The real question is whether the “brighter future” is always so distant. What if it has been here for a long time already—and only our own blindness and weakness have prevented us from seeing it around us and within us, and kept us from developing it
—Vaclav Havel, The Power of the Powerless
How do we talk about mental illness in a world gone crazy? When mundane events increasingly take on the character of the surreal or the apocalyptic, what does it mean to be normal or sane? I believe these kinds of questions will shape our understanding of the future of mental health.
Sober scientists now tell us that human civilization is in imminent peril. In the US, life expectancy is declining, and tens of millions of people, including children, are taking antidepressants and other psychiatric medications in an attempt to deal with ordinary life. We have become a sick society, and the signs are all around us.
Yet these things are not acts of God. They represent catastrophic failures of governance. This was preventable. Our ruling institutions have betrayed us for a profit, and they have lost any claim to legitimacy.
What then must we do?
We’re living in a moment when the public discourse around mental health increasingly relies on terms like “crisis” and “epidemic.” The headlines announce a “depression epidemic,” a “suicide epidemic,” or a “youth mental health crisis.” Additionally, we hear about an “opioid epidemic” or an “overdose epidemic.” This proliferation of terms tends to obscure the larger overarching picture—that of a society in deep distress. What’s going on here?
If we step back for a moment, it is impossible to avoid the conclusion that our various mental health “crises” are part of a larger pattern of interlocking national and even global crises. The prospect of global ecological collapse has created a generation of futureless youths. Extremes of inequality and downward economic mobility have stirred fascist movements around the world. And perhaps the most telling statistic is the declining life expectancy here in the US, likely driven in part by “deaths of despair.” All these factors have to some extent been exacerbated (and obscured) by the COVID pandemic, but all were in place well before that.
From a public health perspective, an epidemic is usually met with efforts of prevention. Causes are isolated, and mitigation programs are put in place. But nothing of this kind can be found in relation to an epidemic of “mental illness.” Public health literature regarding mental illness usually confines itself to projects directed toward expanding treatment. The underlying belief seems to be that we could heal a broken world if only we could pump out enough psychiatric medication.
The inability to see and name the root evils of our society pervades our institutions and profoundly affects the practice of mental health care. We may call it institutional corruption, or we may call it collective insanity. But the result is that our systems of treatment almost invariably start from a premise of individualized psychopathology. The very concept of epidemic mental illness has not entered the lexicon. Those specific methods of treatment that are most appropriate in an epidemic have not been identified or studied for their feasibility in addressing issues of mental health.
Where does that leave us—we who are suffering? If we go to see a psychiatrist, the psychiatrist immediately reaches for the prescription pad without any deeper inquiry, maybe telling us about a “chemical imbalance.” If we go to see a psychotherapist, the psychotherapist has his or her own theoretical bias—cognitive, psychodynamic, etc.—and confidently tries to fit our suffering into his or her system.
But what if we’ve just caught the thing that’s “going around”—the epidemic disease? What if we’ve spent our whole lives surrounded by others, starting with primary caregivers, who were themselves anxious, depressed, distracted, isolated, and emotionally shut down? What if we’ve spent our days of work and play staring into electronic screens? What if every dimension of our lives is controlled by huge, faceless bureaucracies that could at any moment take away our livelihood or refuse to pay for needed medical care? What if our life consists, as Chris Hedges said of the poor in America, of “one long emergency”? If our existing systems of care cannot even name these things, how can they treat them?
The exact nature of the factors behind the epidemic is complex and has yet to be more clearly explained. Wilkinson and Pickett in The Spirit Level have shown the pervasive psychological effects of economic inequality. Economists Case and Deaton have explained the behavioral health aspects of downward mobility in their work on the “deaths of despair.” The ACES research shows the extent of the profound mental and physical impacts of trauma. Existential factors endemic to modern society include social isolation, loss of meaning, and disempowerment.
One theory now gaining some currency holds that smartphones are a primary culprit. While this may satisfy our need for simple explanations of what is going on, it is far too reductive to account for the broad scope of the crisis. However, the problem of smartphones is in some ways particularly emblematic of the perverse dynamics of our technological society. Almost every advance in technology makes corresponding demands on the human person. The servant becomes the master.
From this standpoint then, the systemic and institutional failures of mental health care are just reflections of a larger catastrophic failure of vision and governance that touches almost every aspect of modern life. These failures have been extensively explored in the pages of Mad in America and elsewhere. The same kinds of forces that make the larger system so resistant to change also block worthy efforts at reform in mental health care. If we can’t even see the need to save the planet, how can we be cognizant of the need to reform psychiatry?
