Mad in America: Rethinking Mental Health

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. We 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.

This week on MIA Radio, we turn our attention to Open Dialogue and we chat with psychotherapist and Open Dialogue trainer Alita Taylor. Alita is a licensed Marriage & Family Therapist, trainer and facilitator based in Tacoma, Washington USA. Her passion is working from a community-based, non-expert, need-adapted Open Dialogue perspective, which utilizes social networks, family, and co-facilitation with other professionals. In this recent blog, Alita shares why Open Dialogue ‘cannot be taught, but needs a teacher‘. Love Is In the Air… I am in love. I’m in love with this way of working. And I won’t stop. Open Dialogue Washington began in 2018 upon my graduation/commencement from Jaakko Seikkula’s dialogic approaches to couple and family therapy trainer/supervisor training, in collaboration with Dialogic Partners and the University of Jyväskylä. In 2016, I embarked to partake in the best training course I had ever experienced as a family therapist. The embodiment I experienced working with my Open Dialogue colleagues felt like the missing key in psychiatry and psychotherapy. Something intangible, yet what I knew all along. Something ineffable, yet also a shared language. Something deeply and autonomically human, yet unrepeatable and fleeting. It led me onto a moment-by-moment path where everything I learned in my 27-year long career about systemic family therapy and emergency psychiatric protocols ebbed, and the present moment of love flowed, neither the ebbing knowledge nor the cresting wisdom having any lesser value than the other.  The complete work we do in mental health care is this ocean of love. We are in constant change when we are in crisis. Timelessness sets in. Growth is happening.  We don’t exactly know what we need. That is what mental health work is, sitting with this human happening. In the in-between space, something happens, and we don’t know what will. This is the paradox. We are navigating the ebb and flow of incoming knowledge we have from research and the ebb and flow in each patient and family’s difficulties (the meanings they make of them). “It cannot be taught, but it needs a teacher.” After getting trained to facilitate and supervise Open Dialogue, I found that this is the crux of the work, holding more than one truth. As human beings, as a society, as mental health practitioners, we must be able to ask what is helpful, and we must be willing to co-provide this “help” creatively, without barriers, between the digitized rows and columns of tick-boxes and presumptive diagnostic menus.  Remember the analog world of dials and infinite decimals? Agency lies within ourselves to expand the possibilities, to be willing to open to solutions that have not yet been tried. Michael Pohl wrote about dialogical leadership and culture in which he referenced Karl-Martin Dietz and Thomas Kracht of the Hardenberg Institute for Cultural Studies in Heidelberg, Germany. Michael remembered a discussion on whether dialogism can be taught or experienced. It was argued that the dialogic attitude cannot be learned and that any thought of teaching it is unnecessary. Michael disagreed. He writes, “It cannot be taught, but it needs a teacher.”— Medium.com, March 2018. In Helsinki and Tornio while learning the Open Dialogue approach, I had many teachers: Jorma Ahonen, Pekka Borchers, Birgitta Alakare, Aino Maija Rautkallio, Kari Valtanen, Tom Erik Arnkil, Jaakko Seikkula, Tapio Salo, Tanja Pihlaja, Eija-Liisa Rautiainen, Pekka Holm.  How did they do it? To quote Birgitta Alakare when she was asked about the beginnings of the development of Open Dialogue in the 1980’s, “It was not only me, it was all of us, everyone.” When we include all the stakeholders, all the voices, polyphonically, something extraordinary is given space to emerge. This is challenging to enact when there are systems of health care based on bed occupancy, lengths of stay, productivity, staff ratios, definitions of “emergency” or “inpatient” levels of care. Well, Open Dialogue Washington is bringing to the fore the question, “What is our role as helpers??”  To quote Mia Kurtti, Open Dialogue trainer of Tornio, Finland, “What are we really doing here?” Caring for our mental health, however defined (crises, hard times, depression, psychosis), is a human need that varies from moment to moment. I learn from every client and family I sit with. In Open Dialogue, multiple perspectives are allowed, in fact invited. Unusual experiences are uncategorized mystery, and understanding between client and family/social network is continuously underway. The course of schizophrenia was reversed in Western Lapland, and their inhabitants trust their mental health system. Hmmm… if we want to save State and Federal dollars and our own livelihoods, perhaps we should allow ourselves to practice psychotherapy and psychiatry with more questions than answers. Perhaps the ones in crisis will teach us what we didn’t know. Love is somewhere, here, in the air. Relevant links: Open Dialogue Washington Open Dialogue Training, April 2019 Open Dialogue UK

