinary mistake in our system. I think we’re paying for it dearly all across the board in this country, in terms of sensitivity to each other and ourselves, but that’s a whole other issue.

That is one reason why I very strongly feel that I want to do what I can to support people in all kinds of situations in our country who have experienced a great deal of emotional impoverishment, as well as economic. It’s, obviously, particularly difficult to be a recipient of emotional deepening and contact when one is just striving to get bread on the table or work to scrape a living together.

This is one reason why I feel so strongly about a Psychologist General position who helps to represent psychology in a larger way, with a larger influence, and can help people gain access to quality mental health care. I’m talking about longer-term, intensive, emotionally corrective relationships. We are so deprived of this in so many settings in our country.

Karter: After having these early experiences, you found your way into the field of psychology, and then into the subfield of humanistic-existential psychology, and you studied with the famous existentialist Rollo May. How did you find your way there? What was this experience like? Did these ideas challenge you at the time?

Schneider: Again, that stems from my very unique upbringing. My dad was immersed in articles and books by Abraham Maslow, Carl Rogers, and Rollo May. All humanistically oriented. I still remember that I would play with some of these books in my playroom. They were part of a building that I would create, you know.

So I came to them very organically through conversations with my dad. It was kind of a natural evolution, growing up with a fascination with the human condition. To me, it is clear that a lot of that fascination comes out of this very early terror in my life experience that just took me into other worlds when I was very young and exposed me to these radical terrors and the unknowns of living and dying.

Fortunately, again, I had the support that could help me tap into those new worlds in a way that eventually, after a long time, got me to a place of being able to be intrigued with them and wonder about them and not just be paralyzed them. I was paralyzed by these fears for a good part of those growing up years.

Karter: It strikes me that even having confronted some of those terrors, or even tears, in the fabric of your reality, it’s still not inevitable that you would seek out the field of existential therapy, where those “unknowns” are what you continue to read about and face on a daily basis. What was that like to kind of have to intellectually meet those ideas? Was it terror over and over again?

Schneider: I like to say that I was introduced to existentialism at two and a half. I mean, basically that’s the reality.

What was it like? I lived in a scary, scary world. I was afraid of dying. I was afraid of germs. I was quite hypochondriacal. I was afraid of sort of demonic influences. I had fears of my parents as well at times. As a kid, I had all kinds of fantasies around death and almost no perspective and no layers of experience to contextualize something. Of course, your mind goes all over the place. These are a lot of the things that I needed to work through.

When I went to college, I was alone, which had its great sides in terms of being able to develop more of an inner life, creative life, imaginative life. I did make up a lot of stories and I love science fiction. Some of the programs in those days (even before college) were fantastic, at least for a kid like me.

I related to a lot of the strange worlds that were shown on shows about the paranormal, like The Outer Limits,  and the early Twilight Zone episodes. They opened us up to the radical mystery of being. That’s really the path that I see that I’ve been on for 64 years. And one can be horrified by it and overwhelmed, which I experienced at significant points in my life. But you can also be fascinated with it and see it as awesome and not just horrifying and overwhelming. That’s a great place to be if one can find what I would call a ground within groundlessness, and deal with the paradoxes of that.

Those shows actually helped in a lot of ways because I was getting the other support to be able to deal with it. I was so scared of them too. My trajectory was more and more moving toward the arts and humanities. I loved English literature, drama classes, sociology classes. Then, in college, I blossomed with psychology. I had the good fortune of going to some great places to learn with people who were disciples of Maslow and some of the direct forebears of humanistic psychology.

Karter: Will you say a little bit about what humanistic psychology was about at that time. As it was emerging, it was seen as counter-cultural and it was changing psychology in significant ways. What was the culture of humanistic psychology at that time?

Schneider: The most substantive aspect of it was an attempt to try to understand the whole human being to the degree that’s possible, our whole-bodied experience of life.

The feeling among a number of the founders was that psychology had become reduced into part processes. Psychology, at that time, was focused on behavioral studies, focused on intellective changes (changes in thoughts), conditioning changes, and physiology and medical approaches.

The sense was that we weren’t really getting to understand the agentic capacity to discover one’s core values and aspirations in living, what life was about in a fuller sense, what really mattered to each individual. So this whole field blossomed from that, and it was connected with revolutionary movements in the culture in the sixties that were on parallel paths, trying to break out of the straight jackets of the Victorian era of the fifties.  It was a very dynamic time but that also led to excesses, which I think are very problematic and unfortunate, but understandable.

For example, I have the greatest admiration for RD Laing and his work. I think it’s just pivotal in our field in terms of understanding, and being open to, alternative ways of seeing reality and so-called ‘psychosis’ and really blowing the lid off of our so-called ‘normal functioning’ in society. It really moved toward a much more socio-political-cosmological context for understanding human behavior and experience. But, I feel he made some mistakes; personal mistakes that had something to do with his own struggles.

That compromised the really important messages that he and others were attempting to convey to psychiatry and psychology.  Some of that I think was encouraged by the excesses of the sixties with experimentalism, and not knowing what would happen if people took an excessive amount of drugs or experimented in very freewheeling ways with intimacy, etc.

Rollo May wrote a very perceptive book about this, called Love and Will, where he was calling people to acknowledge the beauty and the wonder and the absolute richness of the opening up that was going on in the sixties, but also to have some caution about the fragility and vulnerability of our humanity as well.

Karter: Sometimes humanistic psychology is characterized in terms of just focusing on the positive elements of human behavior, what might be possible, how we might change. Then existentialism is seen as overly focused on these deeper, darker confrontations with the harder to answer parts of being human. Your work on “awe” integrates both sides of this. Can you talk a little bit about how you came to develop this idea of awe?

Schneider: Integration has been a thread through much of my life and I’ve come around to it through hard experiences of my own.

I did have some of those experiences in my graduate years at the State University of West Georgia, which was one of the first real concentrations of humanistic psychology on the East coast and was created at Maslow’s blessing. I had wonderful professors there, a wonderful community, but I also struggled some with the radical openness of it. I actually had some of the most important psychotherapy and existential analysis of my life there. That was a pivotal follow-up to that earlier analysis I had as a kid, but some of my earlier issues were sort of getting activated at that time. That was extremely important and has really made me an advocate for a more holistic, depth approach to therapy.

I’ve been aware of deep fragility and humility or humiliation, if you will—a sense of smallness in my life—as well as a great capacity to venture out and to take risks. Those risks can often be extremely rewarding in one’s life, but they need to be tempered with humility about how vulnerable we are and how powerful the subconscious forces of the psyche can be; the notion of being a fragile creature before the vastness of existence.

At least for me, that dynamic or dialectic between smallness and greatness has been extremely important. I find that it embraces a vital sense of life, a holistic sense of life, which allows you to be able to be as present as possible to the deepest dreads and sadnesses as well as the most dazzling desires and possibilities. What more can one get out of life? To me, this is the gift that we’ve been handed and both are extremely important to each other. As May put it, they fructify each other. Without one, you don’t have the other in its depth and intensity and it’s a possibility for discovery. I feel I’ve been very fortunate to have been led, and to have led myself, along that road.

The sense of “awe” has been an organic notion that came out of a lot of personal experiences, professional experiences, and from seeing people getting stuck either in their smallness or in being over-identified with greatness or expansiveness. What I’ve found is that, almost invariably, these extremes that I call polarizations—the fixation on a single point of view to the utter exclusion of competing points of view—pertain to a trauma. They’re doing almost everything they can to avoid any hint of the opposite in their lives.

It makes perfect sense then to design a life around hyper-arousal and let’s say grandiosity or narcissism if one feels terribly small and imperceptible and not counting in life. I definitely see a lot of that problem in our current culture and especially among certain leaders. And I’m not just talking about one area. I’m talking about among our profession, young professionals, as well as among business, social, political, and religious leaders.

But people can also go the other way where they’re just terrified of taking any chances outside of the box because of their particular traumatic matrix. They hunker down and keep themselves small and avoid any hint of a more expansive way of living.

Karter: This conception of awe is a little bit different than other ways of thinking about helping people in psychotherapy, right? It’s not necessarily about taking up some middle position between feeling small and feeling expansive. It’s about being able to experience both of those things, simultaneously; being able to bring your experience of smallness into your experience of your potential; being able to bring your experience of your potential into your experience of feeling small.

Schneider: Yes, to the degree one can. From an integrative perspective, we realize that we all live on a spectrum of capacities and not everybody is ready for (or desirous of) that sort of fuller range of contact with these diverse experiences, within and without one’s self. I think we need to respect that.

I do think that there’s a lot of people—a lot more people than we realize—that do yearn for a much fuller and richer range of living, who are trapped in much more restrictive forms of living because of the systems that emphasize a more quick fix, instant result model of living. The sense of awe brings us, I believe, a kind of psycho-spiritual dimension.

We don’t often think about psychotherapy in this way, but I believe it can evolve from a therapy that is available for a deeper level of exploration of one’s concerns, which can then open to one’s possibilities for living. I call it an existential integrative therapy and I see it as a kind of staging ground for cultivating a sense of awe because you’re moving continually between crushing humiliation, smallness, and fragility and gradual and incremental, venturing out.

That venturing out can be with your therapist, expressing a feeling toward that therapist, anger, or sadness, allowing a more feeling-full life, or with others in your life or with regard to a project. And then, of course, there are invariably times where people become unable to maintain that venturing out so then they squeeze back in and go the other way, attempting to restrain themselves with more discipline and focus. And they can also end up going back into the original, trauma-based position.

In many ways, this kind of therapy I’m talking about, at its best, is a movement between a sense of abject terror and paralysis and an incremental intrigue and even fascination with the possibilities of a larger life. It’s that back and forth movement between terror and wonder that can eventually lead somebody to find that ground, that foothold, within the groundlessness that we all are living in. That’s the larger context of life and existence as far as we know it.

Karter: You present awe as a mode of resistance for what you term “the robotic revolution.” As you just spoke about how collective traumas and individual traumas can encourage us to polarize, I wondered about how social systems can encourage us to pull away from life and become “robotic.” What is the robotic revolution and how is that limiting our ability to live with this sense of awe?

Schneider: A lot of my recent concerns have been with the increasing technologization or technocracy of society and of our increasing reliance on the machine model for living. The digital mediates our experience between self and world—what is the cost of that?

It’s clear that we’re all becoming more reliant on our smartphones, the internet, and our computers. Now, with the pandemic, there’s even more of a press to rely on our Zoom meetings and plug into our virtual realities. By no means am I a Luddite. I don’t paint this as all bleak, but I do have a lot of questions and unsettling ideas about it that I feel are shared by many people who really think about what all this portends for our society.

In The Spirituality of Awe: Challenges the Robotic Revolution, I define a concept I call roboticism, which is the gradual attempt to emulate the machine model of living, and ultimately, the prospect that we don’t just emulate that model, but that we become that model. So an actual melding with the machine world. This is not an idle fantasy. This comes out of the work of people like Ray Kurzweil and others who are affiliated with something called the “transhumanist movement,” which, as they see it, is about the expansion of consciousness based on robotics and genetic engineering. They see this as a very positive thing and they talk about moving toward the singularity, which is the point at which you can no longer distinguish the human being from the mechanical.

Of course, we’ve seen this type of scenario in a lot of science fiction. I know that’s extreme and it’s not the reality of where we are now, but there’s certainly hints of that. I guess my sense is we really need to be careful. We need to be vigilant about how much computerization takes over our world.

Karter: In science fiction, the worry is often that we’re creating robots who have human consciousness, but it sounds like you’re saying that we should also worry about the opposite—that we achieve the mind-meld with technology, not by technology becoming like us, but by making ourselves like technology.

Schneider: There’s some logic to that. At some point, our machines are going to be so efficient that it’s very possible that it will no longer be functional to have the kinds of vulnerabilities and peccadilloes that we have as humans. You know, the flesh and blood problems that we have. And, certainly, the idea of lasting indefinitely is appealing to a lot of people.

This is part of that whole lineage of the search for the Holy Grail and immortality, and some of the themes that people like Ernest Becker warned about—striving for an immortality project, writ large. It’s extremely seductive. I understand as a human being that we all get sucked into the idea of living a more efficient life, a more convenient life, a much longer life and I’m a believer in that too. If we could supplement our flesh and blood way of living with the mechanical and that helps us live a longer and more enriching kind of life. Great. But here we get back to the problem of what’s driving this. If it’s fear, which, as I was saying before, is the driver of so much extremism and polarization, then we’re in real trouble.

I don’t think we’ve examined the collective fears that this movement has come out of enough. People like Michel Foucault have done profound analyses of these shifts. Take, for example, his focus on this major turn toward industrialization after the dark ages and the attempt on the part of at least Western civilization to do everything it could to move away from any hint of our primal relationship with nature. It was important in so many ways and led to great intellectual developments and brought rationality to the fore, which is obviously helpful in terms of improving our standard of living, and the way we treat each other, and avoiding illnesses. But the big question he raises is, did we throw the baby out with the bathwater? In this headlong striving to try to create a hyper-sanitized, controlled world, what’s the price?

Karter: As Foucault did, we can look at how this critique applies to the fields of psychology and psychiatry, right? You were talking about the seductiveness of creating models of human behavior that are more predictable than humans are themselves. Certainly, we might see that playing out in psychotherapy research, where we’re looking to create manualized short-term models, delivering it almost as a drug, and just looking at whether or not we’re decreasing symptoms defined in a very medical way. I’m wondering, how does this whole-person approach, how does this integrative approach to seeing the fullness of our human vulnerability fit? How do we integrate that view with studying psychotherapy and making sure people have the best services available to them when they go into mental health treatment?

Schneider: This is a huge question, and it relates back to this socioeconomic context that many of us are living under. If our world presses us toward instant results, appearance, packaging, and getting things done in a mechanistically efficient way, then that’s going to impact every other part of our lives. Certainly, science and psychology are not exempt.

This is where I have a lot of empathy for the position that psychology is in. To a large extent, it’s driven by this larger socioeconomic context, and pressure by funding agencies and corporations to maintain this model.

I think part of what we can bring with a more holistic, integrative perspective is the ability to recognize that this is part of our world and that it’s helpful at some levels. I believe, for instance, that people sometimes benefit greatly from medication; to get through the night, to get through the week, to get through very rough patches in their lives. Or they benefit from other kinds of physiological support or cognitive-behavioral support. There are people in life circumstances where they don’t have the luxury to take more time and to look more deeply at their whole bodily experience of life or to question how are they presently living and how are they willing to live? These are two very fundamental existential questions at the deepest levels of treatment.

So, yes, helping somebody to think more rationally or to behave in a way that is more functional in the world or to be supported by external inputs to help them stabilize their life can be extremely important. However, there are many people who are being severely cheated by this model and shortchanged, and it’s a tragedy. It’s a tragedy running right through our entire system from training therapists to the way it’s practiced in my view.

I think we can, as a field, as a profession of psychology, bring a larger perspective to this problem, especially if we develop the backbone and find the courage to stand up for the fuller offerings of our field.

We have many brilliant people in our field. There are brilliant people in these more practical, programmatic types of treatment, that tend to be focused on the medical-like research methodologies, as well as therapies that are more psycho-spiritually concerned, and therapies concerned more with the multicultural perspectives of the clients—patients that they see who don’t necessarily fit into these standardized, some would say colonized, models—as well as in those therapies that are concerned with a depth perspective, such as psychodynamic, existential, humanistic, etc.

They all have a lot to bring to the table. We really can bring the pendulum back toward a more fruitful dialectic in our field and bring our field more to a holistic perspective. But we need to use the bully pulpit to stand for our fuller science and the fuller range of our outcome research. A lot of that outcome research is done by extremely reputable researchers, such as John Norcross and Bruce Wampold, etc., who find, over and over again, that these more holistic relational contexts are pivotal to effective psychotherapy.

That great consumer reports study that Seligman did that surveyed clients about what they most appreciated about psychotherapy, found that it was these more intensive, longer-term, relational kinds of approaches that were more enduring and more central to them feeling a vitality about their life. I believe we can contribute to the whole culture by having a greater influence from our full range of offerings as a field.

