Start here.
Right now, I am trying to write a cover letter for a job application I am trying very hard to care about.
Inside my apartment, I hear the low hum of my dishwasher and a zoom call through the bedroom door, but mostly I hear the man yelling at the end of the alley. He’s been at it for 2 hours, pacing back and forth between his things, yelling expletives. I’ve never seen him before today, but he definitely caught my attention. I’m closing the google docs tab for the day.
People in cities love to distinguish themselves from naive tourists and corn-fed visitors through their difference in reaction to displays of human suffering. Your mom, visiting you in the city over a long weekend, jumps when someone nearby yells. You look straight ahead, unbothered, used to it.
In recent years a shift in popular politics has shaken this up. There are now more options. When faced with someone in a situation that is, at minimum, a circumstance of mental health problems, we have an expanded set of options.
1. ignore them
2. call the police on them in a republican way
3. call a crisis line (usually the police) on them in a liberal way
4. publicly call them your houseless neighbors, offer food/water/cash, make eye contact, learn their names, say hello
If you’ve been following along, you know that in most cities, option 2 and option 3 do the same thing. Just like option 1 and option 4 do the same thing in the long run. There is value in providing each other with dignity and making sure no one around us is acutely dying of a lack of basic needs provision. But it doesn’t change tomorrow. So option 4 does option 1 and emotionally we treat it that way. I think we do the outward-facing parts of option 4 so that people who might take option 2 don’t freak out and do something rash. If a passerby knows the difference between active crisis and someone simply having mental illness symptoms, they might not put them in danger by calling the police on them for no reason.
But I think we’re too hard on the expression of affect that spurs people to act. We’re being too chill about this. Being homeless is a crisis. Being unable to access healthcare is a crisis. Someone who is screaming at the top of their lungs is probably in some kind of crisis. If you allow your heart to feel it, it will hurt you too. Our stoicism in the face of homelessness is a perfect reflection of Mark Fischer’s concept of capitalist realism. The only reason we’re not all freaking out all of the time about our society’s disposal of disabled people, including strangers and loved ones, is that we’ve been robbed of the ability to coherently picture an economic system in which people do not have to sell their labor to have a safe place to live. Collective avolition is a symptom of our collective depressive orientation. What the hell are we to do, cry every day? We harden, so we can live. Or at least go to work, so we don’t end up in that same situation.
I want to wrap this up as quickly and clearly as possible. Right now, if you are a social worker in a community mental health setting, you’re expected to show up in someone’s life to meet one need without being able to help provide for most of them. I think the right language would call you a “tool” or “resource,” not a “provider” or “healer.” That all makes sense in a narcissism/paternalism prevention way, but it also lowers our own standards for ourselves and our field, doesn’t it? Because then, it makes sense why the agency can’t provide housing or heal your trauma. I'm just one insignificant resource in an ecosystem of advantages and disadvantages. We then make inappropriate the act of demanding housing, food, and money. We carve out a little appropriate space of counseling and provide one of many phone numbers to call so a person can go on one of the many lists that someday might get them somewhere to live with a bathroom. The dominant model is one of decentralized answering machines to nowhere and minimization of human desperation. We can’t person-first language or anti-oppression training anyone out of a problem like homelessness.
In my last several pieces, I’ve talked around the forces that shape our current perception of the problem of serious mental illness. I can’t effectively end this story unless you know why you (and your mom, and your professors, and your senator, respectively) think the way you do about severe mental illness and what to do about it.
Cast of characters:
Treatment Advocacy Center (TAC) - started in 1998 by Dr. E. Fuller Torrey, a research psychiatrist and author of Surviving Schizophrenia. Lobbies for increased spending for outpatient mental health treatment, expanding treatment access, and psychiatric beds. Cites violence, including mass shootings, as a possible consequence of non-treatment without documenting a fear of further criminalization which they condemn. Mad in America’s enemy, but they don’t talk about it. You are influenced by TAC if you know the word “anosognosia,” speak about how much more expensive revolving door hospitalization is than treatment, and talk about how messed up it is that our jails and prisons are our nation’s most utilized mental healthcare providers.
