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Two Kinds of Risk, but the Mental Health System Only Acknowledges One:

As I pointed out at a recent mental health system meeting in my county, people with mental health problems face two kinds of risks. 

The first sort of risk is from the mental health problem itself.  Unless the person finds effective treatment, mental health problems can often cause high distress, disability, and even result in death, such as from suicide.

The second sort of risk, however, is the possibility that the person may receive an unnecessarily hazardous treatment.  For example, some people recover from psychosis without antipsychotics, and some people aren’t helped by antipsychotics, and some are helped but not enough to justify the hazards, and some could be better helped by less hazardous methods if such methods were made available.  So when antipsychotics are used routinely for everyone with psychosis, it follows that many people will be exposed to a treatment which will be unnecessarily hazardous to them.  This treatment itself can often cause high distress, disability, and even result in death.

(Some argue that most psychiatric treatment offers more risk than help:  for a good summary of those arguments, see Robert Whitaker’s new book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America  If you click this link you can both find out more about the book as well as get many of the main points and the supporting data on the website.)

The mental health system is organized to prevent the first kind of risk, the risk from the mental problem itself.   Billions are spent to address this risk.

Strangely enough though, the second kind of risk is usually not even discussed within a mental health system.  At the meeting in which I was talking, we wanted a document on guidelines for treatment to mention this sort of risk, but our attempt to get it simply mentioned was labeled as “inflammatory” and was being denied.  Why?

How did the system get so “unbalanced”, so as to spend billions to address one kind of risk, while forbidding even mention of a second kind of risk, which is also potentially deadly?

One reason is that the steps needed to address the first kind of risk involve looking at possible flaws in the methods and behaviors of mental health consumers, while the steps needed to address the second kind of risk involve looking at possible flaws in the methods and behaviors of mental health professionals. 

Mental health professionals are experts at looking for flaws in “patients” but are extremely poor at critically examining themselves.  This partly follows from the excessively polarized nature of the way mental health problems are defined:  some people are labeled as “insane” or “ill” while others are defined as “sane” and as entirely benevolent helpers:  any rejection of offered” treatments” is seen as a result of “lack of insight into the illness,” rather than being even possibly due to actual problems with the treatment being offered.

I work as a therapist, specializing in cognitive therapy for psychosis.  I find it is usually easier to hold a collaborative conversation with my clients about possible problems with their world view and with the way they are approaching things and behaving, than it is to hold such a conversation with mental health professionals aligned with the dominant paradigm about possible problems in their worldview and the way they are dealing with mental health consumers.  In other words, it seems that the consumers have more insight into their own imperfections than does the mental health system into its imperfections.

I find that the best sorts of mental health programs allow everyone and everyone’s assumptions to be questioned, including, or even especially including, the professionals.  In this kind of climate, both risks from lack of treatment and risks of possibly unnecessarily hazardous treatment will naturally be discussed, along with possible alternative options, and “balance” can be achieved, while everyone is honored as a human being with something to say.  Mental health programs that do this are less sure of themselves, but in their lack of certainty, are incredibly more competent in actually helping people.

9 comments… add one
  • IMO, it lies all in the nature of the institution of psychiatry (which most places dominates the mh system in general) itself. Why was psychiatry established, if not to label people who hold from the predominant ideology deviating views, beliefs, etc. as being incorrect (“deluded”, “insane”), and to relieve society from the disturbance these deviating views, beliefs, etc., by questioning (sic) the predominant ideology represent? Psychiatrists are a kind of “mind or thought police”. In order to be able to do which they are appointed to do by society, they, their thoughts, opinions, beliefs, etc., need to be indisputable. The moment their authority no longer is absolute their labels become worthless, and if their labels become worthless, they’re out of business. So, it is indeed “inflammatory” (it actually equals to a shout-out for a revolution 😀 ) to suggest that the system maybe is not as indisputable as it wants us to believe it is.

    I don’t say that the individual psychiatrist or other mh-worker is aware of that they’re not supposed to help people in distress, but rather to help society get rid of people in distress. But this idea is the foundation on which psychiatry is built, and everything in the mainstream mh system is imbued with it.

    • Hi Marian,

      Yes, this is a big piece of why psychiatry is resistant to criticism – in itself psychiatry represents part of the dominant culture’s resistance to forms of experience that threaten it. People who work in psychiatry and the mental health establishment often got ahead in their own lives by conforming, and so their idea of “helping” people is to help them conform too, whether people like it or not!