This week on MIA Radio, we interview Professor Jim van Os. Professor van Os is Chairman of the Division of Neuroscience at Utrecht University Medical Centre, Utrecht, The Netherlands, and Visiting Professor of Psychiatric Epidemiology at King’s College, Institute of Psychiatry in London. He trained in Psychiatry in Casablanca, Bordeaux and the Institute of Psychiatry and the Maudsley Royal Hospital in London. We last spoke with Jim for the podcast in August 2017 and this time we focus on a recent paper written by Jim and co-authors that was published in the journal World Psychiatry in January 2019. The paper is entitled ‘The diagnosis evidence-based group-level symptom-reduction model as organizing principle for mental health care. Time for change?‘ In this episode we discuss: What the diagnosis evidence-based group-level symptom-reduction model is and how it currently informs mainstream mental healthcare. How mental health funding and mental health professional partners work together to monitor and assess the effects of current evidence-based interventions. How this curative medical model is attractive, but often fails to work for patients. That the focus on biological, brain-based diseases and symptoms conflicts with the experience of people who are attempting to develop a narrative view of their difficulties and suffering. That the paper is an attempt to start a discussion about building a synthesis between the diagnosis, symptom-based medical world and the lived experience of individual people. How the creation of specific and discrete diagnoses has reinforced the symptom-led approach to mental health and has also necessitated the stratification of doctors into silos of expertise. How Jim favors a spectrum-based approach over a fixed diagnosis and that an example is autism spectrum disorder as described in DSM V. The limitations of using ‘target symptom reduction’ as an outcome measure for mental health. That symptom reduction can be beneficial in the short-term but is not a good long-term measure of recovery. That the paper attempts to make clear how important individual experiences are and the need to be sensitive to the existential domain, saying “restoration of health is not the goal, it is the means to enable a person to find and pursue meaningful goals, accordingly, the person’s existential values become central”. That the evidence suggests that any treatment effect or improvement is often down to meaningful interaction rather than the specific expertise of the treating professional. That, in many countries, we still see a huge gulf between mental healthcare and social care which remain separate and remote from each other and that this separation is not how the person experiences their world. The importance of including lived experience in the evidence base, particularly because randomized controlled trials, considered the gold standard of evidence, are often not conclusive in the field of mental health. That, in mental health, evidence shows that 30% to 40% of the response is down to placebo and the expectation of being helped. That the desire is to make the existential domain the primary lens through which to view human experience and to respond to mental or emotional suffering. That, arguably, ‘love is the most powerful evidence-based treatment in mental health’. Relevant links: Professor Jim van Os The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? Tedx: Maastricht, Connecting to Madness ISPS Liverpool Conference Jim Van Os Keynote Address Schizophrenia does not exist © Mad in America 2019

In this second interview in our Science and Pseudoscience of Mental Health series, Dr. Sharna Olfman interviews Dr. Darcia Narvaez.  In 1955, Erich Fromm published a book called The Sane Society. The basic premise is that cultures that support our existential needs for love, community, autonomy, creative expression, purpose, meaning, and communion with nature, enable us to become fully actualized, sane human, beings. Cultures that fail to do so, engender mental illness. Darcia Narvaez,1 a Professor of Psychology at the University of Notre Dame, has taken up the mantle of Fromm’s quest to identify and promote sane cultural practices that foster mental health. A prolific multidisciplinary scholar, her recent books include Neurobiology and the Development of Human Morality: Evolution, Culture and Wisdom (2014) and Basic Needs, Wellbeing and Morality: Fulfilling Human Potential (2018). To read more about Dr. Narvaez' work, visit this link: https://www.madinamerica.com/2018/12/reclaiming-humanity-dawn/ © Mad in America 2018

When we discuss the issue of forced treatment, coercive mental health interventions like involuntary commitment, forced drugging, and electroconvulsive therapy usually come to mind. But force and coercion can be much more subtle. Many researchers and thought leaders have argued that our society mandates us to be happy and perform well-being at all times through cultural norms, media depictions, and workplace and school regulations. This week on MIA Radio we interview Will Davies, Reader in Political Economy at Goldsmiths University of London, and author of The Happiness Industry, a book that explores the rapidly growing culture of mandated happiness and well-being surveillance. In this interview, we discuss the increasing pressure people face to be happy and think positive, and how this pressure serves the interests of the corporate elite and the State. In this episode we discuss: What the “happiness industry” is and the history of its development How the notion that happiness can be quantified or measured, as well as advancements in neuroscience and medicalized frameworks of depression, have influenced our culture How employees are increasingly pressured to be happy or perform happiness within the workplace How people receiving welfare or government benefits are required to engage in positive thinking programs or cognitive behavioral therapy That holding individuals responsible for attaining their own happiness relieves responsibility from structural and institutional determinants of well-being The coercive and forceful aspects of the “happiness industry,” including surveillance in workplaces and mandatory self-help programs in schools The role that positive thinking and self-help culture play in upholding neoliberalism and capitalism Relevant Links: Dr. Will Davies The Happiness Industry: How the Government and Big Business Sold Us Well-Being The Managed Heart: Commercialization of Human Feeling The Power Thinker: Why Foucault’s Work on Power is More Important than Ever The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age Dr. Davies’ next book, Nervous States: Democracy and the Decline of Reason will be published by Norton in early 2019. © Mad in America 2018