Karter: The critique is made of psychotherapy that you can do the best work with somebody an hour a week, but if they keep going back into a society that’s trending towards greater inequality, discrimination, and marginalization, we might help them through that, but we’re not addressing the larger problems that are driving people to have some of the experiences that are incredibly difficult that we see in therapy. You’ve made this decision to run for President of APA to address some of these larger issues. I’m wondering if you could speak about your decision to run and your efforts to get psychology to address some of these larger, systemic, cultural issues that are affecting everyone.

Schneider: Well, it’s all about that. It’s all about bringing the voice of psychology to the national scene in a way that represents a more integrative holistic perspective.

One of my proposals is around a call for a Psychologist General. I can’t go into detail right now about that, but I’ve written about that in Scientific American and I’m continuing to develop the concept in discussions with people at APA council. Basically, it’s about having someone to be a point person who works in coordination with APA advocacy and our APA resources to be a bigger megaphone, advocating for many of the areas where we’re underserved in the population. We have a tremendous mental health crisis, from depression to anxiety, to addictions, to horrifying hate crimes, racism, suicidality, and, in many cases, despair about living in our current world.

There’s a great need to bring these resources to bear. I do think that having a representative from inside the government to focus strictly on the psychosocial aspects of mental health care is vital. Really, it seems, our time has come.

We’ve had the medical domination of that arena within the government. Why shouldn’t it be paired with the mind as well? Mind and body, you know, they go together, and they can be integrated and be coordinated. I think we need authorities that are just as powerful in the psychosocial area as well as in the medical.

I also believe very strongly in healing dialogues, and I think we can bring these to bear within our own field. I’ve called for, if I am elected, the assemblage of leaders and presidents of all our psychological divisions to come together to talk about what each specialty can offer to the crises of our times. Then we collate that data, we bring it together, and we communicate that to the larger public. Perhaps out of that comes more research and projects that are engaged by funding agencies, et cetera.

I also believe in healing dialogues in terms of their ability to bring together the various factions that we have within APA. We can bring leaders from the scientific wing and the practice wing, qualitative research and quantitative research, depth psychology and cognitive-behavioral psychology, ethnic and cultural perspectives on psychology, and more standardized perspectives on psychology. We can bring all of these various factions together to learn about and understand each other as much as possible.

What we’ve seen from these healing dialogues that I’ve been involved with nationally is that when the focus is on attempting to understand and learn about the other, it, it tends to enhance the likelihood of achieving common ground and building bridges. It’s so different from the kind of verbal flame-throwing that so easily devolves from our usual way of conversing in this culture.

The alternative is we continue the verbal flame-throwing, which is like pouring more gasoline on an already raging fire. A second alternative is to devolve into violence and war. And a third alternative is to devolve into helplessness and despair and total stuckness.

So I ask people who are very questioning of a dialogue approach, what are the viable alternatives? Certainly, I believe that one viable alternative is to make your voice heard, to engage one’s righteous indignation about the status quo. I think that’s extremely powerful. We’ve seen through many movements in history, civil rights being a more recent one, that can be a very powerful impetus for then promoting the national conversation. That is a springboard or an impetus, but ultimately we need to come to the table and talk to each other.

It’s not just about the intellectual exchange of views. I have worked on developing a one-on-one dialogue format that I call the experiential democracy dialogues and have also worked with Braver Angels, a national organization that brings groups of liberals and conservatives together for living room style conversations. For me, it’s more than learning about and understanding each other. It’s about supporting people to be more present to themselves and the other, even at nonverbal levels.

That’s the next step for our democratic process. To address the kind of social breaking that we’re experiencing right now, racially and politically, it has be more than just heady. We need supportive groups where it is as safe as possible, where structured dialogues that adhere to ground rules can take place. Otherwise, it so quickly devolves into these flare-ups.

Karter: I’m hearing the potential for the dialogues in two ways. One, you’re talking about working to create groups across the country so that people can come together and start to find common ground to face some of these challenges of racial justice, climate change, and the political crises that are facing us. Then there is also a role for healing dialogues within psychology, so that psychologists can come together and speak with an integrated voice about some of the policy level initiatives that could help heal some of these mental health crises. If psychology could speak in such an integrated voice, what kinds of policies do you think could be advocated for that would help to address some of the rising rates of suicide, anxiety, depression, addiction, etc.?

Schneider: First of all, through these bridge-building dialogues, we become a much more potent force and we can concentrate our priorities in a much more powerful way at the national level. What might we bring? One thing that immediately comes to mind is advocacy for making longer-term, in-depth, relational, emotionally corrective, therapeutic contexts available to a much larger range of people.

We have thousands of dedicated, extremely astute professionals working in the public mental health arena, but many of them are handcuffed because of the constraints that they’re under for efficiency, which is shortchanging to a lot of people. We could certainly advocate at the level of priorities and federal funding. We could point out that we do have studies that show that people getting quality mental health care, even at the levels that they’re being presented now, offsets medical costs. Imagine how many expenditures could be offset, not only in medicine, but from reducing the level of attrition in work, increasing motivation in school, decreasing prison populations and taking pressure off of the legal system, lowering recidivism, supporting people to find new leases on life and motivations for living, which could certainly have a serious impact on economic growth, and even, perhaps, on decreasing the emphasis on militaristic elements in our society.

The question again goes back to priorities. Do we fund what we know and what our science tells us about what will lead to a flourishing society in the longer run, or do we just keep patching up these holes that are cracking in the walls of our society? They’re going to blow through, it’s pretty clear.

Karter: To bring it full circle, I’m struck by how this kind of advocacy might affect a child who may be experiencing a great deal of anxiety for a variety of reasons, having lost somebody close to them or not having sufficient supports. How might this kind of advocacy at a federal level allow more children to have the sort of corrective experience with mental health care that you had as a child?

Schneider: Exactly. I want to see children have the kind of experience and support that I had as a kid, because I know I would have gone off the rails if I didn’t have that support. I was headed that way at points, especially in my early elementary school years.

I feel extremely strongly about that. I want to see others have that available to them, and it can happen. We are a productive and forward-thinking and innovative enough society to do so much for ourselves if we allow ourselves to think outside the box more and face these kinds of issues.

Karter: Is there anything that we didn’t get to touch on today that would be important to mention?

Schneider: I appreciate you asking that because as I was describing the experiential democracy dialogue and Braver Angels format, I didn’t have time to go into detail, but much of this is laid out in my recent book, The Depolarizing of America: A Guidebook for Social Healing. If people are interested in going into more detail, it is available there. People might be interested in my, my website: kirkjschneider.com, where there is a lot more about all of these themes.

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Cover Photo: Kirk Schneider facilitates a healing dialogue for Braver Angels in 2019 (Photographer: Kathryn McDonald)

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Justin Karter serves on the communications committee for The Society for Humanistic Psychology, which has officially endorsed Kirk Schneider for APA President.

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MIA Reports are supported, in part, by a grant from the Open Society Foundations

The post Leading Psychology in Existential Times: An Interview with Kirk Schneider appeared first on Mad In America.

He is a member of the executive council of the Association for the Advancement of Philosophy and Psychiatry. He has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry.

He leads the interview series Conversations in Critical Psychiatry for Psychiatric Times, which explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo. He is also a member of the Psychiatric Times Advisory Board.

In this interview, he explores his journey into both philosophy and psychiatry and how he understands the relationship between these two disciplines. Aftab goes on to discuss how he began the critical psychiatry interview series and what he has learned from this experience and the pushback he has received. He then elaborates on how studying the philosophical issues in psychiatry, through a “conceptual competence” curriculum, could transform the doctor-patient relationship and improve mental health care.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: Can you tell us about your background and what led you to a career in medicine and psychiatry?

Awais Aftab: I think a lot of people might not know that I’m from Pakistan, and that’s where I was born and grew up and went to medical school. Before I went into medical school, I was really interested in philosophy, and I was seriously considering whether I could pursue that on a professional basis. But philosophy as an academic discipline, especially as a way of making money, was pretty much nonexistent in Pakistan.

I do have physicians in my family. My older sister is a physician herself, so there was all this passive exposure that I was getting through family members who are physicians in Pakistan. It seemed like a natural choice for me to go into medicine as well.

I was interested in philosophy and psychology before medical school, and it became pretty clear to me early on that the only medical specialty that attracted me was psychiatry. It was not an easy decision, though, because there is a lot of stigma in Pakistan surrounding mental health, and this stigma also applies to people in the mental health profession.

There was a general perception at that time that good doctors don’t go into psychiatry and, if you’re intelligent, then you’re going to be drawn to specialties like surgery. I had to explain to family and to teachers that I’m passionate about this field and about changing this field.

Karter: You spoke about the stigma in Pakistan around utilizing psychiatric services and also the stigma toward professionals in the field. What was psychiatry training like in Pakistan? How do cultural differences impact training and practice in the field? Did any differences jump out to you when you began practicing in the US?

Aftab: There are tremendous differences in how medicine, in general, is practiced and in Pakistan versus the US, and those differences are present in psychiatry as well. Most of the medical training loosely follows the British model.

I think psychiatry in Pakistan struggles with being under-resourced, and the ratio of psychiatrists to patients is very low. The availability of medications, especially newer drugs, was a big problem. In general, there were a lot of challenges within the system.

When I started my psychiatric training in the US, one thing that was different was the legal apparatus that exists here with regards to mental health care. There is a system of rules that exist that set boundaries and also establish some accountability.

In Pakistan, there are very few legal regulations that apply to mental health care. It can create a sense of chaos when you’re treating someone who is experiencing symptoms of psychosis or mania, and the family is concerned. This can lead to deception on the part of the families, which sometimes can cross ethical boundaries.

It is pretty common there that family members would obtain psychiatric medications and mix it into the food of a person without that person knowing. That’s not ethically defensible, but I think you can see it as a consequence of a society that has failed to develop other ways of addressing these situations.

In the US, to obtain the majority of psychiatric prescriptions, you have to go to a doctor, and they have to prescribe the medication to you. In Pakistan, things are changing now, but when I was there, essentially, you could go to any pharmacy and get any medications you wanted. The psychiatrists were not the gatekeepers of psychiatric drugs, and anyone could go to any pharmacy and get a benzodiazepine or an antidepressant. So even though the number of psychiatrists was limited, the use of psychiatric medication was still widespread.

Another interesting difference between psychiatry in Pakistan and the US that I noticed was in terms of patient presentations. When it comes to depression and anxiety, a lot of people in Pakistan presented with what would be considered a neurasthenia presentation, where they’re focusing much more on somatic symptoms, such as headache, physical fatigue, weakness, or digestion issues.

There was this emphasis, privileging body problems, and physical problems over mental health problems. So people tended to present when they were depressed or anxious in that classic neurasthenia manner.

We used to see a lot of conversion disorder cases—far more than I’ve seen in the US. I think this is partially due to the fact that conversion disorder is seen much more often in women who are highly oppressed in many ways within the larger social system. I think that the higher rates of conversion disorder were sort of a barometer of social oppression.

Before I started my psychiatric training in the US, I had spent almost one year of psychiatric training in Doha, Qatar, where things are very different from the US and Pakistan in the way their society is organized. There is almost what you could call a ‘slave class.’ You have these laborers that come from various South Asian countries, like Nepal, Bangladesh, India. They come to Qatar seeking work, and then they get trapped there for various reasons, and they’re working in really horrible conditions.

While I was working there, we saw extremely high rates of what is called a ‘brief and reactive psychosis’ that refers to episodes of brief psychosis that seem to arise in situations of really high stress. That was a very common presentation among those laborers in Qatar. In contrast, it’s relatively rare to see a ‘brief reactive psychosis’ when the society’s not as oppressive for as many people.

Karter: It sounds like your experiences were really rich for thinking about these philosophical questions that come up in psychiatry and psychology about the role of culture in the experience of mental distress, and about ethical issues around coercion and deception in psychiatry. How did your philosophical training continue to develop during your medical training?  You produced a blog on the “History of Modern Philosophy” while you were in medical school. How did you see its relevance to medicine and psychiatry?

Aftab: My real love was always philosophy. Even though I was in medical school, I still was devoting a lot of time to my personal reading of philosophy. At that time, I was doing a lot of reading in the history of philosophy, especially the history of modern philosophy from Descartes onward.

As I was doing that reading, I was keeping notes, but once I had accumulated a relatively large volume of notes, I realized that with some more effort, I could give them a little bit more form and shape as a sort of book in a blog form. It ended up being this blog on the history of modern philosophy from an amateur perspective. I think that personal study gave me a solid foundation for further philosophical inquiries that I was interested in later on.

Initially, I didn’t see it as being that relevant to medicine. There was a bit of a disconnect in my mind. As I progressed, I began to appreciate how philosophical thinking can inform medicine. There are all of these hidden conceptual dynamics present in the way people make sense of distress, talk about disease categories, and approach them. I began to see this hidden philosophical structure beneath the practice of medicine, and this became much more apparent to me when it came to psychiatry.

Psychiatry is one area where things are relatively more subjective, and there’s a much stronger influence of values. It’s easier to see the influence of some of those philosophical assumptions on how things are practiced. But I don’t think that the nature of the underlying philosophical assumptions is that different in the rest of medicine.

Another big influence in this area happened during my final year of medical school when I became familiar with the work of the famous existential psychotherapist Irvin Yalom. At that time I was, I was personally really interested in the existentialist philosophers. I was exploring the views of Nietzche, Heidegger, Sartre, Camus, and when I discovered Yalom and started reading him, that made a huge impression on me as a medical student.

I love the way Yalom integrates existential thinking into his practice of psychotherapy and psychiatry and the way he makes sense of people’s distress and their anxieties. It gave me a much richer appreciation of what psychiatric practice could be like if done in the right fashion.

Later on, before starting my residency, I also read “The Divided Self” by R.D. Laing, who many people would recognize as being one of the so-called antipsychiatry philosophers. It’s a fascinating book because Laing is trying to understand psychosis from the perspective of existentialism. He’s trying to make sense of delusions, the disorganization, and the paranoia from an existential perspective, and he’s desperately trying to see meaning in those experiences. I don’t think I was fully convinced by what I read, but the sheer force and beauty of that intellectual effort left a deep mark on me.

Karter: You mentioned that you started reading works that applied philosophy to clinical practice in different ways. Yalom applies existentialism to psychotherapy, and Laing’s work takes existentialism and phenomenology and applies it to the lived experience of psychosis. How did this lead you to explore more of the critical psychiatry literature, and how did that shape your thinking?

Aftab: When it comes to the relationship between the field of philosophy of psychiatry versus what we now loosely call critical psychiatry, there is a big overlap, but they are also relatively distinct and somewhat insulated from each other. For much of my psychiatric training, I was reading literature in philosophy of psychiatry, and I was familiar with the intellectual work of the classic antipsychiatrists, such as Thomas Szasz and Michel Foucault.

Despite having this familiarity with the classic antipsychiatry thinking, the philosophy of psychiatry literature that I was engaging with wasn’t explicitly dealing with critical psychiatry issues. The critical psychiatry movement has very strong roots in the UK, particularly in the Critical Psychiatry Network. Until recently, there was not as much of a critical psychiatry influence in the US and the American journals and academic literature that American trainees are exposed to.

Even though there were articles related to critical psychiatry that were showing up in British journals and international journals, I wasn’t getting a lot of exposure to that in my training in the US. I think a lot of these critical psychiatry debates were happening in a much more prominent fashion online, especially on Twitter and on some of the blogs.

The result is that my exposure to what we would call critical psychiatry happened pretty late, near the end of my psychiatric draining. It was only shortly before the edited book on critical psychiatry by Sandra Steingard came out.

About a year before that, I did end up reading “Anatomy of an Epidemic” by Robert Whitaker. Reading “Anatomy of an Epidemic” and engaging with those ideas was quite an experience for me. Most of the people that I had spoken to or who I had mentioned that book to before had been pretty superficial and dismissive about it, calling it extreme or antipsychiatry. When I decided to read the book, I was expecting that it would be something I could quickly go through and thought it wouldn’t be something I had to spend a lot of time and energy on.

Reading “Anatomy of an Epidemic” ended up being a really jarring experience because I quickly realized that a lot of the arguments and a lot of the data presented in the book were not easily dismissed. And the nature of what was being discussed—the possibility that psychotropic medications can worsen outcomes, at least in a subset of patients—was one that was particularly unsettling to me.