      I walked into a group room at our county mental health agency yesterday, and saw the handout of the day used in the group that had just finished up. It was about “rebellion” and asked people to reflect on the role rebellion had played in their lives (it seemed focused on noticing problems of course) and then had people look for ways they might change, to be less rebellious. Talk about conformist! If I was doing the group, I would have looked at both positives and negatives that came about as a result of rebeliion, and then might have had people reflect on how to select the right times and places to be rebellious and how to be more effective at it when they did!

  • Ron: I remember that I once told my therapist that I felt like I’d never got done with youth rebellion, or even “the terrible two/three” in my life. Luckily, she didn’t tell me how “bad” it was to be rebellious, but, on the contrary, confirmed what I’d thought beforehand, that both stages in life were extremely important for one’s personal development, one’s individuation, and should never be suppressed.

    Maybe it’s a coincidence, maybe it’s just me, but most of the consumers I know are people with what appears to me an almost symbiotic relationship with their parents.

  • “Maybe it’s a coincidence, maybe it’s just me, but most of the consumers I know are people with what appears to me an almost symbiotic relationship with their parents.”

    Speaking as a parent who has been waiting for her son to rebel, but he doesn’t (unless you consider psychosis a form of rebellion, which I do) what can be done about this symbiotic relationship? This is a real problem. It is preventing him (and us!) from moving on.

  • I don’t think it is a coincidence that many of those receiving treatment are lacking independence from parents.

    As Rossa suggests, psychosis can be seen as a form of rebellion, though not carried out with the best sort of judgment or discretion. The rebellion then gets defined as “illness” and everyone, including the consumer, organizes to prevent more of it, and the parents of course get closer to the child since this is necessary due to the child’s “illness.” Medications given also suppress independent thinking and acting. Since independent thinking and acting are suppressed, the child never sorts out what might have been good about their rebellion versus what was “too much” or a mistake.

    A better way would be to find some good in the rebellion, and look for ways to rebel in the future with more discretion and skill, resulting in more success. When rebellion is accomplished successfully, then young people can reengage with parents now as equals, with their own autonomy.

    This is all much easier said than done, but I think that is the overall road map for what has to happen. A more collaborative and effective mental health system would be less sure about what was “illness” and what was healthy, and would help people find a healthy core within stuff that gets labelled “psychotic.”

  • Thanks for these suggestions. I wish the doctors had seen it for what it probably was, ineffective rebellion. The treatment that followed can be classified as massive overreaction on everybody’s part.

  • Rossa: I’ve been thinking about your question, and ended up with the same conclusion, I use to end up with: if you want someone to take responsibility for their actions, the first thing you have to do is taking responsibility yourself, and doing so will automatically lead to you doing the second thing necessary, which is giving the other the space to take responsibility for him-/herself. It’s the same with everything else in life. If it is that you want someone to truly accept and love who they are, if you want them to rebel and liberate themselves, or whatever else.

    So, are you yourself done with rebelling and liberating yourself, so that you, unconditionally, can allow your son to do the same? Unconditionally not meaning in regard to form, but in regard to contents. Of course, as Ron is on to, “psychosis” is a form of rebellion that is rather inefficient (at least in our culture that doesn’t understand it), sometimes even dangerous (especially if our culture’s blindness ends you up in a locked ward… ). I don’t think, it is absolutely necessary to have reached a state of complete self-respect, self-love, freedom, etc. oneself, but I think it is necessary to be consciously aware and in acceptance of to which extent one has reached these ideals. While that in itself can be tough enough.

  • Thanks! I think my son is teaching me that the status quo needs a face-lift.

  • Thanks for this dialogue. It is entirely relevant to what is occuring with my son at the moment. He’s been off neuroleptics and a whole bag of other psychiatric drugs for over 15 months now. He’s worked through about 250 hours of psychotherapy and it’s had a positive impact. He worked successfully last summer, attended university this past year and was on the dean’s honor roll. He successfully completed the first year of his studies.

    He has a number of accomplishments and achieved goals that he can now be proud of. He has been rebelling considerably the past few months and it’s some to a head. So what do I do? I put him out. I believe this is the essence of taking responsibility in life and I also agree it holds the possibility for transforming our relationship from parent and child to two adults. We’ll see what choices he makes from here. I think as caregiver parents it is critical we move beyond our own fear for relapse to allowing our child (23 in this case) to take responsibility for their life.

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