Thursday, March 15, 2018

How Would We Know If We Overthrew the Mental Health System?

The radicalness of the anti-psychiatry movement has unfortunately become one of its greatest hurdles to overcome. Even in otherwise radical spaces like prison abolition, neurodiversity, or intersectional feminism, the most common reaction to anti-psychiatry ideas is to dismiss them as so intuitively ridiculous they need not be engaged with. Sanism, behaviorism, drugs and force have permeated our culture to the point many people literally can’t imagine life without them.

On a good day, our leaders pontificate about “reforms” that would somehow fix a system whose deepest foundation is a bed of violence, oppression, and at best pseudoscience. They ask for cultural awareness training, yoga classes, art therapy, and healthier food options in psychiatric facilities, without ever questioning the confinement that made those things unavailable in the first place (let alone the coercion involved when participation in such activities becomes a condition of release).

Reform is a jail cell with pretty wallpaper. We don’t need mental health reform, we need total abolition of force and coercion. The system doesn’t just have problems, it IS the problem. So if we really fixed everything that’s wrong with the mental health system, there would be no more mental health system.

We have to be careful, of course, about rebranding. We’ve seen this happen with institutions for disabled people, renaming themselves to talk about independence, while still keeping people locked in and forcing drugs on them. Changing the name to something other than “mental health” means nothing if whatever name we replace it with offers all the same abuses. If we truly eliminated all the horrid practices that are currently committed by the mental health system, what would the world look like? What would it take to go about abolishing psychiatry and the mental health system?

What follows are 15 ways our society would need to change before we could be confident that we are free from the tyranny of the mental health system.

1. No one would be deemed incompetent.

No person would ever be declared unqualified to make decisions about their own life. Not because of a mental illness, disorder, diagnosis, health condition, disability, nor any other title. There would simply be no system in place to allow such a thing. The idea of meeting legal requirements to be conserved, confined, or made a ward of the state would become as anachronistic as the idea of meeting legal requirements to be enslaved. Everyone would be the ultimate authority on their own bodies.

Mentally ill” is a legal term which translates into plain language as “unable to make decisions.” Not biologically, but legally. Unable to decide where to live, whether to live, who to live with, what food to eat, and what drugs to take or not take. Efforts to attack the term “mentally ill” as an offensive slur haven’t done anything to combat this legal designation. All that’s changed is that people with “mental health challenges” or “psychiatric diagnoses” are deemed unable to make decisions.

The fact that such a designation exists within the law — in letter, spirit, and execution — makes the mental health system, and by extension our whole society, intrinsically unjust and oppressive, because someone will always be designated by it. Truly overthrowing the mental health system, as opposed to just forcing it to get more subtle or rebrand, would mean that any remaining systems fully support cognitive liberty: the principle that everyone can do whatever the hell they want, with restrictions only ever placed on actions that harm other people.

2. All psychiatry programs in all schools would be replaced with Mad studies and neurodivergent studies programs.

As part of a total abolition of the mental health system, it would be necessary to put a complete halt on any influx of new mental health practitioners. For students in the middle of their training, it would be unfair to pigeonhole them into finishing, with a degree in a field that no longer exists. Instead, those students would be given transfer credits and an opportunity to change programs with full scholarship.

Mad studies and neurodivergent studies would open up as new programs that these students would have the option to transfer into. These areas of study already exist in a small number of universities, but by freeing up funding from psychiatry programs, they would have the opportunity to expand.

The meaning of the prefix “psychiatric” is undefined in all fields, so the only difference between a medical drug and a psychiatric drug is that one is called a psychiatric drug. The study of these drugs would be taken up by medical doctors, who are already required to learn about drugs.

3. Mad and neurodivergent people would be managers, not “peer specialists.”

The creation of various “peer” positions has accomplished very little besides handing out a few minimum wage jobs to disabled people. A requirement of “lived experience” rather than a degree makes a vaguely defined identity group into the primary qualification.

The essential function of a “peer specialist” is to appear non-threatening, earn people’s trust, and convince them to stay on their meds. Hiring managers know that these positions only exist because others don’t, that there are far more job-seekers than jobs to fill, and thus that anyone they hire is easily replaceable. “Peer specialists” are grunt laborers with no real power to meaningfully affect the establishment that brought them in. If a radical abolitionist gets the job and conscientiously objects to their assigned duties, they just get fired like in any other job.