I think back to my relatively naive days, and I wasn’t exposed to this larger body of work. Whereas now, two years later, after reading the book, I’m still thinking about trying to address those issues.

I think that book left a pretty deep impression on me. It wasn’t just because I accepted all of the arguments in the book, or was immediately convinced that everything that was being said was correct. I could see that a lot of the arguments, at the very least, are deserving of serious engagement.

As I started talking to other psychiatrists in the community, I realized that a lot of other people had actually read the book too. A lot of them were struggling to make sense of these issues in the same way that I was.

This was a relative surprise to me because most of the people who read this book, within the psychiatric community, have a tendency not to talk about these issues. But when you speak to them on a personal level, where they might feel free to talk more openly, I think a lot of them would say that this book unsettled them, that it is not something that they can immediately dismiss, and that this is something that they are actively trying to make sense of.

That book launched me into a whole new, different area of inquiry. Then later on, when I started becoming more active on Twitter, that’s when I started getting more exposure to the critical psychiatry folks and in the UK and started reading their work.

Karter: You’ve produced a series of interviews titled, “Conversations in Critical Psychiatry” for Psychiatric Times with several of the leading voices in critical psychiatry. Can you tell us how this series came about and what’s been your biggest takeaway from these interviews?

Aftab: When I started this interview series, I didn’t quite understand critical psychiatry in the same way as someone from the UK or someone who was active on Twitter might. I had a more neutral idea about the term “critical psychiatry” as being representative of the very diverse ways in which critical thinking and criticisms can be directed at psychiatry.

I was actively reading this critical literature that seemed very serious and worth engaging with, and then I felt a weird disconnect because almost nobody in mainstream psychiatry was talking directly about these issues. There was a tendency to either ignore them, be indifferent to them, or talk about them in informal settings.

That was a little frustrating for me because I thought that these critical perspectives had something valuable to offer psychiatry and that psychiatry would, in fact, benefit by engaging with them. I wanted to start an avenue for meaningful engagement with these critical ideas, where I could highlight some of the issues that I think are important to our field.

I think I was lucky that I had a good working relationship with Psychiatric Times editorial team at that time. When I pitched the idea to them, initially, there was some hesitation, pretty understandably, because no one had done anything like this in mainstream psychiatry, and no one knew what exact shape this would take and how it would be received. But they decided to take a chance on me, and I’m really glad that they did. Overall, the series has done pretty well.

Going back to the reasons why: one reason was that I wanted to highlight the critical perspectives that I think we as a field needed to hear. Even though I may not personally agree with all of the views expressed in the series, I still think it’s very important that we hear these things and engage with these ideas.

Secondly, I was still in the process of learning more and making sense of this body of work. I thought this series would present an excellent opportunity for me to learn more about these critical ideas and perspectives.

Very importantly, I wanted these engagements to happen in a relatively non-threatening, productive manner. I think there’s this tendency toward an unhelpful dynamic that develops where criticisms tend to be aggressively presented, and then the other side reacts in a state of being totally defensive.

That doesn’t help lead to meaningful engagement. It is fine if you want to refute something or if you want to dismiss something, but it’s not conducive to learning. It was really important to me that these interviews happen in a non-confrontational manner so that the readers would think about these issues without being threatened.

Karter: So you ended up in the middle of two worlds that you felt weren’t always speaking to each other in a very productive way. I’m curious about two things: First, what has the response been on both sides—How has the mainstream psychiatric community responded to hearing these critical voices and how has the critical psychiatry movement responded? Second, what have you learned by existing in that intersection? What have you noticed about the dialogue between critical psychology and the field at large?

Aftab: I have to say, and I was a little taken aback by this as well, that overall, the reception has been very positive. I was surprised by how well these interviews were received, at least by the people who were reading them, and even by even by psychiatrists that you would think of as being thoroughly mainstream, and as operating within with the current mindset.

A lot of them found the interviews to be thought-provoking. I think a lot of people may simply have ignored these interviews, at least in the beginning. I think, initially, a large chunk of readers probably didn’t really care for these interviews that much, and then a smaller chunk found these interviews to be worthwhile and positive.

Then there was a smaller group that responded to it in a little bit more critical manner, saying, “I don’t really think focusing on critical ideas is such a good thing. That’s not what we need. That’s not what the field needs right now.”

So there was a small amount of backlash, but it was fairly small within the psychiatric community. I have to say that the criticisms have not been to the extent that I might have feared when I started the series. I have to emphasize that overall the reaction from the psychiatric community has been very positive.

To some extent, that may be due to the way these ideas and arguments were presented. For example, the very first interview was with Allen Frances. I think that said something about the intention of the series because Allen is someone who was essentially part of the psychiatric establishment until, during the DSM-5 debates, he started writing much more about the philosophy of psychiatry. He started writing about the limitations of DSM and the harmful effects that it has had on society at large.

Because Allen has that background, being one of the architects of modern DSM, no one can come out and say, “Oh, Allen, he’s just antipsychiatry.” That’s just not an argument that anyone can make in good faith. I think starting off with someone like Allen was symbolic because it showed the series was aiming to be rooted within the psychiatric tradition, but also honest in genuinely exploring these criticisms.

Another example: when Anne Harrington’s book came out last year, a lot of the initial reaction to that book, within psychiatric circles, tended to be relatively negative because people hadn’t read the book itself, but were mostly relying on the various book reviews.

When I decided to interview Anne Harrington, I was anticipating that there would probably be more backlash for that interview. But when the interview came out, Anne Harrington presented her work in a very balanced, scholarly, thoughtful manner, without any sort of inflammatory comments. And, similarly, the interview was very well received, even though the same people who liked the interview might have reacted negatively to the general perception of the book.

I think that gave me a very valuable lesson about the importance of context—that it’s not just about the content of the argument, but the context of the argument also matters, and the perceived intentions of those arguments also matter. I think that if we want psychiatry to engage with these critical views, we have to present them in a context where the mainstream psychiatric community will be able to engage with them.

There have been some interviews that have generated more controversy. I can think of two interviews in particular. The interview with Joanna Moncrieff generated a lot of discussion on both sides. Some people felt strongly that what Moncrieff was saying was wrong or expressed that they did not like the overarching trajectory of her comments. But, at the same time, Moncrieff has a large fan following, and I think there were a lot of people who liked that interview.

The interview with Giovanni Fava was more controversial because we touched upon some of the more sensitive issues surrounding psychopharmacology, especially these concerns related to the possibility of worsening long-term outcomes in a subset of patients, issues over withdrawal, and some of the other critical problems in psychopharmacology. I did notice that the Fava interview generated more critical comments and some more backlash, at least online and on Twitter.

Talking about how these conversations happen on Twitter, I’m seeing a similar polarization between people defending mainstream psychiatry and people criticizing mainstream psychiatry. You see this exchange, this back and forth, between relatively extreme positions. People get emotionally engaged in these debates, and sometimes these debates turn pretty ugly.

I think a philosophical perspective can offer you a little bit more nuance, and a little bit of stability in the debate.  Having a little bit of that philosophical sensibility can help you be grounded in the polarized debates that we are currently seeing on social media.

Karter: Does the success of the interview series and the way it has been received indicate that things are beginning to change in psychiatry?

Aftab: I would like to think so. My generation of psychiatrists (who is just entering the psychiatric workforce) is much more mindful of the ways in which the profession has been unable to deliver on the promises of the last three decades.

Around the time I started my residency, NIMH’s Research Domain Criteria (RDoC) was all the rage, and Thomas Insel had famously described the DSM as lacking validity and had said that patients with mental disorders deserve better. Allen Frances, on the other hand, while no fan of RDoC, was on a crusade against DSM-5 of his own and campaigning against widespread medicalization.

So my generation of psychiatrists trained in the shadow of these debates. Very few of us see our current diagnostic system with rose-tinted glasses; we are acutely aware of the limitations. At the same time, the literature on the long-term efficacy of psychiatric medications has accumulated, and studies such as STAR*D don’t paint a very pretty picture.

There is increasing awareness of bias in research, particularly misconduct by pharmaceutical companies, so I see a lot of caution among my colleagues with regards to research studies funded by pharma. My generation is also much more mindful of social justice issues and takes them very seriously. So I think there is a strong sentiment in my colleagues to question received wisdom and to look for alternative answers, and my series reflects that to some extent.

Karter: You’ve proposed this idea of conceptual competence as a framework for improving mental health training in psychiatry, and the goal is to bring some philosophy training to psychiatrists and other mental health professionals. I’m wondering what you think philosophy training would add. How would conceptual competence help trainees in the field to be part of these conversations between critical perspectives and mainstream views? What do you think some of the major theoretical issues are that trainees should be exposed to? How would this training change everyday practice?

Aftab: I’ve been very engaged in efforts to promote the philosophy of psychiatry among psychiatric trainees. While I was chief resident in my psychiatry residency program, I developed this preliminary curriculum for teaching philosophy of psychiatry to psychiatry trainees, which I implemented at my program for two consecutive years, and it was received very well by the residents. We ended up publishing a report on that in Academic Psychiatry.

Recently, Scott Waterman and I got together, and we wrote this piece arguing for this notion of conceptual competence in psychiatry. We are definitely not the first ones to talk about this idea of conceptual competence. You, yourself, have written about conceptual competence when it comes to psychiatric diagnosis.

But when it comes to mainstream psychiatry, we were probably one of the more prominent voices talking about this. Our basic notion is that it’s pretty well established now how all these implicit conceptual assumptions are guiding psychiatric research and practice. Including assumptions, for example, related to what mental disorders mean and what constitutes the border between “normal” and “disordered.”

If it is recognized that all these conceptual assumptions are influencing a psychiatric perspective, then why don’t we talk about these assumptions and examine them and engage with them more explicitly and rigorously?

The main idea is that we train psychiatrists to recognize the conceptual ideas that are influencing their approach and the conceptual ideas that are dictating and guiding their practice. I think it is precisely our neglect of these conceptual ideas that lead to some of the more widespread problems, such as the reification of psychiatric constructs.

When we think that these DSM constructs represent some sort of discrete diseases, and we attribute more reality to these constructs than is warranted, it raises issues of widespread medicalization.

How do we draw the boundary between what should fall within the domain of medicine and what should not? Right now, the process of medicalization is operating through its own logic, and we’re seeing this steady expansion in the proportion of the population that falls under these various psychiatric constructs.

My main goal in promoting conceptual competence is that trainees start asking these questions and that they become more explicit about these hidden philosophical ideas. Once that happens, then we can begin to ask more meaningful questions about what to do next and how to change things?

If you have more awareness, if you have more understanding, then then I think we can engage with these philosophical issues in a more productive manner, and we can start making the changes in our practice that need to happen.

Karter: There have been other movements in the field of psychiatry. The movement for multicultural competence and humility helps to train mental health professionals to think about the role of culture in experiences and expressions of distress. Structural competence is a movement to think about how institutional discrimination and systemic racism impact clients and patients. How do you see conceptual competence complimenting these other movements, and what does it add to those existing movements in the field?

Aftab: I think that the development of cultural competence and structural competence are some of the most promising developments that have happened in medicine and psychiatry at large over the last 10 to 15 years.

I think that these movements are forcing us to engage with issues of cultural diversity. These movements have challenged to consider the way culture affects medical presentations, including psychiatric presentations, and, very importantly, to get away from taking the Western perspective to be the default natural perspective. We can be more mindful, we can be more respectful, and we can be more understanding of the way culture interacts with medical and psychiatric problems.

Structural competence is doing an excellent job of highlighting how various social systems and forces of oppression—whether this is gender discrimination, racial discrimination, economic inequality, extreme poverty—influence medical conditions, prognosis, and access to treatment.

There is a pretty good body of literature to show that psychiatrists need to be more mindful of the ways social forces operate if we are to provide good care.

Karter: To take this a little bit further, if a psychiatric trainee or a psychiatrist were to make a study of a conceptual competence curriculum and utilize the framework, how do you imagine that would change daily practice? If you were a service-user showing up to a psychiatric visit, how might you experience that visit differently if this training were available?

Aftab: It’s difficult to say precisely how a conceptual competence would change psychiatric practice, primarily because the emphasis is first on recognizing what the hidden assumptions are and what the questions are that need answering.

The approach of conceptual competence doesn’t necessarily provide the answers themselves, because when it comes to philosophical questions—whether these are questions in philosophy medicine, philosophy of psychiatry, or philosophy of science—they rarely have clear cut and settled answers. It’s more of a process of dialogue where you have to engage with a question, think about it, and reflect on it.

One thing it does do, though, is it helps weed out some of the bad answers. There are some approaches to psychiatry that, if you are conceptually competent, you can see that they are mistaken. Take, for example, this reified view of the DSM as representing discrete disease entities. I think that someone who is conceptually competent is better able to understand the pragmatic nature of these constructs and the functions that these constructs serve.

I think conceptual competence can help psychiatrists become immune to some of the misguided tendencies that we see in current practice. By being more thoughtful, I hope that they would be able to engage with patients, and with the society at large, in a much more healthy fashion.

Right now, if you look at the public education that is being done with regards to psychiatry, the public is getting a very biomedical understanding of psychiatric disorders. There was all this talk of chemical imbalances, and there still is to some extent. There’s even talk of disorders being brain diseases.

The public is getting a certain version of how these things should be understood, but someone who has a better conceptual and philosophical understanding of these issues can easily see that these claims that are being made about brain diseases are somewhat simplistic and that they might not be helpful and that more conceptually healthy understandings of these categories are going to look very different.

If they have an openness and this conceptual understanding in their mind, I think that it will influence how they’re informing patients about a diagnosis, and how they’re educating and listening to their concerns. We might then be able to think more outside the box, and we might be able to listen in a more healthy and sincere manner to some of the longstanding concerns raised by the consumer, survivor, ex-patient community.

Karter: It sounds like conceptual competence may lead to a change in the relationship between service-users and providers as well, in that there might be more humility and maybe more openness; less an expert who is identifying something and more of a dialogue between parties.

Aftab: Exactly. I think the emphasis on humility is something that is very important. In fact, one of the elements of conceptual competence that is outlined in our paper is conceptual humility.

It is the idea that these are challenging questions, there are often competing answers, and reasonable people can disagree. The best approach we can take is to be open-minded and be humble about the possibility that what we are thinking may not turn out to be the case, and that we can wrong.

I think that a sense of humility can enable us to have a dialogue in a more open and sincere manner and to also listen to other perspectives, even if you may not agree with them immediately. At the very least, we can begin to engage with them, listen to them, and give them the respect and the attention they deserve.

I think we would see a very different sort of psychiatry if that happens.

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MIA Reports are supported, in part, by a grant from the Open Society Foundations

The post Bridging Critical and Conceptual Psychiatry: An Interview with Awais Aftab appeared first on Mad In America.

Please join us for an MIA “Urgent Conversation” about diagnosis and treatment in response to trauma in the COVID era.

Please register HERE.

Concepts of mental “illness” have always been employed to explain people whose degree of distress threatens to overwhelm our ability to understand and respond. However, in times of shared stress such as war, veterans’ extreme reactions—shell shock after World War I, battle fatigue after World War II, PTSD after the Vietnam war—were understood in context, and society responded with support, gratitude, and a healthy awareness of the majority’s good fortune in being spared the same fate. Similarly, after natural disasters, or childhood trauma, we are often (if not always) able to understand in context reactions that might otherwise be seen as “psychotic,” and give people what they need.

Absent observable traumas, however, those who have fallen on the back side of society’s bell curve and suffered the consequences are often misunderstood, if they were heard at all. Their unmet efforts to be understood may become increasingly strident or bizarre, or they may give up completely, in the face of a society that has yet to hear the words of those whose experiences reflect society’s unrealized potential to care for its own.

In the COVID era we are all affected to at least some degree by these unmet ideals. So far empathy for those in distress is sufficient to direct energy and money toward supporting people in distress, without thinking they are mentally “ill.” Peter Kinderman, in discussions leading up to this panel, spoke of the U.K.’s notable response to those in crisis as a shared social response to trauma, rather than as a “mental health epidemic.” However the time may come that worries about frugality and a loss of collective will—fueled by the opportunity of profit—will lead to a search for “cures” for otherwise perfectly explicable trauma.