On the front lines of the battle to stave off climate disruption, many are now reluctantly acknowledging that the window for preventing disaster is closing and that we must shift our focus to local efforts at mitigating the worst impacts. In the same way, local communities cannot wait for institutional mental health care reform to become a reality. Instead, they must begin the urgent work of mitigation of the worst mental health impacts now.
If it proves impossible legally to compel the ruling power to change the ways it governs us, and if for various reasons those who reject this power cannot or do not wish to overthrow it by force, then the creation of an independent or alternative or parallel [society] is the only dignified solution…
—Ivan Jirous, Parallel Polis: An Inquiry
In the second half of the twentieth century, in the Communist states of Eastern Europe, the concept of parallel society emerged as a response to totalitarian systems of governance. Rather than directly confront the oppressive power of the state, a variety of grassroots, non-state institutions grew up outside of official control. Something similar is now happening in the field of mental health. Already a series of initiatives are taking shape outside the field of professionalized mental health care as communities begin to take ownership of their own healing. The goal, then, is not to reform the existing practice of mental health care, but to make it possible for individuals and communities seeking mental health support to be able to opt out of the institutional system.
[The parallel society] began in spontaneous acts of mutual self-defense in different parts of society. Those who take part are active people who can no longer stand to look passively at the general decay…rigidity, bureaucracy, and suffocation of every living idea or sign of movement in the official sphere. And because these people sooner or later recognized that efforts to bring about the slightest improvements in the official sphere were exercises in futility, it was only a matter of time before they said: Why not invest our talents, abilities, goodwill, and enthusiasm into something that no one will be able to corrupt, that we will be able to decide about ourselves in the end.
—Ivan Jirous, Parallel Polis: An Inquiry
This emerging “parallel mental health care” is remarkably diverse in its origins in a variety of academic disciplines, social movements, and cultural influences. For the same reason, it remains painfully fragmented and siloed. Its different elements often exhibit tremendous growth and vitality in their isolation, but they appear to have little awareness of each other. And any notion of joining and integrating these diverse elements remains purely speculative for the moment.
These elements include the following:
Peer-led initiatives: Peer respites, for example, are now an established alternative to acute care psychiatric hospitalization in some communities. Also, Community Bridges or level-of-care transition programs by peers have demonstrated success. Support groups are a common element, including specialized support group formats like the Hearing Voices Network.
Trauma and resilience initiatives: Drawing largely on the research into adverse childhood experiences (ACES) and emerging primarily from a social work milieu, these projects focus on raising community awareness of widespread trauma and its effects, as well as various paths to mitigation. Projects like the Community Resilience Initiative are showing how we can teach effective nervous system regulation practices to groups. Examples like the Self-Healing Communities Model in Washington State demonstrate that these approaches can be effective on a large scale. Bob Doppelt’s work on Transformational Resilience provides a blueprint for how communities can organize themselves to build resilience in the face of climate change.
Psychedelics: While still controversial due to a welter of legal, cultural, and safety concerns, it now seems unavoidable that psychedelics will be part of the mental health care of the future. Further, it will be impossible to restrict them to a professionalized container, as many would like to do. Even as legalization proceeds apace across the country, ayahuasca circles and similar events can already be found in many communities. Initiatives like Medicinal Mindfulness in Boulder, Colorado are teaching how groups and communities can safely use psychedelics for collective healing.
Recovery education: NHS-funded Recovery Colleges in the UK and similar programs in the US take an education-based approach to mental health challenges that is loosely based on a recovery model. These typically involve some significant degree of peer leadership.
These and perhaps many other threads will come together to make up the new parallel mental health care. The current challenge is to begin to integrate these into a viable model of community-based and peer-led mental health support that can function outside of the institutional framework of regulation, licensing, insurance, professional norms, and so forth. Dutch psychiatrist Jim Van Os and colleagues, in a visionary paper looking to the future of mental health, have suggested that “the concept of recovery may serve as the organizing and integrating principle for the novel mental health service” of the future.
They further describe a vision of a “local healing community fostering connectedness and strengthening resilience in learning to live with mental vulnerability. Peer support, for example, organized at the level of a recovery college, may form the backbone of the community.” In the future, perhaps these community mental health education centers will offer, in one location, classes and support groups on topics like individual and collective healing, trauma and resilience, safe psychedelic use, mental health lifestyle and self-care practices, and so forth. It will also be necessary to make clear to people that their suffering is not the product of an idiopathic broken brain syndrome, but is a result of living in a toxic culture that has reached its breaking point.