This week on MIA Radio, we interview Dr. Sandy Steingard. Dr. Steingard is Medical Director at Howard Center, a community mental health center where she has worked for the past 21 years. She is also Clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 25 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard serves as Board Chair of the Foundation for Excellence in Mental Health Care. She was named to Best Doctors in America in 2003 and writes regularly for Mad in America. She is editor of the book Critical Psychiatry, Controversies and Clinical Implications due in 2019. In this episode we discuss: What led Sandy to her career in psychiatry and her particular interest in the critical aspects of psychiatry and psychology. That Sandy’s initial interest was in biomedical explanations of psychotic experiences. How, in the late 80s, the advent of new antipsychotic drugs caused an initial excitement because of the promises made about safety and efficacy, but that Sandy came to realise the problems with the drugs. How she witnessed the over-promotion of the drugs and that the promotion was markedly different to the results of studies and her observations of patients that were taking them. How a series of disappointments and recognition of some inherent flaws in psychiatry led Sandy to her interest in alternatives. That the book, The Truth About the Drug Companies by Marcia Angel MD, had a big impact on Sandy’s view of the drugs during the 2000s. Other influential books were The Daily Meds by Melody Petersen and Side Effects by Alison Bass. That reading Anatomy of an Epidemic and particularly the problematic aspects of the long-term use of antipsychotic drugs caused Sandy to question how she was practising. That she found colleagues were sometimes angry at the conclusion that antipsychotic drugs might not be safe or lead to better outcomes for patients. That this led to the investigation of alternatives such as Open Dialog, training with Mary Olsen at the Institute of Dialogic Practice and discovering the Critical Psychiatry Network and the work of Dr. Joanna Moncreiff. How Sandy approaches practising from a critical perspective, particularly when expectations are in line with the dominant biomedical narrative. Her book, Critical Psychiatry, due in 2019 which aims to help clinicians apply transformational strategies in their clinical practices. That psychiatrists would be well served by welcoming lived experience input to their daily practice. Why informed consent should be viewed as an ongoing process rather than a one-time agreement. The problems that arise in clinical studies where experience is translated into a numerical form. Relevant links: Critical Psychiatry, Controversies and Clinical Implications (due 2019) How Well Do Neuroleptics Work? What We Are Talking About When We Talk About Community Mental Health The Truth About The Drug Companies by Marcia Angel MD (video) The Daily Meds by Melody Petersen (review) Side Effects by Alison Bass Open Dialog The Institute for Dialogic Practice Critical Psychiatry Network

This week, MIA Radio presents the fourth 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. 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 and former Research Associate at the Refugee Studies Centre at the University of Oxford and consultant and 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.

Today, we bring you the third in our series of podcasts on the topic of the global mental health movement. Part one of the series featured Dr Melissa Raven and part two featured Jhilmil Breckenridge and Dr Bhargavi Davar. These interviews are led by our Mad in America research news team. In this episode, we interview Dr China Mills. China participated in organizing the open letter in response to The Lancet Commission on Global Mental Health and Sustainable Development. In this interview, China shares her concerns and reactions to the Lancet’s proposal, elaborating on deeper issues related to the framing of global mental health as a “burden” and the underlying implications of coloniality, technology, and medicalization. In addition, China tells us about her insider perspectives after attending the Global Mental Health Ministerial Summit hosted by the UK government. In her recent piece for Mad in Asia about the summit, she writes: “It was ironic to listen to a range of UK Government minsters talk about the importance of mental health whilst sat in a room just over the river from Westminster, where governmental decisions to cut welfare, and sanction and impoverish disabled welfare claimants has so detrimentally impacted people’s mental health and led to suicide. It felt like arrogance on the part of the UK Government to position themselves as world leaders in mental health when in 2016, the UN found that the Government’s austerity policies had enacted ‘grave’ and ‘systematic violations of the rights of persons with disabilities’ . It was equally jarring, given the cuts to social security under austerity, to be transported by boat about 2 minutes away, to an evening drinks reception at the Tate gallery.” China Mills is a Lecturer in the School of Education, University of Sheffield, UK. Her research develops the framework of psychopolitics to examine the way mental health gets framed as a global health priority. In 2014, she published the book ‘Decolonizing Global Mental Health’ and has since published widely on a range of topics including: the inclusion of mental health in the sustainable development goals; the quantification of mental health and its construction as a technological problem; welfare-reform, austerity and suicide; and the intersections of psychology, security and curriculum. She is Principal Investigator on two British Academy funded projects researching the social life of algorithmic diagnosis and psy-technologies. China is a member of the editorial collective for Asylum magazine and for the journal, Critical Social Policy; and she is a Fellow of the Sheffield Institute for International Development (SIID).

Today, we bring you the second in our series of podcasts on the topic of the global mental health movement. These interviews are led by our Mad in America research news team. On October 9th and 10th, 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 our 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.

This week, we present the first in a series of interviews on the topic of the global ‘mental health’ movement. These interviews will be led by our Mad in America research news team and today’s interview is hosted by our lead research news editor, Justin Karter. In this episode, Justin interviews 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 10th, 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.