In the midst of this pandemic, tools of pathologization continue to proliferate. The American Psychiatric Association currently has a proposal to add “Prolonged Grief Disorder“* as a new diagnosis to DSM-5 (Depressive Disorders). In a time when many are losing loved ones and unable to bury or grieve their deaths in accordance with their wishes and traditions, efforts to characterize diverse responses to grief as disordered and abnormal are particularly egregious. In addition, the US is moving toward expanding universal depression screening in primary care for adolescents.** Standard screening instruments are unable to account for heightened symptoms resulting from social and environmental stressors, and therefore risk diagnosing an ever-increasing number of young people with mental disorders for simply exhibiting normative responses to world-changing circumstances amid increasing uncertainty and precarity.

Many have noted that Sweden has chosen to not go the route of a nation-wide lockdown, and have so far avoided mass infections. Panelist Carina Håkansson notes, however, that this success is in the context of Sweden’s leadership exhibiting a significantly different approach than has characterized the past decades of psychiatric diagnosis: an ability to publicly say “We don’t know.” Carina points out in addition that there ARE things we do know that have informed Sweden’s success so far in containing the virus: that we need to cooperate, that we need to look after each other, and we need to have solidarity.

Panelist Noel Hunter spoke of her personal journey through New York’s COVID crisis, and the similarity to her experience with psychiatric diagnosis and treatment. In the context of inexact or entirely absent criteria for diagnosis, she relates, she experienced yet again being disenfranchised and feeling gaslit by an entrenched system of treatment that had little or no help to offer. Laura Delano’s experience with withdrawal from psychiatric medication and the diagnoses that incurred them provide an important lens and skill set with which to assess the perils and opportunities we are encountering now.

We hope that as we emerge from the COVID crisis we can avoid repeating the last decades’ mistakes—mistakes referenced in Thomas Insel’s famous statement shortly before leaving his stewardship of the NIMH that “while DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each … The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”

The opportunity to shape our understanding of mental health and its contributors, reflecting the ways that we are all responsible for—and share in—it, could not be more compelling than it is now. Join us to discuss how we can use this moment to strengthen our capacity to understand each other’s distresses, and respond to them as we move into the uncertain future together. Now, as ever, none of us is stronger than the most vulnerable among us. As the world has been driven into retreat, and the global economy is faltering, there could not be a better or more necessary time to reflect on the possibility that, in very real ways, mental health is our common wealth.

*The “Prolonged Grief” proposal is open for public comment on American Psychiatric Association website: https://www.psychiatry.org/psychiatrists/practice/dsm/proposed-changes

**The U.S. Preventive Services Task Force posted this week a draft research plan on screening for depression, anxiety, and suicide risk in children and adolescents. The draft research plan is available for review and public comment from April 30, 2020, through May 27, 2020. To review the draft research plan and submit comments, go here.

The post Mental Health Is Our Common Wealth appeared first on Mad In America.

Two organizations that played a prominent role in challenging the Bible of psychiatry prior to 2013, the British Psychological Society and the Society for Humanistic Psychology (American Psychological Association – Division 32), subsequently joined to form the Task Force for Diagnostic Alternatives (TFDA).

Today, February 12, 2020, the TFDA released a new Open Letter regarding the reform and revision of diagnostic systems. MIA spoke with two leaders of the Task Force, Sarah Kamens and Peter Kinderman, about this effort.

Sarah Kamens is an Assistant Professor of Psychology at the State University of New York (SUNY) College at Old Westbury and co-chair of the Task Force for Diagnostic Alternatives for the Society for Humanistic Psychology. Her research examines the intersections between extreme emotional distress and structural marginalization. More specifically, she studies the ways in which lived experiences of psychosis and trauma are entangled with social conditions in the world.

Peter Kinderman is past president of the British Psychological Society (BPS) and a Professor of Clinical Psychology at the University of Liverpool. He is also a past guest on the Mad in America podcast and the author of A Manifesto for Mental Health, Why We Need a Revolution in Mental Health Care (2019) and A Prescription for Psychiatry: Why We Need a Whole New Approach to Mental Health and Wellbeing (2013).

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: Sarah, can you give our listeners a little background on what the Task Force for Diagnostic Alternatives is and why it was formed?

Sarah Kamens: The Task Force for Diagnostic Alternatives is a task force of the Society for Humanistic Psychology, Division 32 of the American Psychological Association (APA). We originally came together back in 2011 when David Elkins was the president of the society.

This was around the time of the development of DSM-5. At the time, David Elkins had read a letter that was published by the British Psychological Society (BPS) written by Peter Kinderman critiquing the proposals for the upcoming DSM-5. Dave read this and contacted Brent Dean Robbins, who was then the Secretary of Division 32, and me, because I had written a master’s thesis on the DSM controversies and had some expertise in the area. We put a team together a team to produce a letter from professionals in the United States.

We felt that if our colleagues across the pond were critiquing a diagnostic system that’s developed in this country, we should be inspired by their efforts, follow suit, and publish something from our own perspective as well. We developed an open letter, put the letter online on a petition website, and we thought, “We’ll send this out to our colleagues and we may get a few dozen endorsements from like-minded professionals.”

Then within the span of a few days, we received support from over a thousand individuals and, at the same time, institutional endorsements started coming in and we were absolutely overwhelmed by the response. It seemed that we had tapped into something: a kind of concern or discontent with the developing DSM system.

By the end of our campaign, we had endorsements from over 50 professional organizations, including 16 divisions of the APA and over 15,000 individuals, many of them mental health professionals.

After this, we really wanted to understand the kind of collective concern that we had tapped into so we started to expand our efforts.  We decided we would continue to critique the basis of the DSM systems, but also look and explore the possibility of whether or not there are alternative systems out there.

Justin Karter:  Peter, Sarah mentioned past letters, published prior to 2013, which contested the validity of DSM-5. How is this new open letter different?

Peter Kinderman:  First, this approach is different because of the timing and the professional context that we live in. Back in 2011, we wrote both the BPS and the Humanistic Psychology letters specifically as a response to the proposed revision to DSM-5. Both letters questioned whether the experiences that fall under the remit of mental health symptoms can accurately be considered illnesses at all. They asked, “Is this the best way to think about our mental well being?” There was a particular challenge.

Since then, obviously, the DSM-5 has been published. It hasn’t been boycotted. It hasn’t been ignored and it’s evolved into the new crazy Bible of psychiatry.

We’ve also had the proposed revision of the World Health Organization (WHO) classificatory system, ICD 10 to become ICD 11, which is in draft form. We’ve also had the development of RDoc. We’ve also had a number of people proposing alternatives to the DSM.

In talking about these issues, we realized that we were talking about the inadequacies of the crazy medical pathologizing diagnostic system and that, instead of critiquing a particular proposal, we had views on the whole nature of what it means to go about proposing diagnostic systems.

Rather than trying to write a response to each proposal, we thought we would group the whole issue of diagnostic approaches in psychiatry together and write to the leaders of the main groups involved in those efforts.

It is intriguing that you’ve got different diagnostic systems that purport to be better than each other, which, by definition, critique the validity and utility of the other systems.  Yet, at the same time, they purport to have read-across (similarity) between the systems. So you can go to websites that tell you how an ICD 10 diagnosis reads across to DSM-4 or DSM-5 or ICD 11. It is like they’re saying, “Their diagnosis is invalid, ours is better, and yet they’re the same thing,” which is kind of is nonsensical.

Bringing this all together, we decided to write a critique of how we should go about the business of searching for appropriate psychiatric diagnosis, or more properly, alternatives to diagnosis. We ask questions like:  What’s the purpose of this? Is this a diagnostics system to identify the pathologies in the population and sell drugs, or are you aiming to improve the wellbeing of the population?

Who should be leading this? Is this an exercise by psychiatrists and mental health professionals for psychiatrists and mental health professionals or is this a democratic exercise?

Are you starting by assuming that there are such things as mental illnesses and trying to examine the entrails of the slaughtered goat in order to find out which diagnostic system is best? Are you critiquing the system at all from first principles? Are you considering alternatives?

Are you considering different perspectives? Are you including sociologists, philosophers, critical psychologists into the mix? Are practitioners open to alternatives? Are you exploring psychological classifications, which, personally, I don’t think are that much better than pathological classifications, or are you considering the sorts of approaches used by social workers or social pedagogues? Are you considering phenomenological approaches? Are you considering a public health perspective rather than a pathologizing perspective?

Our open letter sets out all of these possible alternative perspectives and presents some of the principles that we think should apply to the business of looking at diagnoses.

Sarah Kamens: To add to what Peter was saying, we have all of these different alternative systems being proposed. It is a really unique time and, in some ways, it’s an exciting time because there was a period after DSM-3, where researchers and practitioners were really laboring under the DSM-3 system and very invested in its success and had strong beliefs in its success.

It was a period of what Thomas Kuhn would’ve called “normal science,” where people are doing a lot of studies trying to support that paradigm. Then this anomalous evidence started to emerge that the system wasn’t really holding up empirically by its own standards. There was all of this overlap or comorbidity between the diagnoses, fuzzy boundaries, and other types of empirical problems.

Now we’ve got of these different systems being proposed and, as Peter said, they critique each other. Then, at the same time that you have these critiques out there, there is this continuation of using the DSM system that has been widely identified as problematic for not having the types of validity and reliability that you would hope for.

We also have a situation where, paradoxically, the DSM is used in clinical and counseling settings, and we ask those accessing services to have belief in this same system that we as researchers and professionals are permitted to identify as faltering and problematic. Yet, if those with whom we work do not hold a belief in that system and their own place in it, we say that “they lack insight into their diagnosis or their ‘mental illness.’” This, to me, seems to be the great hypocrisy of the present time.

As our open letter identifies, a lot of the systems that have been proposed would not be a true paradigm shift if they’re successful. A true paradigm shift would occur if, as we propose in the letter, we somehow tie in this overwhelming evidence for social and structural factors to mental distress.

Peter Kinderman: To build on that, one of the things that happened when we came together and criticized DSM-5,  was that people responded by saying, “well, we’ve got HiTop and we’ve got RDoc and we’ve got ICD 10 and 11.” But our point in this letter is that all of them have assumptions and failings built into them.

They make assumptions of pathology, assumptions that we can make subjective judgments and define what normal is and define what abnormal is.

We wanted to take a step back and challenge all of those underlying assumptions. So if the leadership is by psychiatrists for psychiatrists, because after all the job of psychiatry is to define illnesses and then treat them, then you’re not doing your job properly.

We need to challenge that. Are you including alternative and diverse voices? Are you including the voices of people who think that those assumptions need to be challenged? I think we did a good job in 2011, but we need to do a broader job now and a more conceptual job. That’s what this letter is about.

Justin Karter: I want to pick up on these assumptions that are built into the current diagnostic systems. One of the points made early on in the letter is that current diagnostic systems, “identify and locate problems within individuals.” Sarah, how are our relationships, communities, cultures involved in the symptoms that then get diagnosed by psychiatry and psychology?

Sarah Kamens: When we think about the quantitative research evidence, it is really clear that social factors play an enormous role in the generation of mental distress.

We can take the example of psychosis, which is an area of interest of mine. The research evidence has clearly laid out that the experience of psychosis is very much tied to social and structural experiences such as homelessness, not having a place to live, housing insecurity, economic inequality, racial and ethnic segregation, multiple deprivations, and childhood trauma. From the side of human experience, we might say that these “symptoms” are also results of exposure to our particular world.

Peter Kinderman: I was just thinking that maybe we should also point out some things have happened in the world of psychology and critical psychiatry since the DSM-5 was published.

After 2011, I think that we were surprised by the level of positive response that people had to our letter. There were a lot of people who are hungry for alternatives.

We’ve seen more research into the networks of associations and mediating processes between life events and mental health outcomes for people. We’ve seen the development of cogent, coherent alternative approaches such as the Power Threat Meaning Framework.

For me personally, one of the things that’s happened since the letter in 2011 is that I started to realize some of the potential for systems to not only capture information about individual psychological phenomena but also to capture those social determinants that Sarah talked about.

We’ve been so focused on identifying disorders, we’ve taken our eye off the fact that it’s perfectly possible to measure, to identify, to categorize, to respond to and take seriously both clinically and politically the phenomena that people experience (like low mood or hearing voices ) and the events in people’s lives (like domestic violence, racism, losing your job, or failing exams).

Sarah Kamens: I want to emphasize that there are serious consequences to ignoring the evidence we have for the role of social structures. When we locate symptoms within an individual, it can be detrimental on a number of levels.

One is to that particular person who is then not encouraged to or supported in examining the way in which their unique life historical circumstances might play into their distress. The person is not encouraged to explore the ways in which their social environment contributes to how they’re feeling.

On the broader societal level, exposure to this sort of mental health discourse that identifies problems within individuals gives us an excuse not to look at these social structures that make us suffer and that make us “sick.”

Peter Kinderman:  I’m somebody who believes that my thought processes emerge from the physical processes of an organic brain. I know that I think with my brain and I am genuinely interested in neuroscience. I’m interested in what happens biologically when people lose their jobs. I’m interested in whether there are consequences that you can see in not only in the psychological functioning of people (changes to your self-esteem, the way that you relate to others, a sense of optimism or agency for the future) but in measurable and identifiable changes to brain processes.

I’m really interested in that. But it’s more likely that we’ll be able to see changes in brain functioning and psychological phenomena following major life events than we will by studying the etiology of major depressive disorder. It is actually a foolish way to study neuroscience, let alone a foolish way to study sociology and psychology.

I absolutely agree with you that if we want to understand how toxic society’s impact is on us as human beings, we’ve got to move away from a disease model. But you know what? I think that if we want to understand how life events impact on a child’s developing brain, we’d be better off ditching the disease model there as well.

Sarah Kamens: Absolutely. I think that it’s important to say that of course all of these experiences have biological correlates and biological determinants as well. I think one of the questions is, “what does it mean to focus primarily (or sometimes even solely) on those biological determinants?

What happens when I identify someone as having anxiety or depression and provide them with medical treatment or maybe a psychological treatment for that and don’t focus on the fact that they have just lost their job? I think that those are the types of questions that we’re asking.

So absolutely, I think it’s really important to say there’s no denying that we are biological beings and that all of the phenomena that we’re talking about have biological correlates and often biological determinants as well.

I think a really good example of a bio-psychosocial model that really takes all of this into account is the social defeat theory of psychosis. The idea of the social defeat theory of psychosis is that all of these social risk factors that I had mentioned (homelessness, childhood trauma, migration, etc.) share the common experience of social defeat, or being excluded from a dominant social group. That experience of marginalization has an effect on the dopaminergic system.

Social defeat theory draws on animal models and some imaging research to show that, in situations of social defeat, indeed, there are alterations in the mesolimbic dopamine system.

We can, of course, model things like that. The question is what does mean to talk about someone’s dopamine system when they are sitting in front of you and they have just lost their job.  So, there’s a question of context as well.

Justin Karter: This discussion leads to another important question about how the current diagnostic systems impact service users and people who are accessing services. There are also people who find the current psychiatric diagnoses helpful. Can you address this point? What might it look like if this open letter is successful in challenging the current diagnostic paradigm and opening up more frameworks? How might it impact service users if there were multiple systems to choose from?

Sarah Kamens: It’s a wonderful question. First of all, if people have a number of systems that are in play and in the general public discourse, there’s more of a freedom of choice and, I think, more of an understanding of the relativity of these systems.

One of the issues that with DSM-5 is that once these diagnoses are put into play, they’re reified within public discourse. They’re made concrete and seen as these definitive biological aberrations. I think that having options that are different from the DSM would allow people to explore the meanings of what their particular stress distress is to them.

Now I think it’s really important that you’re asking about people who do find the current system helpful. I think that there are certainly psychological benefits to understanding, for example, that one is not alone, that other people have had similar experiences, that those experiences can be named and described, that people have gotten better or have felt better, and that there’s hope there.

One of the questions is, first of all, what are those benefits, and are those benefits unique to the DSM? There are other descriptions of mental distress, like formulation, like the power threat meaning framework, for instance. How can those types of alternatives also help people connect with communities, understand that they’re not alone, understand that there is hope out there?

With alternatives, we will have this greater freedom of choice, but we also have to respect people’s choices either way.