National Alliance on Mental Illness (NAMI) - founded in 1979 as a grassroots support, advocacy, and education organization for people diagnosed with mental illness and their families. Umbrella org with local affiliates. Started by moms of sufferers, and criticized for paternalistic leanings. Historically intertwined with APA. Has primarily supported the medical model. Pharmaceutical companies provide a decent amount of their funding, which everyone thinks is sus. Recently have poured a lot of resources into peer-led interventions. Big enough to manipulate data if they had reason to.
American Psychiatric Association (APA) - the world’s leading psychiatric organization with tens of thousands of members in hundreds of countries. Some find it too conservative and others too loosey goosey. Moves with the times.
Mad in America - a popular critical psychiatry webzine and organization started by journalist Robert Whitaker birthed from the critical psychiatry/anti-psychiatry movement of the 90’s challenging psychiatry itself and questioning its ethical and philosophical underpinnings. Scientologists like them, they say it’s not mutual. Hosts writing from anti-psychiatry and psychiatric survivor perspectives. Speaks to the historical brutality of mental illness treatment and questions the validity of mental illness. TAC’s enemy. You are influenced by these movements if you’ve read any Timothy Leary or much Foucault, or if you’re aware of these concepts: mental illness is a myth, DSM abolition, normality/illness constructs, consumerism movement, psychiatry as social control.
The story is an argument about:
Assisted Outpatient Therapy AOT - the treatment model proposed by TAC. Civil commitment issued outpatient mental health treatment.
I’ve never worked for or with any of these institutions. For the past few months, I’ve tried to understand their opposing statements, and I can’t seem to walk away with a full grasp on things, I suspect this is because I am not a journalist. But the journalism on these issues appears to be published mostly by those with institutional bias, or those who haven’t worked in the systems that live and die by these institutions’ influences. At one time, all the above parties admitted that deinstitutionalization had failed. They may have had different stories about why. Both Torrey and Whitaker have criticized NAMI for taking pharmaceutical money over the years. Both criticize the DSM.
Dr. Torrey was a NAMI man from that first generation characterized by concerned family members who did not know what to do anymore. As the organization grew, NAMI attracted more and more members of lived experience, and the “NAMI Mommy” reputation fell away. NAMI initially supported Torrey’s AOT model but didn’t promote it much. Because of this, Torrey and lived-experienced consumers and family members split off and formed TAC to focus on AOC. Feelings couldn’t have been too harsh, as NAMI welcomed Torrey as their keynote speaker at their annual convention in 2002. Whitaker is a writer focused on building public support for psychiatry-critical ideas, not a doctor or an institutionally connected researcher. While both perspectives have been controversial, they have also been highly influential. If you google any combinations of “NAMI,” “Torrey,” and “Whitaker,” you will find a war that has been raging outside of public awareness. These 3 have been condemning each other in different triangular formations for the past 2 decades. I’ve been reading critique of each other's reviews of books I’ve never read, and outside commentary on these critiques. All I can tell you for certain is that by 2013, Whitaker was a strong critic of NAMI when he was invited to speak at their annual convention. This move shocked many, especially parent members who had been maligned by his writing. His speech started a new era of peace between NAMI and MIA in which the cons of antipsychotics weighed at least as heavily as the pros. The psychiatry-critical blogs expressed that it was a monumental move away from TAC’s perspectives that included, among other priorities, unwavering support for the use of antipsychotic and mood stabilizer medications and AOT protocol. Peer support interventions were increased, and the project of deinstitutionalization was challenged. Something happened between then and 2021, and I don’t know what it is. Because In 2021, the APA awarded its Distinguished Service Award to the Treatment Advocacy Center, a move back to focusing on severe mental illness treatment. According to their 2020-2025 Strategic Plan, their goals are to get people help early, get people the best care possible, and divert people from the criminal justice system. It’s a bipartisan nonprofit 5-year Strategic Plan, so it’s a long document with almost nothing in it. You can’t read between the lines, you have to get to know the players. And from the perspective of a former community mental health clinician, most of us can’t name a single one.