If a patient is prisoner to the medical facility, while their counselor has never been imprisoned and is free to leave at the end of their shift, then the counselor does not have the same lived experience and is not a peer to their client. They are just another generic white coat whose income stream depends on keeping others locked up and coercively medicated.

If the “peer specialist” has more power than the patient, then they’re not a peer, and if they have the same or less power, then they’re not needed.

Advisory committees made up of “peer advocates” are not effective either. They are a token position with no actual power. They can tell the managers what to do, but the managers have no obligation to follow their advice. In many cases all that’s accomplished is to create the appearance of listening, placating any protesters while creating no real policy change.

What reformists say would be fixed by additional “peer specialists” would actually be fixed by having Mad and neurodivergent people in management positions, with actual decision-making power. This situation could be achieved legislatively, through diversity quotas, or culturally, through the understanding that Mad and neurodivergent people not only have instant added value in their wide range of lived experiences, but also can be just as skilled or more than any neurotypical.

The hierarchal structure of business means that putting good people at the top would eventually improve the immediate service at the bottom, because we understand our own needs better than someone who just needed a job.

4. Crisis hotlines would be prohibited from tracking callers or dialing law enforcement without the caller’s consent.

In today’s cultural landscape, crisis hotlines are being pushed as a way to access the mental health system quickly and without insurance. Currently, all hotlines train their staff as mandated reporters, to listen for key phrases and if the caller utters one of them, secretly send people with guns and a history of recklessly using them, directly to the caller’s location. The sole exception is Trans Lifeline, which is of course exclusively for trans people, only a fraction of everyone who might want to call a crisis hotline.

Rather than fixing these serious safety hazards, reforms to crisis hotlines include expanding hours of operation, adding text options, and starting new hotlines for identity groups like teens or LGBT. All that gets accomplished here is increasing the number of people who get tricked into putting themselves in danger, while thinking they’re getting an emotional support or referral service.

Crisis hotlines are undoubtedly part of the mental health system as long as they behave this way. So in order to overthrow the system, the hotlines would need to be more regulated. Specifically, the regulations would give hotline callers the same confidentiality rights they have with a doctor or therapist, which under this new paradigm would of course include the right not to be locked up for hearing voices or being a danger to yourself.

5. Compliance with Olmstead “community living” would mean Housing First with no strings attached.

The supreme court decision of Olmstead vs L.C. declares the right of disabled people, including those disabled by psychiatry, to live “in the community” instead of in institutions.

Unfortunately, the implementation has been a lot more fuzzy than the decision itself. Prisoners of institutions wishing to leave must first establish a place to go ahead of time, which means they must have either the money to leave on their own or a solid support network. Obviously people who have been disabled and stigmatized are not always going to have those things.

A few public supports exist, such as transitional housing for homeless people, but these all come with a heaping spoon of coercion. They may require residents to regularly see a psychiatrist, comply with drug prescriptions, eliminate their use of non-prescribed drugs, get chummy with their neighbors or attend a minimum number of religious cult meetings each week.

Some cities have implemented Housing First programs, meaning that homeless people are taken off the street and given free permanent homes, in some cases with no strings attached. These programs have been a huge success, even by dogmatic standards like increases in employment and decreased use of non-prescription illegal drugs (because they’re not so stressed by being homeless).

If you truly want to free people from institutions and homelessness, just give them homes.

6. Service providers would be trained to consider doing nothing as a valid option.

An emotional crisis or spiritual emergency doesn’t always require an intervention of any kind. Sometimes the interventions we’re told are “best practice” only make the situation worse. Sometimes the person experiencing the situation already knows their best coping strategies, and will do a much better job at implementing them than someone they have to be explained to. Sometimes their friends are already familiar with the best ways to support them. An emergency psychiatrist necessarily isn’t, and neither is a so-called peer counselor.

In a post-psychiatry world, both would be regularly, sternly reminded of their humility. Moreover, they would be taught when not to intervene, and they would not need to have basic respect packaged as just another proprietary methodology, with a sexy name like “Open Dialogue,” “Intentional Peer Support,” “Emotional CPR,” or even “Alternatives to Suicide.”

Suicide attempts aren’t always a “heat of the moment” thing. We all die. Some of us would like to decide how, and some of us would also like to decide when. Sometimes a deeply introspective, thoroughly logical contemplation reveals that suicide is the mode of death most consistent with one’s beliefs and values. An immense degree of arrogance is needed to say that this person should be required to live against their will, in a facility where all their freedoms are taken away, which could only make a reasonable person more certain that they would rather die. An even greater arrogance is needed to say that stripping a person of everything they have, emotionally and literally, would improve their health.