Peter Kinderman: The goal is not to tell anybody how they should think and certainly not to tell people how they should think about their own difficulties, but we are suggesting that there are alternatives.

I’m very taken by a blog that I read a few years ago by a junior psychiatrist. He seems a very pleasant and caring chap who slipped into his blog that he had a genuine belief that if he took somebody who was profoundly depressed and couldn’t tell them that they were ill, he had to respond by telling them they were being weak.

It’s really interesting that we are so constrained into this disease model way of thinking that many people, whether they’re people seeking help from the psychiatric system or people working in the psychiatry system, seem to default to the notion that if they can’t use language of pathology and illness, there is simply no other way of describing people’s problems other than to use pejorative language. It seems that if you can’t say, “I am ill with depression,” you have to say, “I am being weak and stupid,” and I personally want to move away from that way of thinking.

To return to your question Justin, what do we envisage? I would love to see a situation where I could go to my family doctor, tell them that I’m feeling depressed, and my family doctor could say, “okay, well let’s explore why.” They could say, “what’s happened to you?”

Personally, I think that that immediately turning to medication to help would be an unwise choice. I want people to listen to what I’m experiencing, understand what I’m experiencing, but not to assume that by understanding and listening and naming my experience that they’re therefore diagnosing an illness and should treat it.

I think they should listen to my experiences, understand it, name it, report it if necessary. If I turn up at my family doctor and say that I’m feeling anxious and depressed and then reveal that I’m being abused by my partner, then one of the questions is, do I need a safe house? Do I need the police involved? Giving the opportunity to name and describe what has happened and not defaulting into an illness model, and offering a drug to alter the functioning of my brain, allows us to start to think about alternatives that can address those problems.

Justin Karter: I want to dig into the different considerations that the letter recommends that should be addressed by any diagnostic system in order to push forward toward a new paradigm that works better for clinicians, researchers, and service users. What are some of the values and principles that the letter lays out?

Sarah Kamens: The recommendations that we make in the letter, in part, draw upon a document that was recently produced by one of the workgroups that came out of our global summit on diagnostic alternatives. We ended up

producing and eventually publishing the “Standards and guidelines for the development of diagnostic nomenclatures and alternatives in mental health research and practice.”

[These principles include]:

• The guiding values of developing or improving any diagnostic system or alternative should be the general promotion of public health and human wellbeing.
• The purpose of developing or improving diagnostic systems should not be a professional or commercial benefit.
• Diagnostic systems and alternatives should be developed free from industry influence and based on scientific evidence that is unbiased.
• In terms of the leadership, those who are charged with developing or revising diagnostic systems or alternatives should include members of the general public, current or former users of mental health services, experts by experience, and family members, in addition, of course, to professional representatives who are free from conflicts of interest. There needs to be a democratic representation of relevant stakeholders and multidisciplinary professionals.

Justin Karter: The new open letter also lays out some very specific and practical recommendations for immediately improving diagnostic practice that do not require a complete transformation of the existing system. Can you tell us of some of these specific recommendations and how you see them improving practice in the short term?

Peter Kinderman: In the ICD system, because it was set up across the whole of medicine and healthcare, rather than a specific project of psychiatry, there is a system that allows health care professionals to respond to the needs of their patients. So the system includes methods for accounting for issues like pregnancy or taking preventative medicine or even doing things like resetting broken bones.

These aren’t diseases, but they are reasons why people go for healthcare. So, especially within ICD, what we have is a system for saying why has this person presented for help at this time?  These are perfectly legitimate reasons for accessing healthcare, but they aren’t diseases.

What my colleagues and I realized is that, within the healthcare system, there are ways of doing things differently.  We have things like phenomenological codes where you can say this person came in for self-harm or disrupted eating patterns or for low mood or guilt or anger, things that are reasons why you would go to see a healthcare professional, but aren’t diagnoses.

One of the things that we recommended is to look at existing codes for specific experiences of phenomena. The other thing is that, of course, people go to their healthcare provider because things have happened to them. This happens in physical medicine as well. There are codes for these things and we ignore them. There were codes for things like adverse experiences, childhood poverty, experiencing abuse, homelessness. These are all codes within ICD.

So, yes, we would like a total transformation of the diagnostic system, but one of the ways that we get there is to start recording specific experiences that already exist as codes, which will point to those social determinants.

Justin Karter: This letter is addressed specifically to several international leaders in the field of psychiatry. Why address these leaders in particular? How do you hope that they’re going to respond to this open letter?

Peter Kinderman: We’re particularly addressing people who have leadership roles in the most dominant diagnostic frameworks, DSM, ICD, and RDoC. We are also speaking to the wider public, to the media, to healthcare providers generally. In making it public, we’re inviting the leaders of those frameworks to respond.

I would like them to consider very seriously whether they are brave enough to suggest that the leadership issues, the conflict of interest issues, and the guiding values and principles issues are significant enough that they would be able to put their efforts under a slightly more democratic perspective. Instead of this being an exercise by doctors for doctors that is then imposed on patients, we are asking for this to be something that is for the public, by the public.

Justin Karter: Sarah, as you are co-chair of the task force on diagnostic alternatives, I’m wondering what you imagine comes next? What are the next steps for the task force and how will this open letter evolve from here?

Sarah Kamens: The truth is that I’m not really sure. The reason for that is that I think that we want to see what the response is to this open letter. With our original open letter, the response was unexpected. It was overwhelming, but it also allowed us to understand more about the perspectives and opinions and concerns of other mental health professionals as well as the general public.

I think that we’re going to wait and see what the response is and then see where people’s concerns and interests lie and then take things from there.

Peter Kinderman: In a sense, it is a statement of what we are up to and what we are thinking we are inviting comments to further the discussion.

In terms of next steps, we need to be open-eared to people’s responses. There are many people who worry that, because the system is based on so heavily on diagnosis at the moment, changing the system will make services harder to access. For instance, how are people likely to get services? How will people get help, get therapy?

Extending it further to institutions like the civil benefits system, the way in which people get benefits and financial support from the state is often heavily dependent on diagnoses. The way in which the criminal justice system responds to mental health issues is heavily dependent on diagnosis.

As we propose reforms to the way in which we go about making diagnoses, we have to listen carefully to people pointing out the flaws in the proposed alternatives that we come up with and to take those seriously and amend and change.

Sarah Kamens: One hope that we have is that the response to this letter will help us to refine our goals and narrow or expand as needed.

I think that is the general direction we’re headed in. We’re trying to remain open-minded so that we can gather people’s responses to the letter. We would love to hear input from Mad in America listeners today and if people have ideas for our task force or thoughts or suggestions, you can always reach out to us.

Justin Karter: I understand that professional organizations and individuals are both invited to sign on and add their support to this new open letter at the following link (here).

Sarah Kamens: The last line of our letter says as the next step, what we want to do is discuss these issues. That’s the point.

*******

You can sign the letter here: https://forms.gle/yHWjrTxHCv5tXx5t6

MIA Reports are supported, in part, by a grant from the Open Society Foundations

The post Moving Mental Health Work Away from Diagnosis: Sarah Kamens and Peter Kinderman on New Open Letter appeared first on Mad In America.

Bracken, who holds doctoral degrees in both medicine and philosophy, calls for a movement toward critical psychiatry. He was one of the people involved in starting the Critical Psychiatry Network, an organization of psychiatrists, researchers, and mental health professionals that question the assumptions that lie beneath psychiatric knowledge and practice.

Through his clinical practice and his academic work in philosophy and ethics, he has seen the limits and dangers of standard approaches to mental health in the West. As a result, he has become an advocate for listening to different understandings of madness from those who are routinely ignored and dismissed — namely, service-users and people who themselves experience madness, and those from indigenous and non-Western cultures.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter:  You grew up in a Catholic country.  How has that influenced your thinking and your belief systems?

Pat Bracken: I grew up in Ireland in the sixties and seventies, and it was a very different place then. I see my kids growing up now, and the Ireland that they are experiencing and call home is a much more open society, and I think overall probably a better place to grow up and to find yourself. In the sixties and seventies, Ireland was quite an oppressive society. We were very much dominated by the Roman Catholic church.

I’m not anti-Catholic. I grew up in that tradition, and I see a lot of very positive things that religion can bring to people in their lives. I saw it with my own parents, for example, when they experienced difficulties and crises.  The church and their strong Catholic faith offered them something substantial in terms of navigating those issues.

But there was a very dark side to the domination of Catholicism in Ireland. We know now just how dark that was in terms of child sexual abuse. But it was wider than that. It was a very harsh atmosphere for anyone who showed any deviance from the mainstream mores of the time. So, if you were gay, it was a very difficult place to be. I think if you came into conflict with the church in any way, it was a difficult place to be.

It was also the 1970s when we were in the middle of, what we now euphemistically call “the troubles,” which was a war on this island. That had major implications for all of us. Even though I lived in and studied down in the south of Ireland, the conflict in the north of Ireland was never far from us and dominated the political scene of the 70s and well into the 80s. Economically, it was hard times as well. There were not a lot of luxuries around.

I say all of that to say that it was not it an easy time, nor was it in many other places. I think in some ways that also helped to shape a critical response to society. In a society where you see lots of oppression in all its forms, you have to take a position on that. I think it helped me as a young person to know that there were deep problems with the status quo, and I learned that one had to struggle against it.

Karter: How did you decide on a career in psychiatry? Why did you want to become a psychiatrist?

Bracken: Very early on, actually. Quite unusually, I think I wanted to be a psychiatrist before I started training in medicine. From a very early age, I became interested in madness. I was very interested in art and extreme states as a youngster in the 1970s. I was fascinated by things like surrealism. What I got from that was a positive perspective on difference and deviance from norms and “craziness.”

Perhaps naively I thought that practicing in the world of psychiatry–to make a living and to make my life in that area–would be a straight-forward kind of process. Like many people in the 1970s, I read R.D. Laing’s book, The Divided Self, and was fascinated by it.  Not that I agreed with it all or understood it at the time 100%, but the way Laing wrote was compelling . . .  there’s no denying just how passionate the man was and the imagination he brought to the territory of “mental illness.”

At that time, people with any kind of serious mental health problem were locked up in great big asylums that were uninteresting, that were places you didn’t want to go. They were, you know, called snake pits. What Laing did was say, “These people are fascinating. These people are interesting. Their take on reality is something that needs honoring and needs exploring and needs a whole different kind of way of thinking about.”

I think I got some of that passion from reading him and other people at that time. I wanted to be part of that work. I just wanted to get straight into the world of madness.

Then when I graduated in the early eighties, of course, I found myself in the reality of the psychiatric system in Ireland. After a couple of years, I thought I can’t continue with this; the contradictions between caring for people and trying to understand them, and at the same time the power and the control that went with psychiatry.

I started really practicing psychiatry in 1983. At that stage, the DSM and the full impact of biological psychiatry hadn’t happened. This is the very early eighties. Psychoanalysis, for example, still had a role in our training, and other approaches weren’t dismissed. At that time, training in the early 1980s, from a theoretical point of view, psychiatry wasn’t as dogmatic as it has become

Once I left medical school and got my exams out of the way, I started studying philosophy. When you’re into the world of studying psychiatry, you’re reading about the mind and the body, and the relationship between the mind and the body and society, and all those kinds of ideas. My immediate sense when I came to psychiatry was the thinness of our understanding of some fundamental concepts. That we were building an empirical science on very, very dodgy conceptual foundations.

After a number of years studying the philosophy of science, ethics, and other things, I became fascinated with the work of Michel Foucault, who of course spent a lot of his time exploring the history, assumptions, and practices of psychiatry and where they came from. That was a really important experience for me to experience the work of Foucault while I was studying and learning psychiatry. Philosophy is about questioning. Never being happy that you’ve reached the point where you have all the answers. There are always more questions.

The point I’m making is that I learned psychiatry from the outside. I never understood the world or saw the world from within a psychiatric way of thinking. I could see the concepts, where they were coming from, how contingent they were, how local they were, how partial they were; so I never believed them. I never believed that there was a thing called schizophrenia that somehow that was just there as a disease process. I understood the history of that concept, the assumptions in it, the problems with it. I’ve never had a relationship with psychiatry where I see the world through a psychiatric set of glasses.

Karter: Through the work of Foucault, you could see that there was a set of philosophical assumptions built into the science of psychiatry. I’m wondering what those assumptions are. What assumptions about being a human being were being baked in, without a lot of reflection, to the practice of psychiatry at that time?

Bracken: Well, the great irony is that if you go back in the history of psychiatry, to the 1920s and thirties, psychiatry had a much richer discourse about conceptual issues.

For example, the tradition of phenomenology. If you train in psychiatry, you train in what they call phenomenology, but that has become, over the second part of the 20th century, little more than a list of psychiatric symptoms and a description of them. For most psychiatrists, they think of phenomenology as simply this kind of listing of symptoms and asking the patient whether you hear voices or what kind of voices they hear.

Whereas in philosophy, phenomenology is a huge, rich way of encountering our position in the world and how the world opens up for us as human beings. There are huge insights if you go to philosophy and use that to understand various experiences of one sort or another. Phenomenology has huge things to offer, but the concept of phenomenology in psychiatry became restricted, distorted.

What’s been handed down now to psychiatrists in their training, philosophers wouldn’t recognize what psychiatry has called phenomenology. I think that’s been a huge disadvantage for us. I would encourage us as a discipline is to go back to our history in psychiatry and to reengage with some of those debates psychiatrists were having in the early twenties.

Karter: You mentioned earlier that the rise of the Diagnostic and Statistical Manual (DSM) and medicalized diagnosis transformed the practice of psychiatry in Ireland. How has the DSM changed the thinking of psychiatrists in practice?

Bracken: When the DSM III came out in 1980, it represented the coming to power, within American psychiatry, of a group of people who rejected the psychoanalytic way of thinking. Who said, this is getting us nowhere, if we want to be proper doctors, we’ve got to have a proper diagnostic system, that’s our first step. We’ve got to be able to get that right, and we’ve got to be able to do studies where the same patient will be seen by different psychiatrists and be given the same diagnosis.

That move to operationalized diagnosis meant that psychiatry was saying that mental problems can be addressed in just the same way that we address problems of the liver or the lungs. So the move to DSM III was, in fact, a deeply philosophical move. It was a move towards what I would call reductionism.

What happened then through the 1980s, and the late 1980s, in particular, was that Pharma started funding a lot of psychiatric research and psychiatric practice. Then you also have, in the United States, the emergence of managed care. All of those factors came to produce a psychiatry in the late 80s, 90s, and into our own time, which has become conceptually very impoverished.

Psychiatry now is modeled on making quick diagnoses with a list of symptoms and applying a drug to the problem. That kind of psychiatry is an anathema to me. I find that it does a lot of violence to the reality, the messy reality, the complex reality, the encultured reality, the embodied reality, of people’s problems. That very simplistic, narrow approach can do a lot of violence and leads to a lot of suffering. It has led to the sort of problems that you at Mad in America are addressing today, and have done for the last number of years.

Karter: The latest version of the DSM, the DSM V, has faced critique from mental health professionals and service-users, and some alternatives have been offered. Some are on the sociopolitical end, like the Power Threat Meaning Framework (PTMF) in the UK. Others seem to be doubling down on finding answers in the brain, like the RDoc initiative from the National Institute of Mental Health (NIMH) in the United States. I know you’ve written on RDoc – what are your ideas about the alternatives that have been offered?

Bracken: Quite incredibly, the response to DSM V from psychiatry has been a redoubling of reductionism. The RDoc is a disaster as far as I can see. It has consumed billions of dollars and has delivered nothing. It is incredible.

If this were in any other branch of medicine, it just would be scandalous. If the whole United States research budget on cancer for a period of 10 years had failed to deliver anything of use to patients, people just wouldn’t stand for it. Somehow, these people have been allowed to get away with this scandalous waste of resources.

But it’s not just RDoc. The Lancet Psychiatry World Psychiatric Association Commission report, which came out in the last few years, drew on psychiatrists from around the world and asked them to imagine what the challenges are and what the future would be, and obviously, a lot of thought was put into it, but it is really sad. The imagination is not there. Again, it comes back to seeing the future from a very medical point of view; that the job is more biological research, neuroscience, genetics. It’s a highly technicalized understanding of the field of mental health and where progress will come from, and it is missing the exciting things that are happening in the world of mental health.

