Mental Health Forum - Your two pence worth

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In not listening to what I was saying about the abuse being perpetrated by my father, and pathologizing me instead, psychiatry was unwittingly protecting my father. It was as if the field of psychiatry had become subsumed into unknowingly becoming an instrument for a deeper, archetypal process of “protecting the abuser” to play itself out in form and in real time. Having my father be care-taken by those in a position of potential authority over him, combined with my being solidified as being sick by those in authority over me was a doubly sickening experience.

During my hospitalizations I was trying my best, giving every signal in the book, to get across and communicate about my experience with my father to the psychiatrists ... the psychiatrists never had any clue that there was abuse going on. My perceptions were deleted from having any validity whatsoever. Being concretized as mentally ilI, I was being treated as a mental “in-valid.” ... in a crazy-making double-bind, the fact that I wanted to talk about the abuse with my father became the very thing for which I was pathologized. Crazier still, in a seemingly never-ending game without end, my attempts at meta-communicating about the nature of the double-bind I found myself in was itself pathologized. The psychiatrists weren’t just not hearing me, they were actually perpetrating a hard to pin down form of psychological abuse...

Instead of help for my problems with my father, the psychiatric system, on the other hand, unwittingly colluded with, supported, and protected my father in his role of abuser...

The psychiatric community got “into bed” with my parents (my mother was under my father’s spell), aligning with them “against” me, in the sense that, being the one identified as sick, I was seen as the member of the family who both had a problem and was the problem. Though the sickness was fundamentally nonlocal in nature, as it pervaded the whole family system (which now included psychiatry), it was being “localized” as if existing only in me. Being conjured up in the role of the identified patient, I was “carrying,” as if in the role of the archetypal scapegoat, both my family’s, as well as the psychiatric community’s, unacknowledged, split-off, and unconscious shadow of madness...

Not only did the psychiatrists fail to recognize the deeper process of spiritual awakening that had become activated within me as a result of the abuse, their ignorance insured that they didn’t have the slightest idea what to do with me other than to pathologize me, which is their default setting. People who are in extreme states, and are having non-ordinary experiences, or who see things differently than the agreed-upon, consensus reality are (arche)typically pathologized by those in positions of power. Psychiatry’s un-reflected upon propensity to see only illness is an expression of psychiatry’s own pathology...

“When I told my psychiatrist that I thought my mission in this world was to spread the message of love, she prescribed me an anti-psychotic.” Contrary to supporting the healthy part of me that was awakening, the psychiatrists pathologized, mis-diagnosed and medicated me (with “anti-creative” medication), temporarily aborting my mind-expanding spiritual emergence, traumatizing me even further...

In a similar dynamic that played out with my father, psychiatry, instead of protecting me, was what I needed protection from. Instead of helping me to heal, my psychiatric experience was something from which I’ve been in recovery from and needed to heal. My intimate relationship with psychiatry created quite an overwhelming cocktail of abuse for me to digest... I felt totally violated, branded, humiliated, and dehumanized as a result of my treatment with the psychiatric system, a pill-pushing club “med.”...

Don’t get me wrong – There are plenty of well-intentioned psychiatrists, including the ones with whom I worked. I am not talking about individual psychiatrists, I am talking about the underlying psychiatric system as a whole. There is a certain consensual agreement with reference to behaviors that are considered “normal,” the nature of health and sickness, as well as fundamental ideas of who we are, that all representatives of the “academy” have to accept in order for them to be considered a card-carrying member. There is an axiomatic set, a way of looking, that has been drilled into psychiatrists heads during their “training” in medical school, for them to take on in order to be a true initiate. Built into the very institution of psychiatry, into the very organ-ization of the field, to the extent that self-reflection is not part of its practice, is the hidden abuse of power. It takes more than good intentions for a psychiatrist to not unwittingly become an instrument for “the system” to play out its unconscious, destructive aspect

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... Faridah Newman explains how mental illness can often represent a vulnerability which is exploited by abusive partners...

Though stigmatised as "unstable" and "dangerous", mentally ill people are more likely to be victims than perpetrators of violent crime, and more likely to have experienced intimate partner violence than the general population...

The links between mental illness and intimate partner violence are all too well known. It is estimated that at least 60 per cent of female mental health service users are survivors; 70 per cent in inpatient settings... Mental illness can often represent a vulnerability which is exploited by abusive partners in ways similar to those experienced by people with physical and learning disabilities... (Women with disabilities are twice as likely to experience domestic violence as non-disabled women, and over one in ten young men with a longstanding ilness or disability say they have been assaulted by a partner in the previous year).

