The text that follows is the English translation of a speech I gave at The Danish Psychiatry Top Summit in 2024. A video of the speech, with English subtitles, is available here.
The Danish Psychiatry Top Summit (“Psykiatritopmødet”) is an annual event that is organized by a social-activist organization called The Social Network (“Det Sociale Netværk”). The summit features professionals, politicians, and people with lived experiences. This year more than a thousand people attended. The summit has historically been centered around improving psychiatry through cooperation.
The Danish psychiatric system has historically been exceedingly change-resistant. As a psychologist who’s spent the last five years debating and criticizing the moral, scientific, and practical foundations of psychiatry, imagine my surprise when an invitation to give a 15-minute keynote speech landed in my inbox. Equal parts flabbergasted and excited, I immediately agreed, even if my 15 minutes were later reduced to 10 minutes with no explanation. Every year, the summit has a theme. This year it was “New winds are blowing.” And admittedly, I wasn’t the only critical voice on-stage. Even the invited psychiatrists agreed that “more of the same will not work.”
I do still fear, though, that the new winds that blow will just blow power into new hands… Instead of dismantling coercive and abusive power that stems from dehumanizing pathologization and professional hierarchies. But I was cautiously optimistic after the summit, as I remain to be, though there’s still tons of work and activism to be done before meaningful change can happen.
We need a revolution. A revolution that everyone can contribute to. And that’s what I would ask your help with here today. Everyone’s talking about change. Changes towards a better psychiatry. A more pluralistic psychiatry. A less medical or more therapeutic psychiatry. But always a psychiatry. This discursive monopoly needs to be broken. And the path to that dismantling of the psychiatric monopoly on mental distress starts with a growth in the number of people clamoring for an alternative, for another place to go in a mental crisis, a place where you’re neither pathologized nor treated for your symptoms. The title for today’s conference is “New winds are blowing”. But how strong are these winds in fact? Evidently sufficiently strong to blow critical voices up here on stage. Regrettably not strong enough to blow critical voices with lived experiences up here too.
I want to spend the remainder of my time here today talking about why: Why we need an actual alternative if fundamental change is ever going to happen.
Psychiatry takes something that is pretty simple and makes it unbelievably technical and complicated. It is pretty simple to understand what people in acute mental health crises need. We all have the same basic needs when we’re not OK, when life falls apart. And that’s the need for safety. For comfort. For closeness. And for understanding. In that order. Safety. Comfort. Closeness. Understanding.
The very first thing that a mentally distressed person should be met with is therefore reassurance. We need to reassure the suffering person that they’re safe in the right place: There’s room for your reactions here. We aren’t scared of or discomfortable with your pain. You aren’t sick. You aren’t disturbed. You’ve probably got a million reasons for thinking and feeling the way that you do. That’s alright. We don’t judge or condemn that. We only want to offer a place to feel safe right now. And if you find yourself ready to talk, we’re right here and ready to listen.
This is not a method. It is not an approach. This is natural compassion between human beings that is universally valid and useful at all degrees of mental distress. And psychiatrists know this too. At least they do if it concerns their own children. If a professional’s kid comes home from school in an increasingly depressed state of mind, there isn’t a psychiatrist in the world who’d pull out a Hamilton Depression Scale and go: “Right, let’s measure your symptoms so I know what to do with you” At least I hope there isn’t. So what would a psychiatrist do were it their own child? She’d of course look caringly at the child and say: “Hey… What’s up with you? Are you OK?” and then offer her time, comfort, protection and care until the child is ready to tell more. She would do that, because that’s crucial information to have. It’s imperative to know what the child is reacting to. We’d act differently if our child were growing more and more depressed if the cause was bullying, loneliness, insecurity, body dysmorphia, performance anxiety, assault, harassment and so on. These are extremely different contexts that warrant very different approaches. But first and foremost the child needs to feel safe, comforted, cared for and understood. And then we need to take action aimed at remedying the causes of the child’s mental distress. So why is it that we intuitively know what to do when it’s our own family, but fail to provide the same for people we are charged with helping?
The psychiatric system limits its approach to revolve around the reactions themselves. This corresponds to wanting to minimize the child’s tears, not with comforting care, but with methods, i.e. pills, electricity and/or therapy. And then sending the child back to the context that causes the child’s pain with a “Good luck with your bullies/loneliness/self-worth/trauma!”
And it’s not the fault of the psychiatric professionals that the system works this way. A lot of employees try so hard to be warm in a cold system. But the underlying logic incurs distance. When you ask psychiatric patients who they really liked talking to during a stay at a psychiatric ward, what do they say? They say: Other patients. Their visitors. A porter. A physical therapist. That is: People near them who aren’t tasked with perceiving them through a pathologizing lens that focuses on minimizing symptoms, but who naturally assume that the distressed individual is going through some hardship and therefore is reacting. And yes. These are reactions that we are talking about. Not symptoms. The behavior, thoughts, and feelings of distressed people are always reactions to something. Always. The only place where it makes any sense to label reactions as ‘symptoms’ is in a system that contrary to all science and reason insists on calling patterns of reactions-to-distress diseases that need treatment. And here we find a linguistic rebellion that everyone can be a part of from this day forward: Symptoms are reactions.
