Humans rely on their traditions, rituals and habits. Familiar practices provide us with
feelings of safety and a sense of identity. They help regulate our behavior and allow us to function as a “civilized” society. We use many of these rituals to pass on our cumulative knowledge of human culture to our progeny. But some of these rituals, traditions and habits have had a more nefarious objective. Some have been responsible for inhibiting human development while others have been used to objectify and oppress entire classes of people.
This paper is going to describe one such collection of rituals – those within our modern mental health system and how one community mental health center defied tradition and did away with their rituals. This mental health center created an environment that freed individuals labeled with mental illness from the bondage of mental health rituals.
Mental health rituals which enable disempowerment dominated the pre-recovery culture.
When madness strikes, we repeatedly lose everything again and again with each hospitalization. Cars, houses, jobs, careers, families, books and friends. We experience the despair of passive rebellion, of playing the role of the victim with a one line script that repeats “I can’t do it.”
This is the beginning of disempowerment. Many of us fall into the victim role, and the mental health system encourages us to embrace this role most of the time in most of its programs. This negative encouragement is the enabling of disempowerment. Staff tell us “You need a simple task in a low stress environment. How about a sheltered workshop, stuffing envelopes?” or “You’re stress-sensitive.You need to set a realistic goal, like working in a file room.” I was taught to listen to the experts because I was incapable of living my life without them. This begins the line of demarcation which brands us for life. We are taught we cannot. We are taught disempowerment.
The experts. The experts always seem to think one-dimensionally, and attempt to get “consumer/survivors” to adjust to one-dimensionality. Anytime a consumer/survivor wants to move beyond a very low level of functioning they are seen as needing therapy We need to adjust to reality. The experts are scientists who have operational definitions. As Herbert Marcuse pointed out, operational definitions are “therapeutic definitions” to enforce one dimensionality. We are not a body with a mind. We are a “broken brain”. We do not have many dimensions. We have one dimension. “I” is a body with a broken brain, which acts psychotically. This one dimensionality of the “medical” or degenerative disease model is the essence of “I can’t”, of disempowerment. (On the lack of evidence for this model see What Is The Actual Schizophrenia Recovery Rate
A part of us wants to move beyond this status, to do something else, to have aspirations. We mention this to our treatment team. If the goals are not extraordinarily small, they are called “delusions of grandeur.” Our faulty thinking and aspirations must be done away with and we have to adjust to our lowest degree of functioning. Our treatment is to adjust us to our illness, to teach us “YOU CANNOT”, to ensure disempowerment.
We are behaviorally defined. We can forever only function at a certain level. Everything else, the “mind-shrinkers” tell us, is a “delusion of grandeur.” We live on an entire ward of people who needed to be shrunk, in an entire hospital of people who needed to be shrunk, in a country where millions of people need to be shrunk within systems designed to shrink them. These systems have a long “scientific” tradition of therapy and prescriptions for how to shrink them.
Our choices are narrowed; we can experience the despair of passive adjustment, the despair of passive rebellion and become a victim forever. We can choose the despair of active rebellion, trying to smash the system, pouring drugs down the drain, and convincing others to stop taking their medication. Or we can choose madness. These seem to be our only choices, but there must be something else, some other choice that we just don’t see. Can the medical model be separated from medication? Or can we gain the skills and make the life style changes to taper off drugs. Whether or not these are possibilities, we are defined as outsiders. Or are we to forever suffer disempowerment?
The “outsider” has been an archetype in Western civilization from Montesque who wrote the Persian Letters through Camus’ The Stranger . The outsider is a distorted mirror for “normal” society and helps to define it.
This mirror is distorted because normal society projects its dark side into the mirrors of the outsiders that it selects. Outsiders are forced to make careful observations of their place in order to overcome the distortions of the dark side of American society projected onto them. If one does not become overwhelmed, then the outsider position brings great awareness of self and others, but only through long and deep anguish, or rather angst, the anxiety seemingly at the core of one’s being about who one is.
This is akin to the Hegelian master/slave dynamic.
The outsider archetype is easily observable in mental health programs. Staff spend a good deal of time differentiating “crazy” from “normal” behavior and defending the fact that they are “not like that.” This distinction is made through jokes, diagnostic criteria, or “procedures,” depending on how sophisticated the performer is. The identities of the vast majority of mental health professionals and workers depend on these daily insider/outsider processes and rituals. These we call “normality rituals.” They serve the “normie” by differentiating him or her from the “crazy.” We build our identities by comparisons. We make these comparisons each day.
Staff cope with their life issues, they empower themselves by defining us and our ritual disempowerment. We are insured to be outsiders in their minds and in ours and they are insured of being insiders.