I can’t cosign any of these approaches, even after learning more about them. When I could fully support the Mad in America approach, I saw myself as an outsider practitioner fighting the tyrannical mental health care apparatus and the horrible criminal legal system. I would look you straight in the eye and tell you that antipsychotics are often worse than psychosis. When things went poorly, I could fit it all into my neat little framework: the state failed them, I wasn’t given enough resources, etc. There was a clear answer that could have saved everyone, I could see myself in it, and only political and economic systems held us back from collective well-being.
And I still identify with that movement to some degree. Our mental healthcare system is controlling. It should be restructured, and the only way it will be structured well is inside a new political economy we create through mass action leading to economic and political overthrow. But when will that happen? I, for one, do not see us creating the ideal conditions for general human health in my lifetime. Does that mean we shouldn’t try to make some things better under these conditions? I don’t agree that treatment (including meds) is a bandaid. It’s more of a tourniquet. It prevents things from getting worse. It would be great if we didn’t need it, but the damage many have endured is visible and worsening. Stopping the bleeding opens up future possibilities for healing. Critical psychiatry turns attention towards why psychiatry is bad, and allows us to completely look away from the fact that people cannot get treatment if they want to. Hell, you probably can’t even find a therapist with your private insurance. What do you think it’s like for a poor person with multiple marginalized identities to access treatment for a serious mental illness if/when they want it?
I wanted the Mad in America approach to be the right one across the board, because that was the one that fit into my predetermined worldview and that I had been practicing from already. In 2019, I attended a Hearing Voices Network training. If you don’t know about HVN, it’s pretty cool and I recommend learning about it. It was cool. Both the training facilitators had sensory experiences not shared by other people (typically called hallucinations) and unusual or extreme beliefs (typically called delusions). The word symptom is never used. To be a true HVN group, there cannot be a mental health professional without lived experience in the room. (Any group I facilitated would be an HVN-affiliated group). People can make whatever meaning they want out of their experiences and none of them should require coercive treatment. In some cultures, visions are even divine. I learned great assessment and coping resources to share with my clients.
But to this day, there aren’t any Hearing Voices groups in Travis County, where I worked. And I know why. Some will say it’s because people with lived experience haven’t been empowered to get trained and start a group. That’s likely part of it. But I have to wonder how much of it is related to the thought I had pulling out of the holiday inn parking lot and driving home. This doesn’t apply to almost any of my clients. If they had a solid, if non-consensus, understanding of their condition and were able to do things like run a consistent self-help group, they would not be my clients. There are a ton of people around us with psychosis, both diagnosed and undiagnosed, who would benefit. Critical psychology as a movement also produces interesting, intellectually valuable theory. That’s great. But it still does not serve the people suffering the most at the margins of our society. You know, the thing that critical psychiatry criticizes psychiatrists the most for.
The critical psychology project invites a few more people into the category of the worried well. Good for them. It doesn’t keep many people warm or fed. It doesn’t really help people whose meaning relies on the medical model that they’ve internalized, especially if that meaning helps them live the life they want to.
When I found TAC after my disillusionment, I thought, “maybe it was this all along.” They talk less shit about their opponents than the critical psychology crowd does, which makes sense because they have more institutional buy-in, just without the political will and funding. They genuinely demonstrate a balanced and nuanced position that takes the wind out of their critics’ sails easily. The big critical psychology organizations’ points get less effective as they are more successful. Some struggles reflect criticism of outdated medicine and have been successful in correcting course. I’ve been clearly influenced by TAC in this series, and I don’t mean to hide that. I just didn’t know how to explain it without writing this enormous boring essay. TAC clearly cares about the criminalization of the mentally ill and sees AOT as a means to keep people out of prison. But they don’t take seriously enough the way that courts and law enforcement manipulate mandatory orders to suit their needs. They’re not critical enough of the cops and judges and others who are granted outsized power over consumers/clients/patients/inmates. States have strict legal criteria for AOT participation, but they’re famously ignored. A lack of insight may be asserted, which is impossible to prove and disprove.