In my career, the most exciting thing, the most important thing, has been the rise of the service-user movement or the consumer movement. People come at that from different points of view, but it’s an amazing phenomenon that’s happened in the past twenty or thirty years. People who experience mental health issues, crises, difficulties have started to articulate that, and they’ve come together in groups of different sorts and started to campaign and challenge the status quo.

The challenge for us professionals is to find ways that we can open up spaces for dialogue. To do that we have to change the way we think about knowledge and expertise and we have to move substantially away from the idea that we’ve got to be doing more research and we have to be doing more of our investigations and that the future is about our science and our way of training ourselves.

That way of thinking, as though somehow there is some kind of singular truth about mental health and mental illness and that psychiatry and our allied professionals have access to, goes in the opposite direction from what is needed. As professionals, we have to substantially move away from the idea that we’ve got some privileged source of knowledge and science about mental illness. We have to go right back to basics and say what kind of space, what kind of thinking, do we have to nurture within ourselves and our profession that will allow us to actually engage in genuine dialogue with people who come to services for help.

Karter: How have you been influenced in your understanding of mental distress as historically situated and culturally constructed by your international work?

Bracken: I already mentioned that, in my early days, I became very disillusioned with psychiatry and my first years of training, and I actually decided to quit. I decided I couldn’t continue. I had decided to pursue a career in philosophy instead.

But then I saw an advertisement in the British Medical Journal — it was an ad by an organization that had just set up in London in the late 1980s called the Medical Foundation for the Care of Victims of Torture. They were being asked by Amnesty International to set up a project in Uganda for victims of torture.

I applied for the job, and I went. I found myself in what was still at the time a very insecure place with a lot of problems. I went out there, I met my partner Joan Giller there, and we’ve worked together on a lot of these issues over the years.

Joan is a gynecologist by training and subsequently trained in anthropology and psychotherapy. The two of us were recruited for this project, and we ended up wondering what the hell are we going to do? We realized very quickly that as two white people, white doctors from Europe, in a country that was reeling from a devastating civil war and massive human rights abuses, that we could do a lot of harm by thinking that we have some solution. Or by thinking that the solutions to the problems in Uganda are going to come from Europe, that they’re going to come from western psychiatry or counselors from the Western world who are trained in a particular way of working.

If you come with that kind of way of thinking, then you start to undermine local ways of dealing with suffering, local ways of creating society, collectivity, and solidarity. Because you start to say, actually there is an expertise that we have, that we’re trained in, that you don’t have available to you, and the only way you’re going to move on from your suffering at the moment is by having access to our expertise. Not through your own resources, your own culture, your own religions, your own way of doing things, and finding solidarity.

We became aware very quickly that we have to tread very carefully in that world. At the same time, we also respected the idea that Ugandans of all ages, all groups, all tribal backgrounds, desperately wanted some recognition from the rest of the world as to what they had been through. Some people were very happy to have people there who were interested in that suffering.

You asked about what that experience did, and it was very transformative for me because I became absolutely aware of the importance of social context in shaping how we experience mental suffering, how we respond to it, and how we can help. We can’t do any of those things without understanding the context in which people are struggling.

Karter: Looking at the Lancet Commission on Global Mental Health and the movement for global mental health more broadly, there seems to be an assumption made that there is a paucity of mental healthcare in low and middle-income countries. You have made the point that different cultures have ways of dealing with stress and the results of social issues that we might not see clearly as “mental healthcare” through the lens of Western psychiatry. What have you seen in your work internationally as far as alternative therapeutic or cultural strategies that allow people to recover from or deal with immense amounts of distress?

Bracken: What we have to do is to respect the diversity of responses to distress that human beings have come up with; not try to understand the global issues around mental health with this kind of arrogant imperialistic sense that the only answers are from us in the West.

For depression, for example, some of the papers I have read are just mind-boggling. They’re incredible — the only ‘evidence-based’ treatments for depression, on a world scale, are antidepressants, ECT, and CBT, or some modified form of CBT. I think this is just ridiculous. People have all sorts of ways of coping, of supporting one another, of making sense out of things, and we need to respect that. We also need a critical consciousness around harms that can be done by our by, so-called, ‘evidenced-based’ treatments and by our concepts.

Science can be very helpful to us. There’s no doubt about that. But, in many ways, science is like the bright light of the sun. It shines, and it illuminates things in a particular way, and that allows us to see certain things. But when we think about it, it’s only when the sun goes down in the evening, when the sun is gone, that we can then start to see the stars. For me, the stars are all the different cultural ways of thinking and coping and dealing with distress and the state of madness.

Karter: You were recently a co-author on a paper published in Transcultural Psychiatry, which we covered here at Mad in America (Research report; Interview), about developing culturally responsive and culturally informed therapeutic practices with the Maori indigenous community in New Zealand. How did you come to be involved in that study, and what did you learn?

Bracken: My own involvement was far from central in any way. I got involved there in New Zealand after I retired from my post in the health service here in Ireland in 2016. Basically, I wanted some time in my life that I could not be working in the health service as a clinical manager, clinical lead. I wanted to be able to travel and do a few other things.

New Zealand has a tradition of respecting culture, particularly the indigenous Maori culture. They have set up a lot of different services that work as cultural services alongside traditional psychiatric practices within New Zealand. I read about this, and I was very interested because I’ve worked in services, particularly in the UK, that are struggling to cope and offer something positive to immigrant communities. So I looked around after I retired from my job in Ireland and made inquiries and I was lucky enough to connect with the service on the North Island out on the east coast in the city of Gisborne.

I ended up doing a locum position out there and got to know Diana Kopua, who is a Maori psychiatrist, and her husband Mark, who is a Maori artist, and their work developing a practice called Mahi a Atua, which roughly translates as the ‘Work of the Gods.’

What Diana had been doing for a long time was developing a practice of intervention with individuals and families that drew not on Western psychiatry and its diagnosis and its theories and its assumptions, but instead went back to Maori creation stories. She uses the characters and family events within those creation stories as a way of locating the problems that people were encountering in their lives.

Problems of all sorts, from family conflict to drug abuse, to madness, to states of melancholy and depression and withdrawal. All of those states were dealt with within the rich tradition of Maori creation story and narrative. What Diana was doing was developing a practice that didn’t start by trying to make a diagnosis and rush in with a drug or a treatment.

You started by talking about those creation stories and finding one that perhaps had echoes or resonances with what was going on. Because Maori culture is very family-centered, when we talk about family, we’re talking about the wider family. It is not just the nuclear family; it is much wider. So when you’re talking about family meetings, you can have a whole room full of intergenerational cousins and aunts and all sorts in there. Their approach was about getting all of the people talking and engaging in a dialogue and a discourse using, not western psychology and its assumptions, but Maori psychology and its histories.

What struck me was that to make that come alive, there needed to be a critique of western psychology. When I looked around in New Zealand, while there was great respect for these practices and Maori cultural practices in particular, actually the mental health system still worked according to a logic based in western psychiatry and psychology. So the whole mental health law in that country is set up around a western psychiatric way of thinking. The way in which psychiatrists are trained, the way in which decisions are made in practice, while there was respect for cultural workers and their inputs, in the end, the western psychiatry was dominant.

With critical psychiatry in combination with indigenous psychology, you can start to crank down the power, the authority, the deference, paid to western ways of thinking and its assumptions and practices. When you start to point systematically to the downside of interventions that come from, for example, placing someone with a diagnosis of schizophrenia on long-term neuroleptic medication that really restricts that person’s life, you can critique that and try to find ways of not doing that.

Karter: Many critiques of the movement for global mental health have been published, and now we are seeing that alternatives, like the one you’re discussing, are also being published in well-respected journals. How will this be absorbed?  What do you think are the likely responses from the powerful center of psychiatry and psychology in the West?

Bracken: It depends what kind of day you get me on and how I answer that! If I’m feeling pessimistic, I’d say there’ll be no listening at all. On a more positive day, I think yes, there is hope.

I can be hopeful. Our own critical psychiatry network, for example, has grown and has more people involved now than it did 20 years ago when it started. I think there is beginning to be signs of respect for critical thinking. I also think that there may be increasing respect for the gifts of indigenous cultures, what they can bring to us, not just in the area of psychiatry, but we can and have to start to learn from indigenous cultures about saving our planet.

In indigenous cultures, like in Maori culture, for example, the natural world has personhood. The world that we live in, the forest that we live in, the land underneath our feet, the mountains that surround us, they regard them not just as resources for us to do what we like with. In Maori culture, those natural parts of the world have a status close to us, human beings, and demand respect from us.

I think that way of thinking about the world we live in is the only thing that will save us from destroying the planet that we’re on, destroying ourselves. We have to rethink our relationship with Indigenous cultures and start to think about how it can be given a greater deal of respect. Part of that is about us learning to listen to them. Again, that is about nurturing in ourselves, a critical self-reflexivity that understands the destructive aspects of our own history. In the Maori context, that is about understanding the history of colonialism.

Karter: I can imagine a therapist, psychiatrist, or mental health professional, listening to this or reading this and thinking about this humility being important when working cross-culturally. It may be a little bit less obvious how this approach could be implemented in individual practice within the West. You are talking about being open to both the critique of psychiatry from service-users, anti-psychiatry groups, and psychiatric survivors, but also about having a respect for the alternative ways of understanding mental distress that people might bring in to the therapeutic encounter. Can you say more about that?

Bracken: I think that is very well put. I’m trying to argue for a way of thinking about psychiatry that has a future. I do believe that medicine has a legitimate and positive role to play in the lives of people who are struggling with states of distress, madness, and dislocation but only if we can radically rethink the starting point for that involvement. Psychiatry cannot get there on its own. It has to start that process from a place of dialogue.

We won’t get to that place of genuine dialogue until we fully understand the harm that we’ve done and how we’ve damaged people and come to terms with that somehow. I’ve already talked about postcolonial studies, Queer Studies, feminist scholarship, that are all about trying to undo some of the dominant ways we’ve understood the world and move to a place where we’re not harming each other through the concepts we use. We’ll only get there by really working on this. That’s the role of critical psychiatry. That, to me, is what critical psychiatry is about.

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MIA Reports are supported, in part, by a grant from the Open Society Foundations

The post Toward a Critical Self-Reflective Psychiatry: An Interview with Pat Bracken appeared first on Mad In America.

This week, MIA Radio presents the fifth in a series of interviews on the topic of the global “mental health” movement.” This series is being developed through a UMASS Boston initiative supported by a grant from the Open Society Foundation. The interviews are being led by UMASS PhD students who also comprise the Mad in America research news team.

I was fortunate to interview Dr. Gail Hornstein, a Professor of Psychology at Mount Holyoke College in South Hadley, Massachusetts. She is the author of To Redeem One Person is to Redeem the World: The Life of Frieda Fromm-Reichmann and, most recently, Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness. In her work, she chronicles both the personal narratives of people with lived experience of being treated as “mad,” and also the growing movement of survivor and service-user activism. Her Bibliography of First-Person Narratives of Madness in English (now in its 5th edition) lists more than 1,000 books by people who have written about madness from their own experience; it is used by researchers, clinicians, educators, and peer groups around the world.

She is now director of a major research and training project investigating how hearing voices peer-support groups work, supported by a grant from the Foundation for Excellence in Mental Health Care. This project is training dozens of new hearing voices group facilitators across the US and sponsors research to identify the key mechanisms by which this approach works.

What follows is a transcript of our conversation, edited for clarity.

JK: Thank you for joining us today, Dr. Hornstein.

GH: Thank you, Justin. I’m delighted to be here.

JK: Thanks, to dive right in, in what ways do first-hand personal stories of madness provide a counter-narrative to the dominant discourse in the mental health professions?

GH: I think that using the framing of “counter-narrative” is helpful in that it makes clear that multiple narratives can be offered to explain the anomalous experiences that many people have. The framework provided by psychiatrists, psychologists, and other mental health workers is an important one, and of course, as you say, it shapes the dominant discourse in the United States. However, throughout history, there have always been alternative approaches to understanding the kinds of complicated and often very distressing experiences that are called mental illness or madness, and people who have first-hand experience of psychiatry have provided many of these alternative approaches.

The problem is that because the evidence base for the dominant approach is contested at best and shaky at worst, it is not clear that any one way of explaining these phenomena has a stronger claim to authority than any other approach. And here is where the perspectives of people with first-hand experience become especially important because they often have at least as much evidence to support them as do the perspectives of mental health professionals.

In other words, it’s not just a question of human rights, although of course, human rights are extremely important here. People ought to have the right to define their own experience, but I am also talking about good science as well as human rights. If a perspective like the biomedical model of mental illness does not have clear scientific evidence to support it, then other perspectives, let’s call them counter-narratives, become especially important because these approaches might have as strong, if not stronger an evidential base.

JK: You are currently directing a national study of the effectiveness of hearing voices peer-support groups. Could you speak to how this approach challenges psychiatric orthodoxy?

GH: Psychiatrists see the experiences that get diagnosed as hallucinations — whether auditory, visual, olfactory, etc.–as resulting from faulty brain processes that in and of themselves have no particular meaning. So if someone says, “I hear a voice that’s telling me that I’m a bad person,” for example, mainstream psychiatrists would pay very little attention, if any, to the actual content of what the voice or voices are saying to the person, but rather would focus mainly on trying to stop these voices from occurring. In most cases, a psychiatrist would prescribe medication to the person or would teach them distraction techniques so that the voices might stop entirely or, if not stop, at least be less dominant in the person’s experience.

It’s very rare for biological psychiatrists to ask patients questions about what the voices are actually saying, what their content is, or what they might mean. Their rationale is that if these experiences are the result of faulty biological brain processes, then it doesn’t really matter what the content is. What you want to do is stop the phenomenon from occurring. And psychiatrists worry that if the person talks about the voices or listens to the voices or pays attention to the voices that they will further retreat into what a psychiatrist would call a delusional world, a world that’s not real. From this perspective, an important part of treatment is getting the person to understand that their voices are not real and therefore they shouldn’t be paying attention to their content. Instead, they should be doing things to try to stop them.

The Hearing Voices approach takes a very different view, assuming that all psychological experiences are meaningful, and although sometimes it is difficult to determine the meaning, it can ultimately be interpreted or deciphered. Our assumption is that there is always meaning to experience and paying attention to voices can often allow us to understand more about why the voices are there in the first place. So one of the things that we have learned over the past 30 years in research and practical application of the Hearing Voices approach is that when people pay attention to their voices and indeed when they try to understand specific aspects of their voices and the contexts in which they are distressing, it’s extremely helpful.

What happens in hearing voices peer-support groups is that people ask one another detailed questions about their voices in an effort to understand how they work, why they’re there, and what their particular meaning might be for that person. They might ask one another questions like: “What do the voices say?” “How many voices are there?” “Have they changed over time?” “Is the voice you hear today the same as the voice you heard six months ago?” “Are there certain situations where they’re most likely to appear?” “How do you feel when they’re there?” “What purpose do you think they serve?” “What tone do they use?” And so on. In other words, questions designed to help the person get a detailed and contextual understanding of an experience that has probably baffled them and perhaps terrified them over a long period but which they have been taught by mental health professionals to ignore or at least try to ignore. And what we find in hearing voices peer-support groups is that perhaps paradoxically from the point of view of the mainstream mental health perspective, when people focus on their voices and try to understand them, they often decrease in intensity and their distressing aspects become less problematic.

For example, people might become aware of positive voices that they hear, and these positive voices can help to reduce the distress of the negative voices. In fact, the existence of positive voices that many people experience is something that doesn’t even make sense from a biomedical point of view. There wouldn’t even be a way of assuming that there could be positive voices from the point of view that says voices ought automatically to be considered symptoms of psychosis. And, of course, we know that in other cultures and in many subcultures in the United States, voices can have a very important positive and meaningful function. Every spiritual tradition in the world has inspiring leaders who had some kind of experience of hearing voices: Jesus, Moses, Mohammed, the prophets – they all had experiences in which an angel or God spoke to them. And of course, we don’t consider these kinds of experiences to be evidence of psychosis.

Even people who are not prophets but rather are more ordinary practitioners of various spiritual traditions often report some kind of auditory connection to a voice or voices that serve as a guide, something that plays a positive role in their life.  We wouldn’t even know about the existence of such positive voices if we hadn’t delved into these kinds of experiences in greater complexity, as we do in hearing voices groups.

