Changing American Psychiatry: A Personal Perspective

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This recognition has been prominent in disability studies e. As Beresford notes, it is sometimes not even clear "whether or not madness, distress and psychiatric system survivors are part of the [disability rights] discussion" p. Many factors undoubtedly contribute to the underinclusion of 'mad' discourse within disability studies. Additionally, with the exception of some Centers for Independent Living CILs , for the most part both peer and professional services for mental health, on the one hand, and physical or developmental disabilities, on the other, have developed independently of one another, draw on different private and federal funding sources, and employ clinicians and providers with divergent training and disciplinary backgrounds Mulvany, ; Pilgrim.

Psychiatrists and the pharma industry are to blame for the current ‘epidemic’ of mental disorders

Mental health and disability activists are thus often faced with autonomous systems, infrastructures, and policy issues. Further, when psychiatric disability or "poor mental health" more generally is discussed in the context of disabilities, it is nearly always cited as a worst-case outcome of physical disability or ableism. These are: the relative lack of critical theoretical scholarship, exemplified by 1 the relatively greater biomedicalization and 2 clinical professionalization of discourse about psychiatric disabilities; and 3 negative impacts with respect to the training and support of students and juniors researchers with psychiatric disabilities.

It is worth underscoring that these three impact areas are admittedly not symmetrical. While it is possible to draw on a variety of empirical sources concerning the biomedicalization of psychiatric disability, for example, relatively little work investigates the unique implications of clinicalization , particularly with respect to research and academic discourse about mental health.

It is first useful to compare responses to the increased scientific legitimacy of medical approaches to physical and mental health issues in the 20 th century. However, since the late s, physical disability rights groups and advocates have emphatically and effectively questioned the medical field's practical limits. These views are well-integrated in both the disability studies discourse and the fields from which disability studies derives sociology, anthropology, etc. In contrast, the 20 th century was largely marked by decreased confidence in psychosocial psychiatric services, in particular psychotherapy, as it increasingly became clear that early psychoanalytically-derived therapeutic approaches to treatment were often ineffective in improving mental health Busfield, ; Dowdall, ; Horwitz, In addition, little consensus could be reached concerning what constitutes mental disorder and diagnostic systems varied dramatically between nations Andreasen, ; Kendall et al.

Responding to some of these concerns, psychiatric disease models that emerged in the s e. Additionally, the emergence in the s and 80s of new technologies that made it possible to study the brain for the first time e. The biomedical perspective that has emerged is rooted in an understanding of mental illness as a brain disorder caused by genetic vulnerabilities, early childhood illness and adversity, or other traumas that significantly alter neural function Read, ; Sharfstein, , Although this perspective has served to legitimize the field of psychiatry Mechanic, , it is not entirely without its critics, and social histories of mental health care often characterize the ascendancy of the biomedical model as therapeutically inefficient.

For example, Grob observed that, "psychiatrists tended to engage in a vast holding operation by confining mentally ill patients until that distant day when specific cures for specific disease entities would become available" p. Nonetheless, since it has become the dominant paradigm for understanding psychiatric disability, the low degree of scientific confirmation of many psychiatric disorders particularly compared to physical disorders has not been well recognized publicly.

Additionally, there is little appreciation for the social constructionist nature of diagnostic criteria within scientific discourse, which is evidenced by the lack of specificity and changes in specificity within diagnostic criteria. White , for example, long ago demonstrated that between one-quarter and one-half of patients receiving ambulatory psychiatric care were not able to be diagnosed based upon existing criteria and such ambiguity persists.

While there is persisting concern about the broadening of diagnostic criteria and public acceptance of sometimes alarmist research citing the growing number of people who have a psychiatric or neurodevelopmental disorder as a result of this broadened criteria , these discussions rarely critically question either the etiology or ontology of disorder itself, especially for more serious diagnoses such as schizophrenia.

The nature of the discourse among those opposed to mainstream psychiatry has also been influenced by the dominance of the biomedical perspective. As an illustration, even the critical U. Furthermore, the implications of a biomedical conceptual framework for those with psychiatric disabilities have not been thoroughly investigated.

Changing American Psychiatry: A Personal Perspective

There is growing evidence that simplistic biological and genetic attributions of "mental illness," particularly of schizophrenia, have in fact led contrary to early researchers' and family advocacy groups' predictions , to an exacerbation of public stigma including greater perceived seriousness, permanence and dangerousness Pescosolido et al.

As an illustration, public opinion research suggests decreased interest, compared to 50 years ago, in marrying someone with a serious mental illness because of possible genetic causes Pescosolido et al. We now consider the implications of clinicalization in greater detail. By professionalization and clinicalization, as distinguished from medicalization, we mean to describe the process whereby the power to generate knowledge about particular phenomena is allotted not just to credentialed academics, but academics that have specifically been trained to "treat" individual abnormality or pathology.