Whether you place the highest importance on health or liberty, using force and coercion makes no sense because doing so improves neither. It makes much more sense to think of counseling a suicidal person as end-of-life care: the professional listens, acknowledges feelings, reflects on them, and doesn’t send someone with a gun to make sure their client dies faster or goes to prison. It’s not assisted suicide; it’s just respecting another person’s beliefs and values, even if you disagree with them. You may even find that when people have the freedom to talk about their feelings without having violence committed against them, they might be more inclined to keep on living.

Knowing when not to intervene is just as important as knowing a good methodology. In many situations doing nothing is the best strategy available. To overthrow the mental health system, we must train professionals, as well as the general public, to regularly and seriously consider the option of letting people make their own decisions without trying to threaten them out of it.

7. Short-term and long-term housing would be unlocked 24/7.

Peer respites, emotional wellness centers, urban safety retreats — whatever we wind up calling the former “mental health” facilities — they are all unlocked both ways, allowing the people who stay there to come and go as they please. Common areas like kitchens and TV rooms would remain open and powered as well. Strongly worded legislation would be passed to shut down any facility that resembles an institution, such as ones that don’t pass the burrito test.

Confinement is always violence. Involuntary homelessness is always violence. Lock-ins, lock-outs and curfews cannot ever be therapeutic because they violate a person’s safety and autonomy.

Furthermore, consent is not possible any time the consenting party needs someone else’s permission to leave. Even when people technically have the legal right to refuse drugs, or not choose the “healthy” food, or abscond from group therapy, they can be coerced into doing those things because it influences someone’s opinion of how long they need to be held. Therefore, the overthrow of the mental health system is incompatible with the continued operation of locked facilities.

8. Every care unit would be funded in a way that decreases the length of stay and gives visitors the drugs they want.

It’s bad enough that anyone with a badge, a degree, or a child can create a 72-hour imprisonment with no crime, no victim, no due process, not even a charge. 72 hours can cost you your job, your home, or even your life. Yet for many, those 72 hours are only the beginning.

Most psychiatric facilities try to keep people for even more absurd lengths such as weeks or months. One reason they want people to stay longer is because medical insurance companies are willing to pay for psychiatric services. The longer the stay, the more money the facility gets. Ironically, what is otherwise considered “good insurance” paints a target on the heads of false commitment victims, whereas “bad insurance” may end up saving a person’s life.

In these environments, it’s very easy to get a forced injection of tranquilizers by acting non-compliant, yet it’s challenging to impossible to get the drugs you actually want and need, or even to continue them based on existing prescriptions.

Although we should have already banned outright cages at this point, it’s difficult to completely eliminate all coercion. Doctors and psychiatrists can be persuasive pressurers who espouse the importance of their snake oil, or they can refuse to administer legitimate life-saving services until after an arbitrary screening period.

To fix all of these problems, the end of the mental health system would have to include a revision of how care facilities are funded. Rather than getting a flat rate for each day a visitor stays, they would get a variable rate that diminishes according to the amount of time the person stays in the facility, instead of moving back into community living with proper supports.

This way, care facilities have a financial incentive to give visitors the services they asked for quickly, including drugs if desired, so that those people are satisfied enough to leave earlier.

9. All drugs would be legalized, including prescription drugs.

As said by Thomas Szasz, considered by many to be the father of anti-psychiatry, prescription drugs are illegal. You cannot waltz into a drug store and buy a prescription drug without a prescription. Prescribing to yourself is a crime. Prescribing to your friends or family is a crime. It is a crime to give someone else a drug that was prescribed to you, and it is a crime for you to take a drug that was prescribed to someone else. No other form of property is treated this way, except for illegal drugs.

Criminalization and prescription are two sides of the same coercive coin. Together, they mean that people who need or want a drug either can’t get it at all, or can only get it if they are wealthy enough, normative enough, and socially savvy enough to convince an arbitrary authority to grant permission. Restricting your choices is not on the same level as forcing a substance into your body, but it is one of the many ways the mental health system oppresses us.