The goal of our specific research project is to understand how exactly hearing voices peer-support groups play such an important and positive role for many people around the world. We know that people find these groups valuable because there are now hundreds of groups all over the world and people often go to great lengths to be able to access a group and to participate in it regularly, but we don’t fully understand precisely what makes these groups so effective. Participation in these groups has helped many people to recover fully from distressing experiences associated with their voices, and our project is focused on being able to identify these specific mechanisms.

JK: Your work with the hearing voices peer-support groups makes clear that the mainstream mental health model is inconsistent and out of sync with the experience of many people who hear voices. To move somewhat more generally to the movement for global mental health, critics have accused the movement of spreading a Western model of mental ill health that is inconsistent with the experiences of people in diverse cultures. What is the role of culture in the experience of madness more generally, and how does including culture in the picture perhaps make this Western mental health model even more problematic?

GH: Well, culture is crucially involved in every aspect of our experience. Indeed, it’s probably a category error to think that we can even separate out some kind of variable called culture and look at it in isolation. There is no aspect of our psychological experience at any moment of our lives that is not shaped by and in response to culture in some respect. So the question is a little bit artificial, but I understand why you’re asking it. And here I think we need to focus specifically on the pathologizing assumptions of Western culture about an experience, for example, like voice hearing, but also many other kinds of experiences that get labeled as mental illness.

As we know, for example, from the important work of Ethan Watters in his book, Crazy Like Us, people in different cultures experience what we might call the same kinds of feelings, perceptions, and thoughts in very different ways. Now again, we can’t be totally certain that they’re exactly the same. There are many methodological issues involved in evaluating private psychological experiences in different cultures. There are problems of translation — what do the words even mean that we’re asking? But still, if we set those problems aside for a moment and just think about overall assumptions about how we understand psychological experience in current biomedical, Western psychiatry – and I emphasize current because this hasn’t always been the case – the assumption is that any distressing experiences that end up getting diagnosed as mental illness come from faulty brain processes and have little to do with the context of someone’s experience and in particular, they have little to do with trauma.

From our experience in the Hearing Voices Network, many, many people identify the causes of their voices, especially their distressing voices, as directly linked to earlier trauma in their lives. The fact that many Western mental health practitioners, but of course not all, ignore trauma makes it very, very difficult to make sense even in our own culture of the kinds of experiences people are having.

But certainly in other cultures where people might understand what is happening to them in terms of, for example, problematic relationships with their families or with their community rather than as some kind of faulty brain process, we see a real disjuncture between the Western biomedical approach and the way people understand their lives on their own. I especially want to emphasize that if we take solely a biological view toward understanding psychological phenomena, we leave out crucial aspects of what makes people’s experience meaningful, especially social, interpersonal, and cultural aspects of their experience and the particularly important role of trauma.

I emphasize that this is the current Western view because prior to the 1970s, and especially from a psychoanalytic point of view, trauma was always considered to be a crucial causal factor in bringing about distressing psychological experiences. And even in the United States prior to the 1960s, the assumption was that people who ended up with a diagnosis of schizophrenia, for example, or any kind of psychotic diagnosis had experienced trauma early in their lives and working through those traumas in adulthood, particularly in psychotherapy, could enable them to fully recover. It is only in the last 30 or 40 years since the biomedical model has become so dominant in the United States, Europe, and the UK, that we have seen such a huge gap between the Western model and other ways of understanding psychological experience.

JK: Thank you. Another criticism of the Movement for Global Mental Health and specifically the Lancet Commission on Global Mental Health has been the failure to include the voices of people with lived experience in the overall project. In your book, “Agnes’s Jacket,” you chronicle the rich history of the psychiatric service user, consumer, and survivor groups developing research and treatments for experiences of madness. In what ways do these personal narratives challenge the global mental health project and how might they be included?

GH: If we don’t start from people’s lived experience, then we rob ourselves of a huge amount of important information that could enable us to understand distressing experiences more fully. For example, if we don’t pay attention to the contexts in which someone’s distress occurs, it becomes much more difficult to help the person figure out how that distress might be lessened. One of the biggest errors I think of the Western biomedical model is to assume that if someone has, for example, a diagnosis of schizophrenia, that their behavior is disordered at every moment and in every context.  In fact, we know that the opposite is true –people’s feelings, experiences, perceptions, thoughts, behaviors, etc. vary a great deal across different contexts and there is crucial information to be gained from understanding those variations and encouraging people to pay attention to them so that they can have a greater degree of autonomy over their own experience.

As I said earlier, this is partly an issue of human rights. The slogan of the disability rights movement, “nothing about us without us,” contains a crucial lesson for all of us to learn. In addition to the human rights aspects of this issue, as I have already noted, we need to have good science, and we don’t have good science if we ignore crucial sources of data. So, for example, one of the things we know from the Hearing Voices Network is that people often fully recover even from very distressing experiences. Even if they have been patients in the mental health system for many years, they can still fully recover. This is not something that the biomedical model assumes to be possible. So if we are exporting to the rest of the world a view that is unduly pessimistic and not based on the actual evidence of what happens in people’s lives, we’re doing everyone a disservice.

There’s an important concept that Dr. Andrew Weil, the natural health practitioner, introduced, which he called “medical hexing,” pointing to examples like a physician saying to a person or to their family, “you’ve got to come to grips with the fact that you’re never going to get better, “ or “You’ve got schizophrenia, and that is a serious and persistent mental illness which you’re  going to have for the rest of your life.” Or, “You have bipolar illness, and that’s a cyclical form of disorder, you’re always going to have these cycles, and nothing is going to be able to stop them.” Andrew Weil argues that it is like putting a hex on someone, basically using the self-fulfilling prophecy in its most negative form to say to the person, “there really isn’t any hope for you here.” And not only is that ethically very problematic, but it’s also factually wrong on the basis of what the evidence that the Hearing Voices Network and many other members of the activist and survivor communities around the world have demonstrated.

JK: Thank you. You’ve spoken today about good science and how including personal and first-person experience actually leads to a better and more robust science for mental health research. How does including first-person experience change the way we even think about what constitutes evidence and effectiveness of various interventions and how would incorporating these perspectives transform our current health care systems and policies?

GH: I think this is really the most important question of all. Evidence in science is of paramount importance, and all of us who have been trained in methodology in graduate school have learned that finding evidence for one’s hypotheses is the crucial activity of science. Hypotheses are not always found to be supported. The criteria for what constitutes evidence is a central question in the philosophy of science and ought to be of concern to everyone who is involved in any kind of mental health initiative.

Unfortunately, the widespread use of medication as a treatment for what gets called mental illnesses has led to a very narrow view and a very quantitative view of what constitutes evidence in the first place. So, for example, the notion of a randomized clinical trial makes a certain sense when what you’re trying to do is evaluate a drug treatment or some other finite intervention. For example, if you have two groups in your study, and you give one group a drug and you don’t give the other group the drug and you have a control group and other proper measures of control in the design of your study, it might be possible to conclude something about whether there is evidence for or against the use of that particular medication or intervention. There’s a certain logic to the use of a randomized clinical trial for that kind of treatment. However, it is a very narrow notion of what constitutes evidence. And we know, for example, from psychotherapy research, that psychotherapy has a profound and powerful effect on many, many people’s lives. But it’s very, very difficult to evaluate the effectiveness of psychotherapy using a randomized clinical trial because we would have to take a group of people and randomly assign them to therapists or no therapists to see whether or not there was any effect of the treatment.

And the crucial thing we know about psychotherapy is that it’s the relationship between the therapist and the patient that is or is not likely to enable change. The relationship is an absolutely crucial part in every form of psychotherapy, and both research and clinical testimony bear this out. So we can’t randomly assign people to therapists in order to evaluate psychotherapy. And this is equally a challenge in our study of hearing voices groups. When we get to something like peer support, we, of course, cannot randomly assign people to groups because the nature of human social life is such that we are going to feel more or less comfortable in a given group. We’re going to find the members and the context of a given group more or less helpful or relevant to the particular situation we’re in and so on. So what we need to do is have a notion of evidence that starts from people’s lived experience and which enables them to articulate in their own way, in their own narrative structures, and in their own vocabulary what it is that is helpful or not helpful about a particular kind of intervention.

What we need in a broader sense are ways of assessing the effectiveness of an intervention using a broader set of methodological tools. This includes, for example, qualitative research, but not only that. It also includes the kinds of measures that people themselves think are important as a way to assess what has helped them or not. We can’t just use a measure, for example, like the number of days in the hospital, which might or might not bear any relation to how the person is experiencing their improvement or lack thereof. In other words, we need to really challenge, on scientific grounds as well as on political grounds and human rights grounds the narrowing of the definition of what constitutes evidence and how we can tell whether or not a given approach is effective.

JK: Thank you very much and thank you for all the incredibly important work you’re doing, and I look forward to seeing the results of your study. 

GH: Thank you so much. It’s great to be part of it. If people want to learn more about my work, there’s lots on my website, www.gailhornstein.com.

The post First-Person Accounts of Madness and Global Mental Health: An Interview with Dr. Gail Hornstein appeared first on Mad In America.

Over the past three weeks, we have published interviews with many of the leading voices in this debate.

Immediately following the release of the report and the beginning of the Summit, on World Mental Health Day, psychiatric epidemiologist, Dr. Melissa Raven, was on the MIA podcast. She questioned the evidence base of the movement, pointing to statistical issues in the prevalence rates of mental disorders internationally, and called for a focus on addressing barriers to health rather than on individualized treatment.

Mental health service-user activists, Jhilmil Breckinridge, of the Bhor Foundation in India, and Dr. Bhargavi Davar, of Transforming Communities for Inclusion (TCI) Asia Pacific were also on the podcast. Each discussed the lack of involvement of service-user and disability rights groups in the UK Summit and Lancet report and laid out alternative frameworks for addressing distress in ways that are sensitive to culture and social context.

Next, Dr. China Mills, a critical psychologist and author of Decolonizing Global Mental Health, spoke to my colleague, Zenobia Morrill, about her experience attending the UK summit and the lack of attention that has been given to the ways in which austerity policies in Britain have contributed to the increased demand for mental health interventions.

You can find these earlier interviews at the links below:

10/10/18 – Interview with Dr. Melissa Raven, psychiatric epidemiologist – The Global ‘Mental Health’ Movement – Cause For Concern

10/20/18 – Interviews with mental health service-user/psychosocial disability rights activists Jhilmil Breckenridge and Dr. Bhargavi Davar – Global Mental Health: An Old System Wearing New Clothes

10/24/18 – Interview by MIA research news editor Zenobia Morrill with Dr. China Mills, a critical psychologist and prominent critic of the global mental health movement – Coloniality, Austerity, and Global Mental Health

Today I am very pleased to announce that we are joined by Dr. Derek Summerfield.

Dr. Summerfield is an honorary senior lecturer at the Institute of Psychiatry in London, former Research Associate at the Refugee Studies Centre at the University of Oxford and consultant at Oxfam. He was born in South Africa and trained in medicine and psychiatry at St. Mary’s Hospital Medical School in London. Dr. Summerfield has published hundreds of articles in medicine and social science and has contributed widely to understanding the impact of war-related trauma and torture on people around the world. He has been an outspoken critic of the global mental health movement for several years, criticizing the medicalization of trauma through PTSD, the exaggerated prevalence rates in the epidemiological data, and the lack of awareness of the different cultural experiences and understandings of distress.

The post Moving Global Mental Health “Outside Our Heads” appeared first on Mad In America.

Justin Karter writes:

On October 9^th and 10^th, 2018, World Mental Health Day, the UK government hosted a Global Mental Health Ministerial Summit with the intention of laying out a course of action to implement mental health policies globally. In the same week, The Lancet Commission on Global Mental Health and Sustainable Development published a report outlining a proposal for “scaling up” mental health care globally. In response, a coalition of mental health activists and service-users have organized an open letter detailing their concerns with the summit and report. The response has attracted the support of policy-makers, psychologists, psychiatrists, and researchers.

In the last episode, we were joined by Dr. Melissa Raven, a critical psychologist and epidemiologist, who discussed problems with the scientific evidence base used by the global mental health movement. She also emphasized the need to consider responses to the distress and suffering of people globally that address the social determinants of mental health, including poverty, education, and healthcare.

Today we turn our focus to the concerns raised by mental health activists in response to the UK summit and the Lancet report. To discuss these issues, we are joined first by Jhilmil Breckenridge, a poet, writer and mental health activist and later by social science researcher Dr. Bhargavi Davar.

Jhilmil is the Founder of Bhor Foundation, an Indian charity, which is active in mental health advocacy, the trauma-informed approach, and enabling other choices to heal apart from the biomedical model. Jhilmil also heads a team leading Mad in Asia Pacific; this is an online webzine working for better rights, justice and inclusion for people with psychosocial disability in the Asia Pacific region. She is currently working on a PhD in Creative Writing in the UK and, for the last three years, she has also been leading an online poetry as therapy group for women recovering from domestic violence. She is working on a few initiatives, both in the UK and India, taking this approach into prisons and asylums. Her debut poetry collection, Reclamation Song, was published in May 2018.

For our second interview, we are joined by Dr. Bhargavi Davar. She identifies as a childhood survivor of psychiatric institutions in India. She went on to train as a philosopher and social science researcher at the Indian Institute of Technology in Bombay and has published and co-edited several books, including Psychoanalysis as a Human Science, Mental Health of Indian Women, and Gendering Mental Health, while also producing collections of poems and short stories. Dr. Davar is an international trainer in the Convention on the Rights of Persons with Disabilities (CRPD) and the founder of the Bapu Trust for Research on Mind and Discourse in Pune, India. This organization aims to give visibility to user/survivor-centred mental health advocacy and studies traditional healing systems in India.

The post Global Mental Health: An Old System Wearing New Clothes appeared first on Mad In America.

Justin Karter writes:

In this episode, we interview Dr. Melissa Raven, who is a psychiatric epidemiologist, policy analyst and postdoctoral research fellow in the Critical and Ethical Mental Health research group at the University of Adelaide, South Australia. Originally qualified as a clinical psychologist, she then worked as a lecturer and researcher in public health and primary health care. Her current mental health research and advocacy is informed by a strong social determinants perspective and a strong critical orientation, which she applies to a range of topics, including suicide prevention, workplace mental health, (over)diagnosis, (inappropriate) prescribing, and conflicts of interest in mental health and the broader health/welfare arena.

On October 10^th, 2018, World Mental Health Day, The Lancet Commission on Global Mental Health and Sustainable Development published a report outlining a proposal to “scale up” mental health care globally. At the same time, the UK government is hosting a Global Mental Health Ministerial Summit with the intention of laying out a course of action to implement these mental health policies globally.

In response, a coalition of mental health activists and service-users have organized an open letter detailing their concerns with the summit and report. The response has attracted the support of critical professionals, psychologists, psychiatrists, and researchers.

The post The Global ‘Mental Health’ Movement – Cause For Concern appeared first on Mad In America.

In 2015 as an editor he launched a book series entitled Psychoanalytic Studies: Clinical, Social, and Cultural Contexts, with Lexington Books. In August 2017, with colleagues Dr. Awad Ibrahim (University of Ottawa), Dr. Gabrielle Ivinson (Manchester Metropolitan University), and Dr. Marek Tesar (University of Auckland), as series co-editors, he launched a book series, Critical Childhood & Youth Studies: Clinical, educational, social and cultural inquiry, to be published by Lexington Books.

Professor O’Loughlin talks about his childhood experiences and how they influenced his narrative and conversational approach to psychological distress.