There are also the limitations of the “sanity rituals” of the chronically normal mental health culture around us. They are meant to teach the ways of sanity to “crazies.” These are the so called Activities of Daily Living (ADLs) – like we never learned how to brush our teeth!
Others reduce our difficulties to a molecular level, “His problem is only biological. It is like Alzheimer’s, a constantly degenerating brain disease.” some advocates say. Though there is not a shred of evidence that this is so. See for example Aaron Beck’s new book Schizophrenia (2006). Schizophrenia: Cognitive Theory, Research, and Therapy
Beck summarizes the evidence for biological differences. There are NO anatomical or physiological differences consistently found between those labeled with schizophrenia and those labeled average. And Beck reports that if you take the best candidates for genes to account for the diagnosis it accounts for only 6 to 15% of the cases. Hardly a law of gravity. Or Courtenay Hardings writings and research on recovery. Recovery from Severe Mental Illnesses: Research Evidence And Implications for Practice, Volume 1
I have summarized Harding’s work ( a good friend of mine). See What Is The Actual Schizophrenia Recovery Rate Or the excellent Robert Whitaker’s book Anatomy of an Epidemic.Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
Bob summarizes the evidence that definitively shows there is NO chemical imbalance of dopamine when comparing those labeled with schizophrenia and those not.
All of the “scientific” arguments to create disempowerment are untrue.
There are many, many ways to dismiss our experiences or the possibility of dealing with it. There are many many ways to enable disempowerment. “He can’t face his problems and if he tries the stress will just make him psychotic.” Sanity rituals are done to patients by “normies” or “the chronically normal” to make them similar to “normies”. They are different from normality rituals which mark a social line between the segregated “mentally ill” and normies: Segregated like other despised populations. Anthropologists point out that to segregate you don’t intermarry or date, you don’t eat together. And you also can’t pee in the same bathrooms, just like the old South. Mental health’s professional “ethics” codes function to enforce these segregation codes. They indeed amount to the segregation codes themselves.
This segregation cements the enabling of disempowerment and all in the name of “caring”. Women know this well for many centuries.
Dialogical Question
When madness strikes, the person who is judged to be mad is considered to be inarticulate. This is the traditional justification for talk therapy as a remedy. The person’s statements are characterized as confused, and bizarre, as ideas of reference, or as having inappropriate affect. Professionally guided conversation is regarded as (hopefully) having the capacity of clearing up the articulation problem and getting the person back “in contact.”
The fear that lies behind society’s need for stigma and separation demands the attention and accountability of the professionals, of course, of course. Indeed the demand for separation is what drives this “accountability”. It drives our disempowerment. But it also reflects what constitutes a dialogical breakdown, a condition which makes it hard for us to make our point. It’s not just professionals who need to be mindful about stigma and separation. We ourselves must consider how to empower our own dialogical position, how to render our voicing communicative.
The “professional defensiveness” creates a resistance to effective helping.
But this is a particular kind of resistance where the person with the power is the one with the resistance. Since ordinary conversation basically doesn’t help us out in this power imbalance situation, we must consider extreme dialogical measures if we choose not to resort to confrontation. What kind of extreme dialogical measures are available, and under what conditions are they practicable?
One solution is to employ Eastern wisdom, ‘insight meditation’, (see Seeking the Heart of Wisdom: The Path of Insight Meditation (Shambhala Classics)
), zen (see Zen Dharma Recovery Mental Health Video) Krishna consciousness (see Bhagavad-Gita As It Is
), Sufism (see Spiritual Dimensions of Psychology (Collected Works of Hazrat Inayat Khan)
and Practical Sufism: A Guide to the Spiritual Path Based on the Teachings of Pir Vilayat Inayat Khan
), raja yoga (see The Yoga Sutras of Patanjali: Commentary on the Raja Yoga Sutras by Sri Swami Satchidananda
) or other transcendent approaches that can weaken the resistance. Many people report that this has helped them significantly in difficult situations. To calm down. To control the panic of having to communicate the years of abuse to unlistening and unbelieving ears. The pressured speech which comes from the seeming impossibility of ever getting a fair hearing. But to bring this to Western medicine, a ‘Western’ adaptation of this approach is required. We can look to the postmodern critique of ideology for possible tools for use when we seek to collaborate on working through the resistance. The work of Jaakko Seikkula from Finland on Open Dialogue or the work of the brilliant Russian Baktin. Or John Shotter. Can a dialogical effort overcome disempowerment?
Social Death Sentence
The difficulty is that postmodernism is distinguished by an idealism that can create its own difficulties. Deconstruction can help break down ideology, but the heavy hand of deconstruction can also break up the realities upon which people depend. And it can be used equally well to negate our experiences. In other words, the recipe of “postmodernism” must be taken with a grain of salt and mediated by our explicit empowerment in the conversation. IF not it is just more disempowerment.