Without the mental health system, there would be no such thing as a psychiatric prescription because all drugs would be legal. Supporters of the status quo often ask “how would you get the medication you need without a doctor prescribing it?” The answer is right there in the question: without a doctor prescribing it. In other words, the same way you get any other product: you go to a store and buy it.

To overthrow the mental health system, we must abolish the prescription system, and replace it with a system of informed consent. Psychiatrists would no longer be the gatekeepers who decide whether you will be allowed to take the drugs you actually want. Instead, the role of a psychiatrist would be to give recommendations and safety warnings. The paper you leave with would simply be a reminder note of what name and dosage to grab off the shelf.

Also, it would be nice if we released, pardoned, and compensated everyone who is currently in jail (including the jails that are called hospitals) on a non-violent drug charge.

10. Adverse drug effects would be independently studied, listed on the box, and discussed without taboo.

Informed consent is the only true consent. The reason is simple: if a person was not made aware of the risks and downsides, then that person did not consent to them. Abolishing prescriptions would be a major victory, but that alone would not guarantee a system of informed consent. Although banning untested drugs altogether is yet another act of paternalism, to protect you from yourself, it is nevertheless the obligation of a responsible society to protect individuals from predatory companies.

There are two parts to this change: Studying and labeling.

Trials for new drugs would be conducted by independent parties. “Independent” must mean sufficiently divorced from the manufacturer such that the people collecting data do not know the name of the drug or the company that made it. Double-blind, placebo-controlled is a good foundation for a standard, but we must also add the full human spectrum to the subject pool, including people of diverse ages, people of size, disabled people, and people who have a uterus (currently biomedical research often excludes anyone with a uterus because it would be inconvenient if they got pregnant).

As a precaution against residual paternalism from the mental health system, the results of these studies would have to be made freely accessible and open source. Once a drug goes mass market, the people who take it would be able to submit anonymous complaints (petition for redress of grievances) to an open-source government site, and a certain number of people submitting the same complaint would automatically prompt a re-investigation.

Once the drug effects are known to the elite few who understand, care about, and have time to comb through data, that knowledge must be disseminated. The most effective method is to require warning labels directly on the product. PSAs on TV, in newspapers or online all have a selection bias, word of mouth clearly hasn’t overpowered marketing money yet, and warnings in doctor’s offices would be a moot point after abolishing the prescription system. A mandatory warning on the package in the store ensures that everyone who receives the product receives the warning. Voila, informed consent.

The warning label method does have one weakness though: Many people don’t bother reading them, not because they don’t care, but because it’s so unheard of that these drugs might not be perfect. For this reason and many others, the overthrow of the mental health system would have to be not only a series of legislative victories, but a cultural shift too. Feeling like there must be something wrong with the individual, rather than the drug, is one of the insidious ways the mental health system prevents survivors from coming out, which prevents conversations about adverse effects from being normalized. More psychiatric survivors must open up about their experiences, and it must be safe for us to do so.

11. Every program that recommends drugs would also offer support for quitting drugs.

Even after the prescription system is replaced by a system of informed consent, psychiatric drug withdrawal is very real. Those who were informed and consented to the drugs may still decide to stop taking them later. Any withdrawal is a difficult process and requires support.

The lack of support for people who want to stop taking their drugs makes it difficult to have free choice over the use of mind-altering substances. Expecting people to suffer alone while they taper off the drugs or go cold turkey is essentially pressuring them to stay on the drugs. It’s a form of coercion, and thus part of the mental health system.

In a world free from the mental health system, everyone who is trained to recommend drugs would also be trained in how to help people taper off, and drug dealer facilities would also have a withdrawal unit, both for safe tapering and for maintaining a relative amount of safety while quitting all at once.

12. All psychiatric diagnoses would be recognized as bunk and removed from medical records.

Despite all the “biological brain disease” rhetoric justifying the pseudoscience of psychiatry, no so-called “diagnosis” in DSM 5 has ever been demonstrated by a biological test. In the few cases where we have discovered a biological cause, such as trisomy 21 for Down syndrome, that classification has ceased to be the domain of psychiatry.

Because these “diagnoses” are little more than pseudoscience, made up by psychiatrists to oppress people and gain money, the end of the mental health system would mean the end of the DSM. Every DSM classification would cease to be a disorder in public or professional consciousness, and they would become obsolete from medical records, because they are not medical information.

What about legitimate identities that happen to be falsely pathologized? How would they get services?

