Locked up: Why some people want psychiatry abolished

“So what would happen after you made the call?”

I was sitting in a therapist’s office among shelves filled with tarot cards and books on topics like ethical non-monogamy and body positivity. There was a rainbow flag in the window. This was not my first experience in therapy, but I was still relatively new to this particular therapist. “The call” referred to the process of involuntary hospitalization during a mental health crisis — one of the few cases where therapists are not only permitted, but legally required to break confidentiality and inform an authority who is able to take somebody to a place where they won’t be allowed to hurt themselves, whether they consent to the process or not. Although I did not view it as an immediate issue, I was questioning them on how the process worked if a client said they were experiencing suicidal ideation. 

Their response: “Well, I don’t actually know.”

I froze, mind in process. Then I felt anger rising up in my body. 

“You mean you have the power to make a call that could lead to me being held in a place against my will, and you don’t know what happens next?”

That short circuited my brain. Part of the reason I’d chosen this therapist was their claim that they believed in questioning systems. Yet they’d somehow failed to question the one under which they held an inordinate amount of power. 

*** 

Legally, therapists are required to break confidentiality if a client is believed to pose an “imminent risk of harm” to themselves or others. This typically means that a patient is sent to a hospital for evaluation. If they go of their own free will, great. If not, the clinician makes a call, often a 911 call, and in that case, it will often be the police escorting the patient to the hospital. Once the patient is admitted, they can be held for a fixed amount of time — in many places, 48 or 72 hours — for evaluation. At that point, the hospital needs to petition a legal authority if they want to keep the patient longer, known as “civil commitment,” which basically means they may be held in the hospital against their will for a longer period of time. If there is a civil, or involuntary, commitment, the patient will not be allowed to leave the hospital without permission and their right to refuse treatment is limited. 

My former therapist never bothered to figure out what would happen after they exercised their power to take somebody’s freedom away. Or, if they did, they didn’t bother to tell me. So, like any Zillennial in the 21st century, I turned to Google and decided to find out for myself. 

And what I found was pretty ugly. There are several sites that compile stories of psychiatric survivors, and some of them are tough to read. Practices like restraints and isolation are not uncommon. I also found a number of stories that discussed strip searches, performed either as a physical exam or to search for contraband. These were not always something the patient could refuse, even if they had a history of trauma. One UN report even likened common psychiatric practices to torture. 

This was mostly new information to me, and I was horrified. If trauma plays such a huge role in so many mental health issues, why would the places designed to treat the most severe of those issues create more trauma?

There was also a term that jumped out at me during my search: psychiatric abolition. Abolition was a term that I was familiar with; in today’s world, it refers to movements meant to abolish carceral, or control and punishment-based, institutions like policing and prisons.

In an essay called “Abolition Must Include Psychiatry,” Stella Akua Mensah asserts that psychiatry is fundamentally a carceral institution: it relies on seclusion, loss of physical freedom and often utilizes restraints. In other words, it’s not so different from a prison. All 50 states still practice some form of involuntary commitment. Even if the purpose is supposedly benevolent, you do lose your freedom in the psychiatric ward — the freedom to have privacy, wear your own clothes or even just leave. The argument for abolishing psychiatry comes down to the idea that mental health care is often more about controlling behavior than healing, and that it’s utilized disproportionately against groups of people who are already marginalized.

If I’m being honest, the more I examine my own experience, the more I can see instances where this is true. In 5th grade, when the teacher would spend extended periods of time yelling at the class and my parents complained, I was sent to the school social worker. Her response? “Let’s make a list of the good things about your teacher.” At 11, when my mom accidentally jabbed me hard in the ribs while learning to strap me into a complicated scoliosis brace, I yelled “ow” and started crying. The prosthetist, without bothering to look at me, informed my mom that this behavior was unacceptable and that she should take me to a professional. In both of these cases, the focus was on behavior modification, or getting me to cooperate with the system no matter how much harm it caused me; not on my own personal healing.

Earlier this summer, I wrote about Mad Pride and how much of the history of mental health care has been based in promoting conformity rather than personal healing and quality of life, which is what happens when that push for conformity meets rigid and impersonal systems.

There’s also an additional problem: If a call is made about a mental health emergency, the police may be the first to respond. At this point, it probably goes without saying that some groups are more prone to police violence than others — racially motivated murders by officers are a prime example. People undergoing mental health crises also face an increased risk of arrest, incarceration or police violence. In movements to defund the police, mental health care is often touted as a more just and humane alternative to police presence; instead of sending in the police and potentially incarcerating people, the argument goes, why not just get them the mental health treatment they need? 

But what about the fact that mental health care can also result in an involuntary loss of freedom? Are we just trading one punitive system for another?

In an interview with The Michigan Daily, Laura Yakas, a lecturer at the University of Michigan’s School of Social Work with interests in Mad Pride and Disability Justice shared her experiences of dehumanization within the mental health system.

“Coercive and punitive, those are the two words that come to mind,” Yakas said. “They don’t expect you to be human and they don’t treat you as human.”