The majority of people I've spoken to through the blog have said they were ill before their abusive relationship began, with some suspecting that their mental health problems may have been a factor that attracted their partner to them. Debbie*, who has multiple diagnoses including Bipolar Disorder and Schizoaffective Disorder, said: "He told me I was beautiful because I was broken. I saw him as a ray of light, at the time."

Jess* has since recognised that her relationship was one of a continuing pattern for her partner: "When we met I was reclusive and hopeless, and he took an intensive caretaker role toward me. Before me, he fostered another young woman in the same way, and as I moved closer to leaving the relationship, he did the same again with another. Both had mental health problems." Her feelings of isolation and loneliness at the time of meeting her partner was shared by others. Forced isolation from support systems is a form of abuse common to many violent relationships; is this why someone with abusive tendencies might seek already isolated romantic interests? David*, who was depressed and suicidal when he met his partner said, "He met me at my lowest and I think this afforded him the power dynamic he was looking for. I don't think he'd be interested in me now that I'm happier, more confident and outgoing."

Having myself witnessed a friend's partner try to dismiss her report of physical violence to the police on the grounds that she was "mental", I am upset but not surprised to find similar experiences shared with me online. Abusers minimise the gravity of the violence, or deny it happened at all using their partner's illness as an excuse. Anna* said, "When I actually sought out some help because I could barely walk from being pushed to the floor multiple times and had marks all over my face from being grabbed by the head, he tried to say that I had scratched myself because I'm "crazy". Luckily, my one confidant knew he was lying, but I could see that kind of thing working, which terrifies me to the core."

The overwhelming feeling I get when reading back through the blog's inbox is that of people slipping through the cracks of service provision, with mental health services viewing abuse as the remit of survivor's services, and survivor's services reluctant or unsure how to cope with people with pre-existing severe mental illnesses.

Research has shown that many mental health professionals do not view enquiry about domestic violence as part of their role or within their competence. Indeed, one person who wrote to me said that within therapy this was simply ignored, "I disclosed my situation of current and long-standing abuse only for her to not acknowledge this at all, move on, and never mention it again." When Debbie* was driven to attempt suicide after an evening of particularly acute violence, her husband's claims that she was refusing to take her psychiatric medication were believed and her disclosure again ignored, "I was taken to the ER for observation, where I pleaded with the nurses, and told them the story. They did not make a report. I wasn’t allowed to speak with a counsellor, or a police officer. I was just 'off my meds' in their eyes." When she later managed to get a private interview at a local domestic violence shelter she said of her caseworker, "When she heard of my mental illnesses and how my husband was taking advantage of them, she outright asked me “And have you spoken with your psychiatrist?” I have honestly never felt so alone in my life."

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Like many psychiatrists, I have been amazed by the debates surrounding the DSM-5, the first major revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in nearly twenty years, which was just released. Never before has a thick medical text of diagnostic nomenclature been the subject of so much attention.

Although I was heartened to see more and more people discussing the real-world issues and challenges—for patients, families, clinicians and caregivers–within mental health care, for which the book offers an up-to-the-minute diagnostic GPS, I was also alarmed at the harsh criticism of the field of psychiatry and the APA. Consequently, I believe that as you read and watch this increased coverage, it’s important to understand the difference between thoughtful, legitimate debate, and the inevitable outcry from a small group of critics –made louder by social media and support from dubious sources —who have relentlessly sought to undermine the credibility of psychiatric medicine and question the validity of mental illness..

DSM-5 has ignited a broad dialogue on mental illness and opened up a conversation about the state of psychiatry and mental healthcare in this country. Critiques have ranged in focus from the inclusion of specific disorders in DSM-5, to the concern over a lack of biological measures which define them. Some have even questioned the entire diagnostic system, urging us to look with an eye focused on the impact to patients. These are the kinds of debate that I hope will continue long after DSM-5’s shiny cover becomes warn and wrinkled. Such meaningful discourse only fuels our ability to produce a manual that best serves those touched by mental illness.

But there’s another type of critique that does not contribute to this goal. These are the groups who are actually proud to identify themselves as “anti-psychiatry.”