How do we get the sort of respect that is required to overcome the ideology based resistances of the professionals and also to act with wisdom? ”Stigma” is a concept that challenges the philosophy underlying the ideology. Portraying us as victims of ‘discrimination’ brings attention to the social implication of the resistance, but it creates an adversarial setting and promotes dialogical breakdown. We then have media campaigns instead of dialogue. The concept of the ‘social death sentence’, of our social re-definition as rendered by the behavior management system, provides more of an opening to authentic conversation. This is what is going on.
We are seen as incapable of ever re-joining society which is of course a self fulfilling prophecy. It produces tremendous disempowerment in a group of people already over stressed.
We lose everything when we are hospitalized and become the charges of the mental health system. This is done for a reason. It is regarded as a treatment necessity for our behavior to be redirected to focus on our treatment goals. We lose effective choice. We again become victims because the choice function that enables us to manage our own lives is disabled. Deeper than the matter of ‘choice’, however, is the lack meaningful involvement in achieving the possibilities of our own lives.
Part of what madness does is heighten some sensitivities. These sensitivities may be creative or debilitating. ‘Philosophical clarity’ is not a priority of providers, and the resistance to helping, downgrades the creative side of the sensitivities, and reinforces our difficulty in voicing them. We are limited by the disempowerment model to “art therapy” guided by a “normie”. We are isolated to the walls of the central office of the mental health agency instead of being at the table. Our disempowerment is presented as again “caring” for those poor unfortunates.
If we are to speak up and be part of the discussion meaningfully, we need to describe our reality in stark terms like ‘social death sentence’ which emphasize the negative character that is typically associated with having a mental illness. This is a grim approach, but we must learn to take it and turn it into a social opportunity. We must first hear in order to converse, which means we must appreciate the value of listening. The rituals of mental health treatment need to be replaced by respect for our our ordinary, everyday, spontaneous responsiveness to the others and otherness about us. They are our living connection to our surroundings and to other voices.” as John Shotter says.
Real Recovery
The self is diminished by the ‘social death sentence’ that is the hallmark of behavioral management. The self is re-constructed by a kind of ‘identity politics’ The boundary of self in this circumstance is delineated as the ‘social death sentence’, and effective recovery depends on effective boundary work – extending and even removing these boundaries if we are to move from disempowerment to empowerment, from “we can’t to we can”. Of course even phrases “we can” is co-opted by agencies like Mental Health America as a totally provider controled “advocacy” movement. We are taught to advocate for our own disempowerment and convinced it is for our own good.
By talking openly about “stigma” and “discrimination” in the context of a ‘social death sentence’, we remove the barriers and can begin the discussion of boundary work. We own the issues which led us to the rituals associated with being a ‘victim’, which enable us better to rationalize the truths of our being that make for a more adaptive ‘outsider status’. As the helping people deal collaboratively with society’s need for fear associated with the ‘social death sentence’, a more nourishing helping protocol is possible.
Our personal narratives of ‘social death sentence’ and our development of advocacy and genuine respect for our beings are creative and need to be cultivated. This perspective recognizes the value of personal anecdotes and provides a basis for identifying moral content. When we become workers for the truth of being we lose the despair, the “lost cause” essence that leads us to fall into ritual. To imitate and introject the professional segregation rituals.
Hope of Managing for Change
It is possible as a mental health practitioner, or agency, to change the culture of service delivery and challenge the beliefs behind sanity and normality rituals. (see When you delve into society’s need for stigma and separation, what lies behind it is clearly fear. “If it happened to you, it can happen to me.” Or worse, “You are debilitated and dependent on me, so in order to keep my job, I must take complete care of you and keep you from appearing anything other than normal.”
In institutions, the lines were clearly drawn—the ones who carried the keys were “normal.” As services moved to the community, mental health workers had an even stronger need to differentiate themselves on outings to the grocery store or the bank, thereby intensifying the public display of such rituals. This public ritual enablement of disempowerment is deeply humiliating. Some people live for the rest of their lives deeply damaged by such ritual shaming. They often kill themselves as a result.
For example, case managers “taught” “consumer/survivors” to use the bank by loading everyone in a van and driving them through the drive-thru where their transactions were limited to exchanges between the staff van driver and the bank teller. Not only was the staff person depriving consumer/survivors of a learning opportunity and the chance to develop community relationships, but they were perpetuating stigma by giving the bank teller the message,
“These people (consumer/survivors) are not safe enough to be in the lobby of your bank or talk directly to you.”
Here is a book on overcoming this in professionally run agencies.
But frankly I have seen this only done very very rarely. Most recovery and transformation is just paint and nothing more. Under the paint the ritual disempowerment and shaming continues. It is just hidden better.