In addition to controversial practices like isolation, restraints and potentially not even being allowed to use the bathroom alone, there is some debate as to how effective hospitalization is at minimizing suicide risk. According to a JAMA article, suicide rates actually increase by about 100 times in the first three months after a psychiatric hospitalization. However, there is debate as to whether this is due to the stigma and trauma of hospitalization, or if those going into hospitals are simply at higher risk to begin with. 

But the bottom line is, there are more than a few people out there who assert that they have been harmed by the current system. One term that some people may use to self-describe is psychiatric survivors. Since the word “survivor” can be a loaded term, Yakas offers an alternative for describing the various ways in which people interact with psychiatric care: C/S/X. C stands for consumer, who is someone who may have some criticisms, but still takes part in the mental health care system. X is for ex-patient, who is someone who avoids contact with psychiatry, or even formalized mental health care of any kind due to previous harms or concern about harm within the system. And S is for survivor. 

Yakas has cycled through all three labels. “I went for a phase where I was very much just a consumer, and a blind one at that, one who didn’t even know that I was experiencing oppression or violence at all,” she said. “The system has told me I have a broken brain and that I’m wrong and that I need all of these medicines to fix what’s wrong with me.”

“Then I went through my radicalization and I discovered my pride and discovered the concept of Neurodiversity and I was like, ‘I’m not fucking wrong. I’m different,’” Yakas said. “I was like, ‘hell yeah, I’m a survivor.’”

Yakas then transitioned into an ex-patient, refusing to accept any form of conventional mental health treatment.

Yakas did eventually allow certain psychiatric medications back into her life, like Seroquel to help her sleep. The difference, though, is that now she’s making an informed, personal choice, instead of being told that she has no choice but to medicate because there is something wrong with her.

*** 

When searching for a new therapist after the “I Don’t Know” debacle, I consulted over the phone with a social worker and posed the same question I’d asked my previous crappy therapist. Their response was: “Don’t worry. We handle it very consensually. We’d warn you before anything were to happen.”

I can’t believe I have to say this, but a warning is not consent. 

In many ways, consent is at the forefront of this discussion. Informed consent asserts that we have the right to decide what does and does not happen to our bodies utilizing full and complete information about the pros and cons of our decision. 

Consent is at the center of the discussion for Kulkiran Nakai, an Ypsilanti-based psychologist who has worked hard to find ways to decolonize their practice and give care in more just ways. In an interview with The Daily, I asked Sakai about the omnipresent issue of suicidal ideation.

“I respect the individual’s right to choose. They have free will and if they want to opt out of this reality, I support that, even if it hurts me, even if I wish for something different for them,” Nakai said. “But I name in my practice too that my job is not to keep you alive. My job is not to convince you to stay alive. My job is to believe you, to love you exactly where you are, and if I can be a resource, I’m here.”

Nakai practices from what they call a “liberation-centered framework,” and autonomy is one important value they try to adhere to.

“I can’t force my will of wanting you to live onto you because that’s control. That’s manipulation,” they said. 

In the interest of brutal honesty, this answer is a total shift from what I was expecting. I certainly wasn’t expecting suicide to be framed as a matter of consent. 

But for Nakai, this way of practicing  seems to be working. They listed off a series of actions they may take to support someone in crisis, starting with being present.

“When they feel heard and seen and respected and cared for, all that excess energy reduces so they actually have access to their own coping,” Nakai said. “They have access to their own logic, their own wisdom, their own inner healing … and they can make a more informed choice.” 

From there, they can look into options, which can include a number of things, such as a consensual hospital admission if that’s what an individual decides.

A lot of the healing for suicidal ideation, Nakai says, comes down to prevention — fixing the systems and norms that push people to the edge to begin with. And that’s no small feat. 

Another therapist, a licensed counselor who spoke with The Daily on the condition of anonymity to protect their professional practice, expressed a similar sentiment.

“I think mental health services can be great when there’s choice and autonomy and when people are choosing it out of care for themselves, and when it’s being delivered from a place of truly wanting to support someone rather than police them or control them,” they said.

However, their practice looks a bit different to Nakai’s. As with many things, their values sometimes come into conflict with the professional standards they’re required by law to adhere to. 

“I don’t know if it’s really honest to say I’m an anti-carceral therapist because I still follow the law,” they said. “I don’t ever promise that I won’t involuntarily commit someone.” 

Despite these restrictions, they said they still try to be as honest and open with clients as possible. 

“I try to give people a lot of informed consent about what I can and can’t promise,” they said.

They try to avoid using coercive and non-consensual measures by discussing alternative solutions with clients. 

“If someone isn’t currently in crisis that mentions that’s something that comes up for them, I try to plan with them,” they said. “Like how would they like me to respond when they’re in crisis?”

“(I) just say like it’s not something I want to do, but I also don’t want to lose my license and not be able to pay back my loans,” they said.

And that’s a key point here — though the power dynamics in therapy are arguably pretty uneven, therapists are stuck inside this system, too. But well-meaning people inside of a bad system can still cause harm. 