Here it is necessary to confront an uncomfortable truth about the creation of these parallel initiatives: mental health professionals, even the most enlightened, will almost invariably be an obstacle. Experience shows that professionals resist any suggestion that they may not be absolutely essential, or that their services may be flawed or lacking in anything regarding mental health treatment, or that there are alternative models that don’t include them or that challenge their guild interests.
Two points need to be made in this regard. The first is that conventional mental health interventions are not very effective. In a massive 2022 study of studies paper, John Ioannidis and colleagues conclude:
In summary, a systematic re-assessment of recent evidence across multiple meta-analyses on key mental disorders provided an overarching picture of limited additional gain for both psychotherapies and pharmacotherapies over placebo or TAU. A ceiling seems to have been reached with response rates ≥50% and most SMDs not exceeding 0.30-0.40. Thus, after more than half a century of research, thousands of RCTs and millions of invested funds, the “trillion-dollar brain drain” associated with mental disorders is presently not sufficiently addressed by the available treatments. This should not be seen as a nihilistic or dismissive conclusion, since undoubtedly some patients do benefit from the available treatments. However, realistically facing the situation is a prerequisite for improvement. Pretending that everything is fine will not move the field nor will findings conforming and producing more similar findings. A paradigm shift in research seems to be required to achieve further progress.
They go on to clarify that these statistically “small” effects may not even be at a level to be clinically detectable.
The second point is that effects observed in these studies are not attributable to the technical aspects of the interventions. While these are sometimes understood as the “common factors” of psychotherapy, Van Os and colleagues point out that this also applies to pharmaceutical interventions. In short, the same effects appear regardless of the character of the intervention. They conclude that “while the diagnosis-EBP symptom-reduction model is framed in terms of technical skills and specialized knowledge, the evidence also indicates that a good case can be made for the relational and healing components of ritualized interactions mediating clinical improvement.” The further implication is that these “relational and healing components” can be removed from the context of professionalized mental health care and administered in community, peer-led, and paraprofessional settings.
Above all, these parallel mental health initiatives must position themselves as correctives to the dehumanizing effects of techological society and Darwinian capitalism. Like the proverbial frog in boiling water, we’re oblivious to what is actually afflicting us. Rarely do we question the assumption that we should meekly take our antidepressants and soldier on in the face of the ever-escalating demands of modernity. This questioning in itself becomes a radical act. It is one small step in the greater project of reforming a society based on profit, and creating one based on love.
We’ve created a complex, expensive monstrosity of a system that just doesn’t work very well. And it is in the nature of such a system run by specialists that humbler interventions are neglected in favor of something elaborate that justifies the salary of the specialist. The basic therapeutic principle that one should start with the most conservative interventions and work toward the more aggressive is forgotten. The perversity of the situation is captured in the observation that physical exercise often works better than medication for relief of depression. But the psychiatrist does not mention exercise before prescribing. This is a disservice to the patient bordering on malpractice. The specialist is incapable of explaining and exploring options with the patient. What you get is what they do. You go to the psychiatrist, you get pills.
The system has at every turn evolved to meet the needs of the specialists for complexity, like a therapeutic hammer devising an ever-evolving taxonomy of nails. Part of the function of the local healing community, then, is to protect patients from the system: to make sure that they understand their options, to help them to fully explore conservative interventions, to provide some guidance on how to think holistically about their situation—spiritually, existentially, physically, emotionally, and so forth.
Of course, professionalized mental health care is not going anywhere. It is now widely reported that there are shortages of mental health professionals in many communities. This in itself is one of the strongest arguments for the creation of a parallel system. According to some recent statistics, nearly one in four Americans is taking psychiatric medication. And the numbers keep going up. Furthermore, it seems that Americans can scarcely bring themselves to question the authority of the mental health profession. A “cult of expertise” prevails in matters of mental health, so that individuals have come to feel that they are not competent to deal with their own most intimate possession – their own minds.
But Americans’ faith in their ruling institutions is declining, and for good reason. The spell of the literal and figurative priesthood has been broken. Just as it has become increasingly common for individuals to declare that they are “spiritual not religious,” I hope and believe that it is only a matter of time before people turn against the psychiatric priesthood and find that the answers are within themselves and within their own communities.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.