[Written in 2011.]
The mental health system in all Western countries is failing, especially when you consider the intensely poor outcomes for people with the most serious issues, such as psychosis. Having been a psychotherapist in New York City, I have given much thought to the mental health system’s failure and have come up with a new theoretical model for the system, from top to bottom. I hereby present it.
1) Abandon Diagnosis and the DSM
My experience as a therapist has taught me that diagnosing people does not further their healing. The diagnostic categories we presently use are so often arbitrary, misleading, stigmatizing, or just downright wrong (and at times all of these) that they end up doing far more harm than good. In fact, I have rarely seen cases where they definitively help anyone.
Also, DSM diagnoses medicalize both emotional problems and their consequences, which is about as arbitrary as using legal, moral, or religious criteria by which to assess people’s emotional conflicts. Also, if the basic medical tenet of “first, do no harm” is being violated by medicalizing — and often, consequently, drugging — emotional problems, then one would think the medical profession would be the first to realize that they are operating outside their appropriate sphere of influence.
This said, who does benefit from diagnosis and the DSM? That is easy. First, the pharmaceutical industry does. They now have drugs marketed to correspond to every diagnosis, and it’s no surprise why they want countless more diagnoses added to the DSM: money! Second, psychiatry benefits from diagnosis. It gives them a reason to be — and places them inappropriately at the top of the system’s power hierarchy. If diagnoses were scrapped what role would be left for psychiatrists, especially the far majority who prescribe pills for a living? And third, the saddest group to benefit from diagnosis is a not insignificant subset of consumers themselves: those who are so broken, both by the traumas of their childhood and the traumas they’ve suffered at the hands of psychiatry, that they have lost hope. Diagnosis gives them an excuse not to have to struggle anymore. It tells them that their brains are hopelessly broken and that they can never recover. And far too many find a tragic comfort in that.
But what would we do without diagnosis? This is also an easy answer: we’d have to start listening to people, and to ourselves, instead of putting ourselves and others in rigid little voted-on categories that tell so little about our personalities, our histories, or the paths we need for healing. If we really start listening to ourselves as people, people with all the nuanced feelings and complexities and histories of individuals, we open the door to real healing.
2) Reverse the power hierarchy of the system: place clients at the top and psychiatrists at the bottom.
At present, the mental health system’s power hierarchy operates with psychiatrists at the top and clients at the bottom. Psychologists, therapists, nurses, and social workers all generally fall somewhere in the middle of the hierarchy. The present system claims to work for the benefit of the client, and the benefit of his recovery, but this is false. If the system really worked so well why are outcomes so poor? Why are psychiatric disability rates so high? Why do so many people end up taking psychiatric drugs for life? Why do so many people distrust the psychiatric system? Why is there such a widespread psychiatric survivor movement, not to mention an antipsychiatry movement?
When this hierarchy is reversed, and psychiatrists are given the chance to do what they should have been doing in the first place, which is ruling out real organic causes of seeming mental health problems, the client naturally becomes the person ultimately responsible for his own treatment. This is empowering. When life reminds him, in a healthy, nurturing, and firm way, that the power of ultimately responsibility is his, he experiences three things: a) the ultimate healthy pressure within himself to self-reflect; b) the ultimate inner motivation to take his own life seriously, and: c) the impetus to make better decisions. This might be terrifying for a time, especially if he feels out of control and has a childhood history lacking in healthy, nurturing models and rife with inappropriate power dynamics with adults, but here others can help him. Thus, when he decides who he wants to work for him and what kind of help he wants — if any — he has to engage his own critical faculties, and thus he takes an inevitable step toward the maturity and independence necessary for his healing and his life.
3) Remove all force from treatment: no forced medication, no forced hospitalization, no forced restraint.