The fears mental health workers face when shifting to an empowerment model are very real, and they come in all forms. The initial resistance staff project when asked to empower “their consumer/survivors” has to do with the perception of limited power. Staff are asked to “give up” the power they used to wield over consumer/survivors, which automatically makes them feel powerless, and has the potential to throw a system into a state of chaos. The key to intervening in the resistance before it hits a level of chaos is to change the management style from one of command and control, similar to the command and control style staff used over “consumer/survivors”, to a management style of empowerment, again mirroring the process of empowering labeled people. We learn that when staff feel fully empowered by administration, it is much easier to turn power and control back to the people they are used to controling to gain and maintain their social personality of “professional”.
This is often claimed to be done. As a matter of fact I ran into this philosophy in an executive director who used it as a front not to actually do it. But I have since actually seen it done
The next logical fear is loss of job security. When administrators begin to challenge the notion that “consumer/survivor/survivors” are debilitated and dependent, staff begins to wonder what they will be doing when consumer/survivors become rehabilitated and independent, and if they will find themselves in the unemployment lines. Staff jobs, and indeed, the entire mental health system, is based on people being sick and dependent enough to need the intensify the “level of services” or degree of control provided at the mental health center driven by the need for ever growing revenues..
The Spirit of Change
Most mental health workers find themselves in this occupational field because of a sense of caring. Often this caring is seeking an identity or image of caring rather than actual caring for the empowerment of others. It is in this case a form of jealousy, jealousy of the others independence. Such jealousy is the identity maintained in the strategic (if subconscious or suppressed ) use of disempowerment. It is this drive to “care for” others that triggers the next fear—that of caregiver guilt. If the caring were genuine instead of just image this fear would not be triggered.
It was common to hear comments such as these in casual conversations during the shift to an empowerment model: “If we shift to Recovery, half of my consumer/survivors will be hospitalized within six months!” “This is going to be terrible; the consumer/survivors will think we don’t care about them anymore.” “How will consumer/survivors know how to spend their time if we don’t provide day treatment for them anymore?” “My consumer/survivors won’t be able to work in the community, live on their own, or manage their lives.” By challenging the staff with a sense of ownership and investment in labeled people’s success, the labeled people were taken out of a dependency role and their right to fail (and to learn and grow from these failures) was reestablished.
The final fear staff face when making this culture shift is a fear of the unknown. There is a false sense of safety in doing the same thing day in and day out. When you begin to expect people you have controled to grow, to learn new skills and to become independent, there is a logical correlation that staff job duties will change and they will have to become flexible to meet the new demands of the agency.
In some cases, job titles become obsolete and staff are asked to learn a whole new set of skills to remain employed within the agency. If staff can summon their sense of adventure and make the leap, the process is ultimately very rewarding.
Staff seldom do this and quickly sink back into control and ritual shaming. At times staff now in this process can marvel at the personal growth happening among “their consumer/survivors” that was never before thought possible. Staff also can appreciate a work environment that is more dynamic, creative, and interesting, and they have come to expect that their job duties on any given day will be contingent upon the needs of the organization, which are constantly changing to meet the needs of people in recovery who are on the road of independent and meaningful lives.
At times heads of agencies see the need for the shift from a command/control management style to an empowering style of leadership, which has changed the expectations on both staff and people in recovery.
Staff used to say, “I do what you tell me to do because you are the supervisor and I am the employee.” Now they know, “I am a trusted employee who is empowered to make routine decisions.” When faced with a new idea they used to say, “That’s not how we did it in the past.” Now they say, “Let me think about how we can do this more effectively.” Command/control management resists change, and encourages repetitiveness, monotony, and boredom. Empowering management is dynamic, encourages change, capitalizes on creativity, and fosters growth for staff and people in recovery. In command/control mode, our task was to keep the “consumer/survivors” from backsliding because it was a direct reflection on how well we performed our jobs. Now we allow the people in recovery the opportunity to fail…..or succeed. Our service delivery system can change from “one-size-fits-all” to a people driven individual unique response by each staff to each person in recovery. We changed our focus for both staff and people in recovery from one of problems to one of strengths, where managers work to eliminate barriers and make weaknesses irrelevant. Staff no longer come to work knowing every task they will do for the day, but bring with them instead a spirit of adventure and flexibility.
This kind of talk is usually just that, talk. It serves as a way of painting over and hiding much more rigid control.
In the agency that actually made this change skills are taught. Some of these skills are found on this page at Zen Dharma Recovery Mental Health Video and at First Attempt Transforming Anxiety and also Guided Meditations These skills are used by both staff and peers and often taught by peers to staff. Role reversal of this kind is rare indeed. It ends the enablement of disempowerment.
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