In this episode we discuss

• How Dr. O’Loughlin’s early experiences growing up in Ireland led to a deep interest in social justice issues, particularly poverty and inequality.
• That as a young man in college he engaged in charity work and activism.
• How, more recently, he became interested in psychiatry when he was appointed as a lecturer in clinical psychology, but realised that there weren’t required courses on trauma or psychosis.
• That this led to teaching courses in intergenerational trauma and the way that our history shapes us as people.
• That Michael has engaged in autobiographical writing to understand the way that deprivations and injustices that he experienced had a formative impact on his own thinking and writing.
• That another course on madness and psychosis was perceived by clinical psychology students as radical, leading to a realisation that mainstream psychology is a very conservative discipline.
• How he became interested in interviewing psychiatric patients and telling stories that represented a diverse group of people and experiences of psychiatric services.
• That this led to a project at Fountain House in New York City to see if narratives could be reinforced and shared.
• That Michael does not himself use the terms mental illness or disorder because he feels that we need to be flexible and that even this terminology can be stigmatizing.
• How he has recently focused on creating spaces where participants can share their experiences and stories and it shouldn’t be a classification or categorization exercise.
• That he has found many that have experienced the psychiatric system have felt that the system impeded their recovery.
• That a collaborative team of Adelphi academics, Fountain House staff and Fountain House members will together publish research.
• That Professor O’Loughlin feels that psychology and psychiatry are traditional and reactive disciplines and that psychiatry has been driven by pharmacological concerns.
• How Michael’s work with children is grounded in his own childhood experiences and a sense that human beings need nurturing spaces and validation.
• That Michael is extremely disturbed about the medicating of young children with drugs that are not known to be safe for them such as antipsychotic drugs.
• The unwillingness to understand that a child’s distress has an origin and that we have a responsibility to engage with the child and create a space for them to communicate.
• How we define normality within such a narrow range that children find it very difficult to conform to society’s expectations.
• That there seems to be little room for a child in school, only room for a student.
• That psychoanalysis has tools to understand our emotions and experiences but also has tools to help understand societal drivers that may underlie psychological distress.
• The worry that talking therapies are being replaced by tick lists and categories and that we need to bring stories back into psychology.

Relevant links:

Michael O’Loughlin, PhD

Psychoanalytic Studies: Clinical, Social, and Cultural Contexts

Arthur Frank

Kathryn Bond Stockton

To get in touch with us email: podcasts@madinamerica.com

© Mad in America 2017

The post Michael O’Loughlin: Exploring Narrative Approaches to Psychological Distress appeared first on Mad In America.

The authors of the study, quoting Borchert (2003), write, “The mistreatment of LGBT prisoners goes above and beyond the normal degradation meted out by the state, enacting a disparate set of punishments for LGBT people markedly different than prisoners perceived as heterosexual and/or gender conforming.”

Inmates were included in this study if they identified as LGBT or if they self-reported having a same sex sexual encounter before incarceration. Currently, correctional facilities do not have policies designed to accommodate transgender prisoners. Among the male prison population, 9.3% were sexual minorities and among the female population, 42.1% were sexual minorities. This is compared to the estimates of 3.8% and 3.4%, respectively, in the general US population.

The researchers estimate, based on these data, that “the rate of incarceration of LGBT persons is approximately 3 times higher than is the already high general US incarceration rate of 612 per 100 000 US residents aged 18 years or older in 2014.19.”

The high proportion of sexual minorities in prison cannot be explained by the data available in this study, but the authors suggest that a combination of prejudice, stigma, and social disadvantage “may lead to discriminatory treatment, from initial contact with the police through various stages of the criminal justice system.”

“Among factors that may increase the risk of incarceration of sexual minorities are stressors related to family rejection, the use of illegal drugs, and community-level marginalization related to the stigmatization of lesbian, gay, bisexual, and transgender people.”

Using an intersectional approach, Ann Cammett, a professor at the CUNY school of law, studies how low-income queer people are affected by the criminal justice system in the United States. She finds that varying experiences of oppression and marginalization raise the risk that an individual will be criminalized and that “queer people are drawn into and experience the carceral system because of sexual identities and expression.”

Up to forty percent of homeless youth identify as LGBT and their homelessness is often a product of their coming out. Without family support, queer youth are vulnerable to pursuing criminal activity as a means of survival and early contact with the criminal justice system reduces access to support services.

Evidence also demonstrates that queer defendants are disproportionately given harsher sentences and face bias throughout the judicial process.

Across both groups, sexual minorities were more likely to be put in solitary confinement or other disciplinary segregation when in prison. Both groups also show a significantly increased risk of sexual victimization at the hands of prison staff and other inmates when compared to heterosexual prisoners. Sexual minorities had significantly greater odds of experiencing sexual abuse in childhood as well.

“Sexual minority inmates, who are put into segregation in significantly greater numbers, experience deprivation that is psychologically difficult to endure. Widespread sexual victimization compounds the risk these inmates often face.”

The researchers found that both gay and bisexual male prisoners were at an increased risk for poor mental health when compared to heterosexual prisoners. Similarly, lesbian or bisexual women in prisons had poorer mental health and greater psychological distress than straight women in prison. The researchers conclude:

“Although incarceration can lead to distress in both sexual minorities and heterosexuals, we found that sexual minorities in jails and prisons experience harsher conditions—including disproportionate sexual victimization, administrative or punitive segregation, and longer sentences—which may place them at higher risk for distress than that of the heterosexual incarcerated population.”

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Meyer, I. H., Flores, A. R., Stemple, L., Romero, A. P., Wilson, B. D., & Herman, J. L. (2017). Incarceration rates and traits of sexual minorities in the United States: National Inmate Survey, 2011–2012. American journal of public health, 107(2), 267-273. (Full Text)

The post Study Finds Mistreatment and Psychological Distress Among LGBT Prisoners in the US appeared first on Mad In America.

“Overall, the findings suggest that the majority of physicians is generally aware of placebo and nocebo effects in antidepressants caused by psychological factors such as expectation and experience from patient and–to a lower degree–physician,” the authors write. “However, these effects are given a subsidiary role when compared to pure pharmacological effects.”

In recent years, researchers have paid increased attention to placebo and nocebo effects in medical research. Placebo refers to the positive effects a drug has that are not directly related to its pharmacological properties. “Non-specific” factors, such as patient and doctor expectations, have been shown to have an important and measurable impact on different symptoms. These same factors can also have negative or nocebo effects on individuals, however, when expectations and contexts lead to unwanted side-effects.

Past studies have suggested that placebo accounts for up to 75% of antidepressant effects, but psychiatrists and other physicians attribute only 26% of their success to these nonspecific factors. It is perhaps telling, however, that in past surveys 38% of psychiatrists admitted to prescribing sub-therapeutic doses – or doses lower than believed necessary to have an effect – of antidepressants. The researchers suggest that the underlying aim in these instances would be to induce placebo effects.

To explore physicians beliefs about the nature of placebo and nocebo effects for antidepressants, the authors of this study recruited 146 doctors, and 87 completed an online questionnaire. The majority of these were specialized physicians, and about 40% of these were psychiatrists.

Nearly 90% of those surveyed reported believing that antidepressants to be effective and only one physician rated them as largely ineffective. Using a rating slider, each doctor was asked to estimate the percentage of total effectiveness they attributed to pharmacological effects, patients’ expectations, patients’ former experiences, the physician-patient relationship, physician expectations, and spontaneous remission.

As the figure demonstrates, 93% of physicians believed pharmacological effects were most significant. Additionally, close to two-thirds felt that patient’s expectations and patient’s former experiences were important.

To a lesser extent, physicians acknowledged the various ways their own roles impacted antidepressant effectiveness. 58.6% recognized that the relationship between the doctor and patient played a role and 41.4% of the physicians knew their own expectations as a possible mechanism of effectiveness.

Only one-third of the physicians, however, reported that spontaneous remission of depressive symptoms could contribute to the perceived effectiveness of antidepressants. In contrast, a 2013 meta-analysis found that 23% of prevalent cases of untreated depression will remit within three months, 32% within six months and 53% within twelve months. 

When comparing the relative importance of these different factors on overall effectiveness, “physicians’ endorsement of the pharmacological explanatory model succeeded nonspecific factors substantially, as the vast majority of physicians agreed to the pharmacological effect of antidepressants and attributed more than half of overall effectiveness to it.”

The researchers point out that doctors underestimated the placebo effect of antidepressants compared to results from research trials. They explain:

“[Antidepressant] contribution is rated lower than evidence-based data synthesis from clinical studies with placebo arms suggest (39% in our study vs. 68–75% in meta-analyses. Although these meta-analyses are based on placebo administration instead of placebo effects within the application of active drugs, we consider it a helpful benchmark to frame the estimation of nonspecific mechanisms of efficacy in our sample.”

The pattern for nocebo effects was similar. Physicians attributed unwanted side-effects primarily to the pharmacological properties of the drug. Patient expectations and past experiences also acknowledged, with close to 60% endorsing these factors.

In summary, the researchers write:

“Ninety percent of the participants endorsed the general effectiveness of antidepressants. Thus, this study documents physicians’ general belief in the benefits of antidepressant treatment. The physicians’ explanatory models for antidepressant effectiveness showed clear favors towards a pharmacological factor. Beyond this, the majority of the participating physicians were aware of the importance of placebo effects in antidepressant effectiveness. They stated their belief in psychological factors such as the patient’s expectations and prior experience, as well as the patient-physician-relationship. However, they did not equally acknowledge the importance of physician’s own expectations.”

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Kampermann, L., Nestoriuc, Y., & Shedden-Mora, M. C. (2017). Physicians’ beliefs about placebo and nocebo effects in antidepressants–an online survey among German practitioners. PloS one, 12(5), e0178719. (Full Text)

The post Study Investigates Physicians’ Beliefs About Placebo and Nocebo Effects of Antidepressants appeared first on Mad In America.

“The urgent need for a shift in approach should prioritize policy innovation at the population level,” he writes, “targeting social determinants and abandon the predominant medical model that seeks to cure individuals by targeting ‘disorders.’”

The report by Pūras aims to inform global policy makers and healthcare workers of the current challenges facing mental health care and lay out priorities and opportunities for improving existing systems. The report identifies three major obstacles to mental health reform, including the dominance of the biomedical model, power asymmetries, and the biased use of evidence in mental health research.

While he acknowledges that many other organizations have called for improvements to existing services, he expresses concerns that these calls, based on “alarming statistics to indicate the scale and economic burden of  ‘mental disorders,’” are too rooted in the biomedical model to “address the grossly unmet need for rights-based mental health services for all.”

“The focus on treating individual conditions inevitably leads to policy arrangements, systems and services that create narrow, ineffective and potentially harmful outcomes,” he writes. “It paves the way for further medicalization of global mental health, distracting policymakers from addressing the main risk and protective factors affecting mental health for everyone.”

Pūras also lays out an alternative framework for mental health care that is founded on a human rights paradigm. Informed consent makes up a key part of the rights-based approach to mental health care and Pūras argues that forced treatment is ineffective and “perpetuates power imbalances in care relationships, causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services.”

In addition, this paradigm shift means that “rights-based strategies” must also target the social determinants of mental health and seek to improve the environments and communities in which people live. Pūras writes:

“The fact that children spend a significant amount of time in schools and most adults at the workplace, means that rights-based action must promote healthy, safe and enabling environments that are free from violence, discrimination and other forms of abuse. Likewise, a person’s mental health affects life within those domains and is integral to shaping the health of communities and populations. Population-based approaches to mental health promotion move health systems beyond individualized responses towards action on a range of structural barriers and inequalities (social determinants) that can negatively affect mental health.”

When more severe forms of mental distress are present, the reports calls for a rapid shift away from “coercion, medicalization, and exclusion” and towards evidence-based recovery services. “People can and do recover from even the most severe mental health conditions and go on to live full and rich lives,” he adds.

Pūras highlights existing recovery-based services including “peer support, when not compromised,” and “recovery colleges, club houses and peer-led crisis houses.”  Open Dialogue and the Soteria House project are both given as long-standing examples of rights-based and effective services for mental health crisis.

“Today, there are unique opportunities for mental health. The international recognition of mental health as a global health imperative, including within the 2030 Sustainable Development Agenda, is welcome progress. The right to health framework offers guidance to States on how rights-based policies and investments must be directed to secure dignity and well-being for all. To reach parity between physical and mental health, mental health must be integrated in primary and general health care through the participation of all stakeholders in the development of public policies that address the underlying determinants. Effective psychosocial interventions in the community should be scaled up and the culture of coercion, isolation and excessive medicalization abandoned.”

Finally, Pūras offers several policy recommendations for confronting global mental health challenges from a rights-based perspective. Among others, his suggestions include:

• States take immediate measures to establish inclusive and meaningful participatory frameworks in the design of and decision-making around public policy, to include, inter alia, psychologists, social workers, nurses, users of services, civil society and those living in poverty and in the most vulnerable situations;
• States and other relevant stakeholders, including academic institutions, recalibrate mental health research priorities to promote independent, qualitative and participatory social science research and research platforms, exploring alternative service models that are non-coercive;
• End all financial support for segregated residential mental health institutions, large psychiatric hospitals and other segregated facilities and service;
• Ensure that users are involved in the design, implementation, delivery and evaluation of mental health services, systems and policies;
• Invest in psychosocial services, that are integrated into primary care and community services to empower users and respect their autonomy.

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Read the UN press release here: http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=21689&LangID=E

Read the full report here: https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement

The post United Nations Report Calls for Revolution in Mental Health Care appeared first on Mad In America.

“Our data suggest that the suicide rates among discharged patients have not decreased in the past 50 years,” the authors write. “This is a disturbing finding considering the increase in community psychiatry and the availability of a range of new treatments during this period.”

Last year, Mark Olfson and colleagues examined Medicaid data of patients hospitalized with a diagnosis of depressive disorder, bipolar disorder, schizophrenia, or substance use disorder. They found that these patients were 15 times more likely to commit suicide than similarly matched patients who were treated for non-mental health issues. (See MIA report)

The researchers of this latest study note, however, that while past studies have “described the phenomenon of postdischarge suicide as a ‘nightmare and disgrace,’ these views may have actually been formed in reaction to underestimates of the problem.

“We agree,” they write, but “our meta-analytic estimate during the same duration of follow-up is more than 6 times higher.”

This study aimed to examine what progress had been made in postdischarge suicide rates, and how these rates play out over time. The study followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A total of 100 studies with 183 separate samples of discharged patients from different countries were included in this analysis.

The analysis revealed a pooled suicide rate after release of 484 per 100 000 person-years, but the rate per sample varied somewhat widely. There was a distinct trend toward higher suicide rates in more recent studies. The difference in suicide rates after hospitalization did not differ significantly by country or geographic location.

It is important to note that while the risk is increasing and is much greater than the general population, these statistics suggest that roughly 0.28% of all discharged patients die by suicide within the first three months after leaving the hospital.

In total, adolescents and older patients both had lower suicide rates than adult samples. Patients with diagnoses of psychosis, affective disorder, and mixed other diagnoses had similar suicide rates, but patients who were originally admitted for suicidality were at an increased risk. Suicide rates did not differ significantly by sex.

“We identified a large number of studies reporting more than 17 000 suicides in almost 5 million person-years at a pooled rate of 484 per 100 000 person-years,” the authors write.

“This figure is more than 3 times the suicide rate estimated in a comparable study of the suicide rate among inpatients and 44 times the global suicide rate of 11.4 per 100 000 patients per year in 2012.”

The researchers state that their results “should curb enthusiasm for restrictive interventions” that attempt to target certain patient groups labeled as “high risk” for suicide.

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Read the full study open-access here: http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2629522

The post Risk of Suicide After Hospitalization Even Higher Than Previously Estimated appeared first on Mad In America.

“Evidence and the experience of rights-holders now tells us that the dominant biomedical narrative of depression as a ‘burden’ on individuals and societies is shortsighted and insufficient for developing appropriate responses in policy and in practice. This is a widespread and systemic public health and human rights issue which demands urgent reconsideration of how we invest in mental health and how we manage conditions such as depression,” he writes.

“Regrettably, recent decades have been marked with excessive medicalization of mental health and the overuse of biomedical interventions, including in the treatment of depression and suicide prevention. The biased and selective use of research outcomes has negatively influenced mental health policies and services. Important stakeholders, including the general public, rights holders using mental health services, policymakers, medical students, and medical doctors have been misinformed. The use of psychotropic medications as the first line treatment for depression and other conditions is, quite simply, unsupported by the evidence. The excessive use of medications and other biomedical interventions, based on a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned.”

Dainius Pūras has been assigned as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health since June of 2014. He is the Head of the Centre for Child Psychiatry social pediatrics at Vilnius University in Lithuania and also teaches in global health law at Georgetown University.

Read the full statement here →­

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