Force disempowers. When a system forces what it thinks is best onto a person, it sends him the message that he is a child, and a child in the ugliest sense of the word. It tells him that he is incompetent and unable to make decisions in his own best interest and that powerful others, the arbiters of the system, are his new parents, and parents in the ugliest sense of the word. It tells him that others know his inner self better than he knows himself, and that only through doing things the others’ way will he gain a better life. No matter that there is an extensive literature on people who have been physically and emotionally traumatized from being forced onto dangerous medications (and other psychiatric treatments, like ECT) that they did not want. And no matter that there is a huge cadre of people who know all too well the traumatizing effects of being stripped of their liberty “for their own good.” Well, the fact of the matter is that these things do matter, and they must matter.
Yes, some people are out of control with their behavior, but when we stop forcing them to “behave,” and instead offer them better and earlier and more respectful opportunities for self-nurturance and self-growth and self-study, we offer something so much more age appropriate and humane.
Also, when we remove force from the mental health equation, we make the mental health field a much less appealing harbor for workers with streaks of sadism. Control freaks cannot thrive professionally in an environment devoid of systematic control. And this change is all the more relevant when we consider the number of adults whose emotional problems result directly from childhoods dominated by controlling, inappropriate adults. Shouldn’t the mental health system avoid reflecting the worst of its clients’ childhood histories, and instead reflect a healthier ideal?
4) Clients have a right to commit suicide, and no one has a right to stop them.
Although this sounds provocative, I mean it in earnest. Allowing clients the right to commit suicide removes the double-binding dual role therapists are forced into when dealing with suicidal clients. At present, clinicians are on the one hand supposed to “be there” for the client and respect his autonomy, yet on the other hand simultaneously determine at what point to abandon their supportive relationship with him, take control of his life, and hospitalize him (or drug him into oblivion). At present clinicians can be held responsible if a client commits suicide — which suggests that the clinician participated in murdering him. To me this begs three questions:
- How in the world does this respect, much less nurture, the autonomy of the client?
- Who says the therapist is supposed to provide the client with the will to live?
- Are therapists supposed to be gods — who also fully prevent the will to die?
When people sometimes comment sneeringly that therapists and psychiatrists believe themselves to be gods, we really need to look no further than the present-day system’s silly standards of care. When we instead create a professional standard of care that treats professionals like the fallible people they so often are, and not gods, professionals will have a much better chance to come down to earth and connect face-to-face and heart-to-heart with those seeking their help.
Meanwhile, in the new system the onus of responsibility for suicide would fall entirely on the client. This would massively free up the therapist to do his real job: to listen to the client, to be emotionally present with the client, to meet the client where he is at, and to respect the client’s autonomy, that is, to respect that he is a human being with an internal locus of control. As the result of this I strongly suspect we’d see a lot fewer suicides in clients, because we’d actually start giving therapists the opportunity to devote their full energy toward doing their jobs: catalyzing healing.
5) All mental health professionals are bound by a primary, basic principle: complete and absolute confidentiality.
The present-day caveats in the confidentiality principle are like cancer in the mental health field. We must remove the therapist’s duty to warn potential victims, remove concepts therapists are supposed to red-flag such as “danger-to-self” and “danger-to-others,” and remove from therapists’ job description the duty to protect children legally from the abusiveness of their clients.
At present therapists are forced to play a conflicting dual role: they work for their client, but only up to a point, and when this vague and arbitrary point is crossed they suddenly become agents of the state. They have to play policemen with any client who admits to certain proscribed deviance. This disturbs the solidity and potential usefulness of the client-therapist relationship first because it makes many clients terrified to tell therapists what they are really thinking or doing or planning, and second because it makes good therapists anxious that if the client says anything that crosses that vague and arbitrary line then the entire therapeutic role will be thrown to the wolves because the the therapist will be forced to betray the direction and focus and energy of his side of the relationship.