Take for instance the psychiatric professional’s own child again. There probably isn’t a professional in the world who’d think that the most important task is to stop the child’s tears in and of itself. Why? Because tears are just that: Reactions. But we could choose to pathologize them if the child was sufficiently anguished. We could dub them symptoms, which would make it our task to quell the stream of tears with…Pills? Electrocution of the brain? Therapy? But is that what a crying child needs? Methods to stop the tears? No. It is not. The crying child needs to cry because it ventured out into the world, got hurt, and is now in need of safety, comfort and reassurance. The child will cease crying eventually once comforted. And when that happens the child may soon be ready to open up about the context that caused the tears. This is both true for the crying child and for the mentally distressed adult. Far too many adults have learned to suppress tears, either from a tough childhood with too much neglect and too little safety. Or from toxic masculinity. Or from a lack of love and attention. But believe me when I say that the mentally distressed adult might just as well be crying if she dared. If she felt safe enough. And after a flood of tears it’s usually easier to explain, to tell what has happened. This tends to take longer the more intersections and the more trauma there is to tell about. But in the end it is safety, comfort, closeness and understanding that paves the way to healing.
This is jumbled around in psychiatry. In the psychiatric system it is the reactions, be they tears, voice hearing, aggression, self-harm, or anxiety; in psychiatry it is the reactions that are central. Because the reactions, the so-called symptoms, are the building blocks of the diagnostical categories that guide treatment. But this is totally backwards. The reactions are not the most important part of mental distress. And by trying to combat the distressed person’s reactions, you’re actively fighting the very survival mechanisms that give rise to those same reactions. You escalate the risk of conflict and oppression by aggravating survival mechanisms. Mentally distressed people aren’t statistically more dangerous than other people. But any approach that is based on fighting natural reactions will tend to create situations of violence where it isn’t the distressed person who does the violence but instead the system that acts violently towards them. Reactions are not to be fought. As caregiving professionals, we need to deliberately practice being with distress. We need to practice the art of pulling a chair up into someone’s darkness and just being in that space without dominating it. This is hard, sometimes. It can be difficult. The darkness may be so horrifying that you feel some of it yourself when you enter someone else’s pain with your guards down. It’s a genuine competency to be able to do that, but it is worth every bit of effort. Sharing someone’s darkness opens the door to safety, then trust, and then towards puzzling the pieces together that may explain what has happened that has brought the person to the cusp of destruction, and this shared grief may help guide us towards the sort of help that the person needs in order to find a path to healing and meaningful existence.
Psychiatry has damaged far too many people by focusing on symptom reduction. Even when successful, the symptomatically reduced individual is still left to the same context that they were in prior to treatment. But now they’re also told that they’ve got a disorder of the mind. This is not helpful, especially not in the long run, even when the person’s symptoms are reduced by rigorous psychiatric methodology. And who is hurt the most by this? The people who suffer the most to begin with. Those that psychiatry would deem the “most severely ill”. The ones whose distress is routinely used as an argument for more psychiatry. These are the voice hearers. The ones with the most and the heaviest adverse childhood experiences. The most marginalized, discriminated, and traumatized. In other words: Those who have the most reasons to react. Those are precisely the ones that are most harmed by ignoring contexts and instead fighting reactions and survival mechanisms with pills, electricity, and therapy.
Ironically, this also means that the people who are best suited for the psychiatric approach are the ones who haven’t got a lot of problematic contexts in their lives. These are the people who have the resources and relationships that a temporary pause may itself lead to sufficient recovery. In those cases, it may certainly be adequate to quell the person’s reactions and then send them on their way. But even affluent people can have their lives destroyed by being told that their natural reactions to temporary crises or sudden trauma are symptoms of pathology in need of treatment. If the distressed person’s reactions are severe, the risk of harmful pathologization and diagnostically legitimated mental and physical violence increases exponentially. This is a path that leads to disability, isolation, and suicide all too often. It’s tragic, and the tragedy is enhanced enormously because it’s often completely avoidable.
Is the psychiatric system able to change at a fundamental level? One can certainly hope. Some of the other speakers on stage today are optimistic, whereas I am more skeptical. But no matter what psychiatry may or may not become, it is my hope that other voices in this debate – both professionals and those with lived experiences – will engage with the possibility of alternatives. The development and implementation of alternatives that aren’t psychiatry. The possible benefits from this cannot be overstated. Firstly, we would finally be able to offer different and often better help to those in mental distress. Secondly, successful alternatives would both force and inspire change within the existing system.
I’ve got one minute left of my time here today. So let’s return to those new winds and what they may carry with them. If the psychiatric system is the giant ship that currently is the only refuge for drowning people, then new winds may cause that ship to change course. More therapy would change the course slightly. Less psychopharmacy. A bit more peer-involvement. With small changes we can certainly hope that the giant ship will eventually sail in a better direction. But we can also utilize these new winds to fight for something else. We can make sure that new winds also carry new opportunities with them, that actual, context-oriented, peer-based, person- and human rights-centered alternatives acquire appropriate funding.
The truth is that we don’t need more psychiatry. Nor do we need better psychiatry. It’s obviously positive if the captains of the dominant ship are attempting to steer the vessel in a better direction. Great. It was about time! And here’s the best piece of advice I have to offer them: The most meaningful change you can pursue within your system would be to thoroughly train every single employee in trauma-informed care. The universal implementation of trauma-informed care would spare countless patients much traumatization and retraumatization.
But real progress grows if we let new ships set sail that can pursue new directions that may prove to be better alternatives than the pathologizing psychiatric system. That would be meaningful revolution.
Support the rebellion. Support the need for an alternative.
Thank you for your time, thank you for the invitation to come here today. And long live the revolution.