Right now our cultural disposition adopts the most contradictory (and in my view, most detrimental) parts of both ideologies. The way our systems respond is nonsensical, dependent on one social worker in front of a suffering person, balancing the ethics of unnamed origins, personal values, and unexamined motivations lurking under the surface. Ultimately, the different ideologies embodied in Torrey and Whitaker and their respective movements are exploited by the state. If Medicaid doesn’t pay for hospital stays, great, that means we’re “moving away from coercive involuntary psychiatric treatment.” Over-medicating and sedating patients qualifies as “preventing avoidable tragedy.”
There are syntheses that make sense to me, and the visions of both camps aren’t necessarily in contradiction. I don’t personally feel confident about organizations of either of the opposing viewpoints holding the project of synthesizing anything. Both sides clearly cherry-pick data on a population without much power to combat their twisted words. I don’t think mental health professionals will be able to devote time to untangle this. I don’t know how much the public cares. I don’t know where I fit in. I don’t think that the critical psychiatry movement reflects the population they claim it does. I reject the state’s broad and indiscriminate power over those with mental illness. I no longer reject the validity of all cases of involuntary treatment on its face. I think that may make me unfit to practice at this time. I think this would not be the case if there were truly any meaningful alternatives to our current treatment paradigm or power given to multiple parties (with decisions led by the consumer) instead of just a social worker “living in the grey areas,” making the heaviest of subjective decisions.
If you feel that I’ve mischaracterized any of the above organizations or left out an important party, please let me know in the comments below. The worst thing about my education was that we were not given any real historical and political context to the models we use. They are only effective or unhelpful, problematic or anti-oppressive. I only just recently found out that Carl Rogers (the creator of today’s constantly stated “person-centered approach”) was a freaky little guy who was also a CIA consultant during the cold war, profiling Soviet leader personalities and overseeing MKUltra projects on brainwashing. His biographical details implicate the models and methods we use today, and most of us don’t even know it. There’s gotta be a ton of that stuff going on. Let me know what I missed.
Maybe that’s what I want out of all of this. I want social workers to have a historical and political knowledge base. As it stands, you will learn the current NAMI perspective, or the Illinois Guardianship and Advocacy Commission perspective, or the Chicago Coalition for the Homeless perspective, or the Trilogy perspective, all depending on your internship. If your policy classes have no record of conflict, they are fairy tales. If our social work education could arm us with context, we might be able to make sense of our perspectives and know when they are being changed.
I’m a strong believer in functional analysis. There is human collateral damage on both sides. What are the uses of championing either camp? I believe that the Treatment Advocacy Center position takes the public health problem of SMI more seriously and leads us in a direction of more research dollars and more attention paid to our mental health system by powerful governmental actors. Improved psychiatric medications for psychosis are needed, as is documented by both sides, but if they are developed through the influence of TAC, will patients/clients/consumers/survivors be listened to regarding their effects, or will “lack of insight” become so cemented that dialogue is even further restricted? Is it possible to adopt some points and not others? Who should get to choose whether or not the risk of further psychiatric abuse is worth the possibility of better outcomes somewhere down the line?
Unfortunately, a functional analysis isn’t adequate. This ain’t a problem of personal belief. Knowing who is right matters. Living in a place of not knowing is a healthy disposition for most people, but under a system that allows/forces so much power into the hands of individual mental health professionals, my residence was denied. Leaving my role should have lessened the pressure to be right, but it just made me a better observer of it. The grey area takes up too much of the full picture.
If you read through all of this series, I genuinely thank you. This has been hard for me to write, especially this last bit. This lifelong over-sharer finally knows what it means to fear being vulnerable. I hope you don’t hate me, and I hope that you can tell that I mean everything I’ve said in good faith. I welcome your thoughts.