With complete confidentiality in place, the therapist would be provided a rock-solid foundation from which to work. His job would then become crystal clear: to be there for his client, and to be there 100%, no ifs, ands, or buts. If his clients tells him dangerous or perverse or violent thoughts of fantasies, the therapist, rather than becoming obsessed about the legality of the situation and the arbitrary ethics of the field, instead becomes emotionally mandated to double his energies toward becoming a better listener and a more devoted, multifaceted ally. And in my experience, when people who think or behave abusively or violently or perversely have a real and trusted and mature confidant on their side, one who won’t switch teams when the going gets rough, they become much less likely to act in destructive or harmful ways, because they don’t have to keep everything bottled up under the high pressure of private silence. Instead they are finally provided an ally who can help them work through their issues. And don’t we all need that?
6) Get rid of lawsuits against mental health workers.
It does not serve the greater good of clients’ recovery if therapists live in constant fear or anxiety of getting sued — and having their own lives destroyed — if something goes wrong with their clients. Yes, therapists can be incompetent and need to be held accountable for that, but, as in most European countries, determining that degree of incompetence should be the role of professional licensing boards, not the legal system. There is a reason that so many European clinicians think that lawsuits against mental health professionals is an insane concept. It is.
At present most American clinicians, especially if they work privately, are required to get malpractice insurance. At times this can be extremely expensive, even prohibitively so. Also, any clinician who has filled out the forms for malpractice insurance, especially after answering the same ugly little questions several years in a row, is likely to start thinking differently about their practice. Since therapists who work with higher risk or less stable clients are more likely to be sued, why would any system want to give disincentives for therapists to work with the most troubled people? If anything, the system should give more incentives for those clinicians who want to devote their minds and hearts and souls to those who could use their help the most.
7) Clinicians are allowed to refuse to work with clients.
Just as clients should not be forced to engage in any form of treatment, clinicians should not be forced at any time to work with any particular client. All treatment, like all healthy, non-therapeutic relationships, must be voluntary from both sides. This might render some clients without any treatment providers, but, incidentally, that is already profoundly the case in the modern mental health system, and certainly much more so presently than it would be in this proposed mental health system. Basically, the purpose behind this particular revamp is that it would allow clinicians one final area in which they would retain their personal autonomy — the right to remove themselves from a particular relationship if they wish.
Interestingly, by and large this item does not entail an entire revamping of the present system. Instead it just operates as a reminder of a healthy component of all human relationships, or at least adult relationships: that they are voluntary. The reason I stress this item here is that this entire list so revolutionizes the power dynamics between clinicians and client that I want to make clear that my goal is not to disempower clinicians. Incidentally, the right of therapists to remove themselves from the therapeutic relationship represents their ultimate power; they do not have to participate in someone else’s healing process if they do not wish to.
This said, I find it worth noting that at present therapists regularly do drop their clients, in a variety of hurtful and inappropriate ways. I hear stories about this all too regularly, both from clients and therapists. Incidentally, I think that in my revamped mental health system therapists and clients would both be so much more empowered and autonomous that we would see a much higher proportion of healthy (and thus beneficial) therapeutic relationships, and a much lower proportion of therapists refusing to work with clients or prematurely terminating relationships.
8) Nationalize pharmaceutical companies: remove their for-profit status.
Pharmaceutic companies have become poisonous to the mental health field. Their drugs cause toxic side effects in a hefty proportion of those who take them. Also, there is strong evidence that they increase, and not reduce, psychiatric disability. Words like the “Pharmacaust” have not been invented incidentally. Psychiatric drugs are also often extremely expensive, garnering huge profits for their companies, and of course for their executives and shareholders. These companies do not answer to the therapeutic good, or to basic ethics. Instead they answer to the calls of “sell more drugs,” “make more money,” and “increase the market share.” And the way they do this is to make drugs that do not assist in healing the problem, but rather, that prolong the problem indefinitely, and if anything that exacerbate it and create the need for more “symptom-focused” drugs. And considering the results of the psychopharmacological revolution, they seem to have succeeded quite well.