Consequently, while much work in disability studies celebrates and explores such themes as disability culture, disability history, disability and the arts, disability identity and disability theory, the literature on psychiatric disability tends to revolve around clinical treatment and rehabilitation. Even those non-clinically oriented US social science texts that address broader sociopolitical issues e. Coleman, ; Estroff, , ; Luhrmann, ; Morrison, nevertheless tend to ultimately focus on clinical sociopolitics as opposed to, for example, explorations of mad culture.

Another consequence of clinicalization lies in the instantiation and reinforcement of the belief that only individuals with highly-specialized training can help, support or understand individuals with psychiatric disabilities. Thus a student experiencing a first psychotic break may find herself suddenly abandoned by friends and colleagues who have absorbed the cultural message that they should simply defer to professionals precisely when she needs them most.

Several reviews of the rehabilitation literature e. For example, qualitative work among people with psychiatric disabilities emphasizes the importance of self-care, which Young and Ensing find is largely absent from the recovery literature, perhaps because, as they note, "self-care is simply not perceived as very interesting or informative" from a clinical standpoint p. As Rose notes, this clinical or therapeutic discourse is inherently positive in the sense that it produces new possibilities of experience and selfhood, but possibilities whose unintended consequences may prove to be significantly damaging.

A patient, for example, might be taught to distinguish between "normal" and "delusional" thoughts—the former properly hers, the latter the consequence of cognitive or neural dysfuntion—potentially leading to the experiential dis-integration of the otherwise assumed connection between agency and "her" conscious mental processes. While clinical control of diagnostic language may not be wholly negative or destructive, socioethnographic work amply documents the dangers of "engulfment" in a clinically framed 'chronic patient' role or identity Estroff, , ; Link, , ; Schur, Moreover, there is little acknowledgment in the mainstream clinical rehabilitation literature that the relationship between clinicians and patients is also a relationship almost irreducibly marked by asymmetrical power relations Rose, Clinicalization, that is, reinforces not only the belief that only sanctioned clinicians can understand and attend to psychiatric disability but also that this assistance can only be accomplished through a very specific, and in most cases intrinsically hierarchical, relationship.

On the one hand, the clinician—whether biomedical, behaviorist or psychodynamic in orientation—remains neutral, objective, and aloof, while the patient "confesses" his or her emotional subjective, raw, naive problems cf Butchart, ; Foucault, ; Hook, Through processes of guided subjectivization—the patient's identification both as the subject that speaks and the psychopathological subject of speech—his or her self-experience is thus brought in line with the "norms of psychological expertise" Rose, , p.

Sabshin, Melvin 1925-2011

To the extent that scholarship on psychiatric disability continues to be controlled by researchers whose expertise is defined in large part by virtue of their neutral and objective second-hand observational knowledge and explicitly clinical expertise, it is not difficult to appreciate some of the barriers to the inclusion of either psychiatrically disabled academics or academic or "scientific" perspectives that are explicitly informed by first-person experiences and narratives.

To some extent, that is, the very premises of clinical expertise are uncomfortably challenged by the potential counter-authority of direct lived experience. In disability studies, conversely, the importance of first-person perspectives, as well as the integration of disability with other aspects of identity, including academic identity, is well-accepted. Indeed, disability studies has been characterized as a place from where "crips strike back" Davis, As an illustration, Zola's e.

However, the equivalent to this type of work in American psychiatric disability research is largely absent; what is more, the prevailing research environment, as we explore in more depth below, may in fact actively inhibit the emergence of such scholarship. Evidence indicates that the academic environment is problematic throughout the typical academic career trajectory, from graduate training through tenure.

Hinshaw explores some of the reasons why such stigma may actually be particularly pronounced within clinical mental health disciplines, leading to a culture of silence and non-disclosure. As Price and Reiss discuss, the consequences of stereotypes centered around dangerousness and unpredictability have recently become particularly salient in the wake of a series of widely-publicized school shootings as well as more general acts of violence in which students or faculty with some form of psychiatric disability were implicated.

These include the Virginia Tech, NIU, Jared Loughner and Aurora shootings, and the recent murder of a graduate student by a faculty member with a diagnosis of bipolar disorder at the University of Idaho. This discourse of risk, in turn, may further legitimize the public's fear of mental illness, and strengthen the objectification of students and faculty with psychiatric diagnoses. In addition to such general psychiatric stereotypes, stereotypes more explicitly directed at the mental or cognitive in capacity of academics with psychiatric disabilities may be particularly destructive.