Perhaps part of the reason the current system is so harmful is that it systematically excludes the viewpoints of those with lived experience. When someone is labeled “insane,” it gets a lot easier to brush off any complaints or criticisms they may have. 

The therapist I spoke with also said that they had received messaging that those who have struggled with their mental health or received certain diagnoses shouldn’t be treating others. 

“I think in my lifetime it’s been more like, if you have struggled in the past and you’re now firmly in recovery, then it’s okay. But if it’s active at all, you shouldn’t be supporting other people,” they said.

***

There are a few noteworthy alternatives to psychiatric care. One alternative to hospitalization is peer support, which can be preferable for some since it often isn’t regulated by the state, meaning it isn’t subject to the same reporting requirements. In this case, working with someone who doesn’t have a state license may feel safer for some people. 

Peer support can exist either in the form of trusted friends and family, or in a small number of peer respites. The therapist described them as “voluntary, short-term, home-like environments where people in crisis can stay that are staffed entirely by people with lived experience of mental health crisis, keyword unlocked. No forced medication, just like a supportive environment.” While these can be a great resource, there are very few — only about 20 in the country.

To my surprise, I found that there’s a peer respite currently attempting to get off the ground in Detroit. Lance Hicks, one of the founders of the Detroit Peer Respite, talked about his organization’s mission in an interview with The Daily.

“The function of a peer respite is actually not to control people, but it’s for people to experience community and not be alone while they’re struggling,” Hicks said. “In my experience, when people have that degree of connection, a lot of the acute risky stuff that makes other people nervous and anxious gets better.”

The program is currently still under construction, with the goal of opening before the end of the year. Instead of doctors treating people in medical institutions, those who seek out the organization’s help will stay in host homes, where they can leave if they wish. Instead of providing therapy, where the power dynamics and reporting requirements can make some people feel unsafe, they’ll also have access to peer supporters, which are often folks who have lived experience with mental health conditions themselves.

There are other non-carceral resources out there, as well, like the THRIVE lifeline, which functions similarly to a suicide hotline, except that no action will be taken without an individual’s consent. There’s also a spreadsheet created by Project LETS, an organization that, according to their website, “create innovative, peer-led, alternatives to our current mental health system,” that includes a list of care providers who operate from abolitionist and/or non-carceral frameworks. And, for those who don’t feel safe in therapy or who simply want support from those with lived experience, organizations such as Project LETS and the Fireweed Collective offer peer support. 

Perhaps resources like these offer a glimpse into what a better system could be. But on a grander scale, if the system we have now is so harmful, what does “something better” look like? 

According to both Yakas and Nakai, it looks like prevention. Since so many mental health issues are caused or exacerbated by trauma and stress, how can we reduce these influences? And for those whose brains are simply wired differently, how can we create a society that doesn’t constantly treat them as less than and dismiss their needs?

In this conversation, factors like economic justice, reduced prejudice and access to resources are mental health care. 

When I asked Nakai what they think a more just and effective mental health care system looks like, they took off and all I had to do was sit back and listen.

“It looks like community care. It looks like divestment from carceral systems and institutions and a reinvestment in our ecosystem, in the environment, in resources for the community. Everybody has their basic needs met and has access to resources abundantly, and that the people who are providing those resources are also taken care of … And it looks like holistic modalities, too, of nature-based therapy or energy work or play — play and pleasure are foundational and trauma healing, but they don’t really talk to you about that because they don’t want that. They don’t want you to be healed.”

“It looks like peace,” they said. “It looks like love.” 

*** 

The societal conversation around mental health is a crucial one. Suicide rates are rising, and as of 2021, nearly one-third of youth said that their mental health was poor. 

To me, personally, this entire massive issue feels very high stakes, both because I seek mental health care regularly and have had my moments of feeling “crazy” and pathologized, but also because I’m in the midst of a big decision. While I was researching for this article, I was offered admission to the University of Michigan School of Social Work. Though not all social workers practice therapy, a lot of them do, and it wasn’t something that was entirely off the table for me, especially if I could incorporate the arts. And if consent, autonomy and Disability Justice are values I hold, then how the hell is this going to work? Is there a way to practice justly under the system as it exists? Right now, I’m not entirely sure. If you meet me in a few years and I have an MFA in something weird like applied theatre, you’ll know what happened. 

Arguably, I wouldn’t be any worse of a human being than anyone else doing their best to stay true to their values in unjust systems. The system we have may be far from ideal. It may even be incredibly harmful. But there are very few alternatives in place, and those that do exist aren’t accessible to everybody. So, if I were to take on the (admittedly terrifying) power and responsibility of a state-sanctioned and regulated mental health license, would I actually do more good than harm? Or would I be just another cog in the system and end up effectively incarcerating people without trial for the “crime” of struggling to cope with a messed-up world?

Knowing what I now know, if I accept a license from the state, what kind of trouble am I setting myself up for? And if I break the rules, whether they blame some perceived pathology with my mind or just call me out for breaking the state’s laws, where will they lock me up then?

Statement Correspondent Cydney Heed can be reached at cheed@umich.edu. 

The post Locked up: Why some people want psychiatry abolished appeared first on The Michigan Daily.