It is time to change that. It is time to increase their accountability. We need to create whole, independent organizations that engage in long-term testing of their drugs — before they reach the general public. We need to deem it illegal for them to advertise to non-professionals. We need to remove political lobbying by the pharmaceutical industry. We need to sever the financial bond between the pharmaceutical industry and academic psychiatry. We need to remove the profit motive from the pharmaceutical industry and instead create an industry driven by real evidence showing what ultimately benefits people best on their path toward permanent, drug-free recovery. Psychiatric drugs — perhaps in low doses, for short periods of time, as a last resort, after other real, relationship-focused alternatives have been tried — might have a place on that path toward some people’s recovery. But for many people, and perhaps for most, I believe they would not. And, after all, why would a healthy system want or too often need to give someone a pill that sends them the message that the ultimate answers to their conflicts come from a chemical?
9) Pump massive resources into quantitative and qualitative research and evaluation of alternative psychosocial treatment programs.
A wealth of data on excellent alternative treatment programs is out there, but is presently given so little attention by policymakers that it is rendered almost irrelevant. The time has come to study our own history of alternative programs, to find out which ones have worked best, and to try to replicate them under a modern microscope, or perhaps a thousand microscopes. But even better than that, we should use our modern imaginations and not just replicate them, but try to make them better. And better than better. Bring creativity — and healthy risk-taking — back into the mental health field. Ditch our reliance on dead, cold psychotherapy manuals and simplistic, reductionistic, biological psychiatric treatments. Breathe life back into the helping profession — and then build on our learning. It’s not that complicated, especially since no lack of successful alternatives have already been documented throughout the literature — and through the experiences of so many individuals.
Look at medication-free or minimal-medication programs like Soteria, The Western Lapland Open Dialogue Project, The Family Care Foundation in Gothenburg, Diabasis, the pre-modern version of Gould Farm (from the 1960s and 1970s), the original Podvollian model of Windhorse, the pre-modern model of Gheel, the Arbours Crisis Center, le 399 in Quebec, the hospitals of old moral treatment, and Chestnut Lodge in the pre-drug era, to name just a few. And, perhaps most importantly, listen to the published or publicly expressed experiences of countless thousands of psychiatric survivors. See what worked. See what helped. And see how it might apply today, on a wider scale.
Also, let go of the clinical grip on “treatment.” Put forth massive funding into non-professional treatment, into peer-run organizations. Study the work of Runaway House in Berlin, Freedom Center in Northampton, Massachusetts, and the worldwide Hearing Voices Network — and others. Fund peer-directed research. Provide the people with the most investment in recovery the power to make the key decisions. And watch: I bet we’d see some profoundly positive results, and for less money than we spend nowadays. A lot less.
10) Clients must face legal consequences for criminal actions.
Mental problems are not a defense for criminal activity. Although many people who work with people in those extreme states that get labeled as psychosis say that such people are often not responsible for their actions, to me this begs the question of what is responsibility. I think people are, to a degree, always responsible for their actions, no matter what the cause. A drunk driver is responsible for his actions when he, in a semi-conscious state, kills someone in a head-on collision, just as a person who unconsciously acts out his own history of childhood sexual abuse is responsible for his actions when he molests a child. So is a paranoid person when he kills a stranger in fantasized self-protection. The issue for me, however, is less about retribution for the seemingly “criminal” action, but instead real prevention of future actions. Everyone who commits crimes or violations against others is only acting out the world’s history of violation against him, and only when people get a chance to come to grips with those original violations — and get real help, and not primitive, moralistic, “eye for an eye” punishment of the variety to which our modern legal system is so addicted — will they be able to take real responsibility for their present and future actions.
This said, the prison system must be radically revamped as well, in an entirely humanistic direction. There need to be two, and only two, purposes for the prison system: protection of society and rehabilitation of prisoners. Logically the mental health system would find a way to work hand in hand — though independently — with the prison system. Prisoners would have a right to refuse treatment, but society would also have a right to protect itself from the potential future actions of its dangerous members. Of those, this begs the question of who would determine the “potential future actions” of anyone. It would seem to me that this question would require a whole new essay, so for now I will close this one.