Price , for instance, discusses a myriad of ways in which individuals with mental disabilities—disabilities that affect intellectual energy and socio-academic relationships in addition to intellectual function—are specifically stigmatized in the context of academic work. These academic forms of stigma are perhaps most likely to negatively impact doctoral students, pre-tenured and adjunct faculty, whose success depends so strongly on successfully projecting an image of academic confidence and competence.

In the context of higher education, stigma and stereotyping may also constitute a threat to perceptions of the quality of individuals' research. Thus even if an aspiring academic with a psychiatric disability makes it through a doctoral program and obtains a university appointment, his or her research may be suspect due to assumptions of additional bias, subjectivity, personal overinvolvement, weak boundaries, or a general lack of rigor Rose, , , ; Saks, , ; Sweeney et al.

Arguably, such stereotypes, as suggested above, follow from the medicalization and clinicalization of mental health discourse to the extent that these discourses tend to privilege neutrality, emotional distance, and second or third-hand observation. Further, in fields in which explicit activist scholarship is rare, researchers' commitment to the advocacy community runs the risk of being viewed as proof of such academics' "compromised" science.

Thus, although students with psychiatric disabilities now represent the single largest disability sub-group receiving campus disability services in the US Government Accountability Office, , many disability services offices are far better equipped to deal with cognitive and physical disabilities than psychiatric issues Collins, In addition to these immediate institutional barriers, legal research suggests that individuals with psychiatric disabilities are often significantly less well protected by key legislation such as the ADA compared to other disability groups, particularly in the context of education and employment Stefan , ; Swanson et al.

In a comparative paper, Sahlin even more specifically unpacks many of the difficulties involved in obtaining faculty accommodations for psychosocial impairment in the US, given the often excessive legal deference granted academic institutions regarding determinations of "unfair advantage," "undue [institutional] burden" and the "essential functions" of academic employment.

As an illustration of several of these issues, Saks , in her autobiography about her experiences completing graduate work after being diagnosed with schizophrenia, details the lack of accommodations offered by the university where she studied and open discomfort exhibited by faculty whenever she acknowledged symptoms exemplified in a tendency to simply suggest she go directly to a mental hospital. As a consequence, and to avoid being viewed as incompetent, she overcompensated in her graduate work to such an extent that her thesis was deemed by her examiners to be of a quality equal to what is typically expected in a doctoral dissertation —also notable is that it was completed while, unbeknownst to others, she was experiencing auditory hallucinations so severe they led to her hospitalization Saks Inadequate accommodations and stigma also pose a threat to many faculty members with psychiatric disabilities, as other personal histories demonstrate Jamison, ; Karp, Jamison , for example, highlights the vulnerability of junior faculty who choose not to disclose a psychiatric disability in her depiction of a chancellor's garden party she attended in the midst of a manic episode: While she thought herself to be having "a fabulous, bubbly, seductive, assured time" p.

Karp additionally describes the profound sense of loneliness occasioned by his vulnerability as a junior faculty member prior to tenure, describing sleepless nights accompanied by the knowledge that his intense teaching load could not be reduced even though he was experiencing clinically-significant symptoms. While such personal accounts highlight the barriers and challenges of succeeding academically as a researcher with psychiatric disabilities, it is noteworthy that these issues are almost wholly absent from the research literature.

Our review indicates that the only published discussions of these themes in the U. Even in texts in which the plight of academics and students with disabilities is discussed more generally, issues specific to psychiatric issues are often not mentioned.

For example, while Olkin very helpfully unpacks the potential difficulties experienced by doctoral students with disabilities enrolled in clinical psychology training programs, she makes no mention of any issues or concerns—particularly pronounced in such contexts—regarding the unique challenges that might arise in the context of psychiatric disability including potentially significant barriers to licensure. Mentoring is another area in which individuals with psychiatric disabilities may be disadvantaged.

While the value of mentoring minority doctoral students and junior faculty has been well-documented and discussed Jeste et al. Although it would be problematic to suggest that non-disabled senior faculty cannot appropriately mentor junior colleagues, given the frequency with which "like me" faculty are often sought as mentors Rockquemore, , the double invisibility of many researchers—invisible due both to the nature of their disability and their decisions not to publicly disclose—arguably decreases the pool of recognizable mentors even as it reinforces an academic culture of silence.

It is, therefore, perhaps not surprising that even a figure as prominent as Marsha Linehan, the esteemed developer of dialectical behavioral therapy DBT , waited until the very end of her career to publicly disclose her own struggles with borderline personality disorder Carey, , June Although we have thus far discussed many of the challenges that face graduate students and faculty in academia, this discussion has excluded the arguably more basic issue of graduate admission. The authors explain:. The discussion of a personal mental health problem is likely to decrease an applicant's chances of acceptance into a program.