Firstly, there is no logical dependency between a group existing and that same group being classified as a mental disorder. You can have one without the other. Legitimate categories such as multiplicity, hearing voices, or Autistic would be recognized as cultural identities, similar to the way we now recognize gay as an identity, now that psychiatry finally let go of homosexual disorder to free its hands to grab transgender and asexual.

A pseudoscientific medical diagnosis is not necessary in order to get services such as communication devices, gender affirming surgery, and the anti-convulsants some people take to hear voices. The requirement of DSM classifications makes it harder to get those services, not easier. Under a system of informed consent, rather than the gatekeeping prescription model, cultural minorities would more often get the services they want and need.

13. Consent laws and consent culture would obsolete compliance.

Enough about information. What about the consent part? Atop the slain corpse of the mental health system, all procedures would require consent from the recipient. Consent must be freely given and can be revoked at any time for any reason. Patients checking into a medical facility would be able to leave whenever they want, not weeks later when the doctor finally signs the discharge papers because insurance ran out.

There could certainly still be conduct agreements, for example “no yelling in the meditation room,” but anyone who can’t or doesn’t want to abide by the rules can opt out of the entire situation.

Mental health is one of a handful of industries, along with education and government, where the person paying for the service, in effect the employer, is expected to complete arbitrary rigors and assessments, or else face inescapable consequences decided by their employee. Without the mental health framework, expecting compliance with doctor’s orders would no longer make sense, because the doctor-patient relationship can be terminated at any time. Instead, the professional would be expected to comply with the wishes of the person requesting their service, or else be fired and replaced.

14. Social Security would be replaced with Universal Basic Income.

Wait, what does welfare have to do with mental health? Well, the legal definition of a disability is still pretty stuck in the medical model — the idea that people are disabled by medical conditions, rather than by access barriers like stairs and strobe lights. Therefore, one must get a “diagnosis” from a doctor to qualify for any disability-based government program.

Aside from the inherent dangers in handing over your recorded history of madness to multiple corporations and the government, the current bureaucracy creates a problem within the mental health system itself: imbalance of power. Those who are unable to work due to systemic hiring discrimination rely on welfare programs, which require you to convince a doctor to say you’re unable to work. If you’re magical and manage to convince them that you’re a victim of discrimination, that doesn’t count.

If your survival within a capitalist system depends on you qualifying as legally disabled, and a doctor wields the power to decide whether you’re legally disabled, then the relationship you have with that doctor is inherently coercive. The doctor can let you die if they feel that your madness is too weird, or that you smell bad, or you didn’t say “please” enough.

Keeping doctors the gatekeepers of disability benefits is no better than keeping them the gatekeepers of drugs. You can’t revoke your consent to the doctor-patient relationship because the doctor holds something you need and can’t get without them. That is the definition of coercion. In order for patients to have the power to revoke the relationship with their doctor, they must not require a doctor’s permission to get the services they need, including income. In order to revoke the power of coercion from doctors, we would have to revoke the power of their signature in disability benefits.

15. Any use of force in a psychiatric context would be illegal.

In case it wasn’t clear, freeing ourselves from psychiatric tyranny requires the complete and total abolition of all interventions that lack the consent of the person whose life is being intervened in. Not reduction, not higher standards of proof, not “last resort” policies, total abolition.

Anything less than total abolition is playing within the system, using the master’s tools to ask for minor cosmetic changes and lip service. If nine hundred people were force-drugged this year instead of last year’s thousand, we still have a problem.

The master’s tools will never dismantle the master’s house. Create a list of criteria so the cops can’t just lock up anyone for any reason, and they’ll use those criteria to shop around for people who meet them. Make force a “last resort” and the first resort will be to halfheartedly skim through a checklist. Add a “peer specialist” to the team and they’ll hire someone who’s up to their eyeballs in the medical model and a paradigm of health first, liberty never.

We are not free from the mental health system as long as one person is under threat of legalized force. All the other changes on this list are ways to keep laws enforced or to reduce manipulation and coercion. But first and foremost, we need far-reaching legislation, with broad definitions, that makes every use of psychiatric force automatically a crime.

1 comment:

  1. I'm incredibly grateful for your post in Mad in America. I've never seen anyone else with such similar views as the ones I hold on the state of psychiatry in the US. It took me a long time to realize that I'm a survivor of the medical model, although I long felt an instinctive resistance to the way it defined me and assigned diagnoses I didn't find appropriate. Many, many thanks for your beautiful writing


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