These are real people who don’t want to improve mental healthcare, unlike the dozens of psychiatrists, psychologists, social workers and patient advocates who have labored for years to revise the DSM, rigorously and responsibly. Instead, they are against the diagnosis and treatment of mental illnesses—which improves, and in some cases saves, millions of lives every year—and “against” the very idea of psychiatry, and its practices of psychotherapy and psychopharmacology. They are, to my mind, misguided and misleading ideologues and self-promoters who are spreading scientific anarchy.

Being “against” psychiatry strikes me as no different than being “against” cardiology or orthopedics or gynecology—which most people, I think, would find absurd. No other medical specialty is targeted by such an “anti” movement.

This relatively small “anti-psychiatry” movement fuels the much larger segment of the world that is prejudiced against people with disorders of the brain and mind and the professions that treat them. Like most prejudice, this one is largely based on ignorance or fear–no different than racism, or society’s initial reactions to illnesses from leprosy to AIDS. And many people made uncomfortable by mental illness and psychiatry, don’t recognize their feelings as prejudice. But that is what they are.

We have, as a nation, aggressively taken on racism, sexism, homophobia and other prejudices. Perhaps the occasion of this new DSM revision (and in the aftermath of the passage of the Mental Health and Addiction Parity Act) is the right time to grapple with the prejudice against mental illness and its caretakers—which every day makes it a little harder for people suffering from mental illnesses to live their lives, and makes it harder for those of us who treat mental illnesses to do our jobs.

I do understand how anti-psychiatry ideas first developed and why they have been so difficult to combat. There is historical fear of mental illness, stemming from when these diseases were viewed first as demonic possessions and later as character or moral defects, before we had any scientific understanding for the biological basis of, say, schizophrenia, bipolar disorder, autism or Alzheimer’s disease. The brain is a complex organ, slow to reveal its secrets, and the effort to understand its myriad functions goes to the core of each individual’s self-identity. Patients are challenged by the intimate aspects of their relationship with any doctor—a caregiver for whom you have to disrobe, and who pokes and pries. But in psychiatric treatment you “disrobe” in an even more profound way, revealing yourself psychologically.

And I do not overlook the checkered history of psychiatry itself. It’s a relatively new discipline which branched from neurology in the 19th century, whose early practitioners were alienists and analysts, superintendents of asylums and Freudian therapists. But, at the time, asylums were little more than humane warehouses, and Freudian theory turned out to be a brilliant fiction about personality and behavior. When psychiatry did make its first forays into medical treatment, it used crude instruments like strait jackets, cold packs, fever induction, insulin shock therapy and psycho-surgery. The underlying theories for the causes of these illnesses at the time were also wrong; it was largely about blaming the parents.

However, that was then and now is now. The scientific foundation of psychiatric medicine has grown by leaps and bounds in the last fifty years. The emergence of psychopharmacology, neuroimaging, molecular genetics and biology, and the disciplines of neuroscience and cognitive psychology have launched our field into the mainstream of medicine and on a course for future growth and success. Though not everyone, including ourselves, is satisfied with the rate of our field’s progress, no one can argue with one simple fact; if you or a loved one suffers from a mental illness, your ability to receive effective treatment, recover and lead a productive life is better now than ever in human history. Moreover, we have every reason to believe that there will continue to be unprecedented scientific progress, which will enhance our clinical capacity and benefit our patients.

For this reason, I am especially shocked when other clinicians—psychologists, social workers, even, in some cases, primary care docs who would rather just dispense psychiatric meds themselves—side with anti-psychiatry forces without realizing these people are “against” them, too. These strange anti-mental health bedfellows include a series of contemporary psychiatrists and psychologists who have fashioned platforms for self-promotion from their critical positions on psychiatry and DSM-5.

But, when it comes to medical illness, the “enemy of your enemy” is not always your friend.

For all the overt anti-psychiatry we see out there, I’m also concerned about the more subtle forms of prejudice among less radicalized segments of our society.

Only recently, I was at a meeting of medical school leadership at my university, where we discussed how to counsel medical students about choosing which specialty to pursue. One senior faculty member quipped “tell all students who get low scores on their board exams not to worry, they just need to change their career plans and go into psychiatry.”

A few months later, the same faculty member called me late one night, asking if I would see his wife, who was having a “psychiatric problem.”

The urgency of his request belied any awareness that the joke he made at psychiatry’s expense in that meeting undermined our ability to deliver the kind of quality care that his wife now needed. But it can, and it does.