Examples of this particular KOD in a personal statement included comments such as "showing evidence of untreated mental illness," "emotional instability," and seeking graduate training "to better understand one's own problems or problems in one's family. Psychiatric disability, these authors suggest, may more or less directly imply some level of academic incompetence or risk regardless of one's academic record, at least for some admissions directors.

Notably there were, to our knowledge, no public outcry concerning these findings, a situation that seems highly unlikely were race or sexual orientation likewise implicated as a "kiss of death. Clearly enough, graduate students and faculty with a range of different physical and mental disabilities and chronic illnesses face significant barriers and an often inhospitable climate in higher education. The development of disability studies programs and curricula, on the other hand, has clearly led to at least pockets of explicit support for and acceptance of academics with disabilities.

To the extent that both psychiatric disability as a research area and students and faculty representing the full spectrum of psychiatric disability are significantly under-represented in disability studies, however, academics with psychiatric disabilities are arguably at even more of a disadvantage. They have, that is, no disciplinary safe haven. Given the increased attention paid to issues concerning psychiatric disability and diversity in the disability studies literature specifically, it is worth highlighting two potential courses of action for scholars within this discipline.

Developments outside the US, for instance in Canada, where 'mad studies' has made more significant inroads in disability studies e. Departments, that is, including prominent US disability studies programs , need to honestly examine the extent to which they currently employ researchers with or without personal experience who approach psychiatric disability from a holistic, non-pathologizing perspective.

A Personal Perspective

Hiring faculty with such interests, in turn, would help create a pipeline encouraging applications from students both with and without psychiatric disabilities with significant investment in these issues. Likewise efforts might be made to fund and organize mad or psychiatric disability focused symposia, conferences, and research initiatives, as well as special issues of relevant journals, in order to promote and encourage progressive cross-disciplinary scholarship on psychiatric disability and madness.

A Personal Perspective

Even in the absence of the formation of a full-fledged mad studies discipline, steps can be taken to address some of the issues specific to the often stigmatizing academic climate in the US, as well as the lack of targeted supports for doctoral students and junior faculty with psychiatric disabilities. With modification, programs already in place aimed at promoting the success of students of other historically disadvantaged groups including special summer institutes, research fellowships, and additional mentoring opportunities might be implemented for students with psychiatric disabilities.

In addition, steps could be taken to empirically evaluate and implement effective academic accommodations specific to doctoral students and faculty—i. The absence of any existing research into "advanced" accommodations highlights the need for further attention to this matter, and suggests that any such efforts might be limited if they do not openly acknowledge and target the full range of psychiatric disabilities, including more highly stigmatized and potentially complex disabilities such as schizophrenia. As Cook notes, "some have argued that institutionalized discrimination against people with mental illness" is in fact "one of the last socially-acceptable, government-sanctioned threats to the rights of a large class of vulnerable individuals" in the United States p.

Open acknowledgement of this underinclusion and its causes and consequences is the necessary condition for change. Abstract There is growing recognition that psychiatric consumer, survivor or ex-patient perspectives are not well-integrated into disability studies work and academic discourse more generally. Introduction Over the past decade, there has been growing recognition that the perspectives of individuals with psychiatric disabilities have not been well-integrated into academic discourse. Biomedicalization It is first useful to compare responses to the increased scientific legitimacy of medical approaches to physical and mental health issues in the 20 th century.

The authors explain: The discussion of a personal mental health problem is likely to decrease an applicant's chances of acceptance into a program. References Albrecht, G. The global emergence of disability. Albrecht, R. Scrimshaw Eds. London: Sage. Aaltonen, J. The comprehensive open-dialogue approach in Western Lapland: I. The incidence of non-affective psychosis and prodromal states. Amador, X. Insight and psychosis. New York: Oxford University Press. American Psychiatric Association.

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Teaching of Psychology, 33 6 , Asch, A. The experience of disability: A challenge for psychology. American Psychologist, 39, Ban, T. Academic psychiatry and the pharmaceutical industry. Barnes, C. Rehabilitation for disabled people: A sick joke? Beck, A. A new instrument for measuring insight: the Beck Cognitive Insight Scale.

Schizophrenia Research, 68 , Beresford, P. What have madness and psychiatric system survivors got to do with disability and disability studies? Thinking about "mental health": Towards a social model. Journal of Mental Health, 11 6 , Theory and practice of user involvement in research: Making the connection with public policy and practice. Hulatt Eds. London: Routledge. Developing a social model of madness and distress to underpin survivor research.

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Cambridge, MA: Ballinger, Critical Issue Paper 2. Hospital and Community Psychiatry 29 —, American Journal of Psychiatry —94, Community Psychiatrist 1 :9, Community Psychiatrist 2 :6, Archives of General Psychiatry 43 —, Skip to main content. Edith Goldfarb Sabshin.

Linked changes in mental health service delivery and psychiatric education | SpringerLink

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