Saturday, March 4, 2023

Blaming The Distressed Is Distortion of Reality (How to Work in Mental Health Reality, Not Mental Health Mythology)

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Hello everyone.

Exited today to share a breakthrough moment I had this weekend in development of the  messaging we use around how to think about the concept of emotional distress (mental health), and what needs to be done to effectively support those in need. I realized that many of the problems in that topic area are very analogous to the related messaging advocacy effort of "Stop Blaming the Poor for Being Poor".

For more on what "stop blaming the poor" is all about, we can start with references to background reading like this one: What can we do about poverty? First, stop blaming people for being poor

Introductory quotes from the background reading...

"What I should have said both those times in recording studios, for the purposes of the tape and for posterity, is that we, as a society and a culture, really need to stop talking shit about poor people if we want anything to change."

"The false statements about, and type of language used around, poor people needs to become as taboo, as clearly bigoted, as with any other form of systemic prejudice. When we hear it, we need to call it out."

Let's now take a look and how a similar effect plays out in the mental health space.

What is the Problem?


How does this message relate to the world of mental health and trauma? We are doing a very similar thing in the world of mental heath services. We are blaming the emotionally distressed for being emotionally distressed.

This plays out in several ways. There's the medical model of distress, which can include notions where emotional distress is blamed on some innate biological defect. For example, the shockingly persistent myth about chemical imbalance. There's plenty to discuss about separating fact from myth and conjecture in the the world of biological psychology and neuroscience, and that's a whole article series unto itself. 

The medical model, in addition to problematic, harmful, and false biological analyses, also makes false assumptions about social responsibility versus individuals responsibility. I've started calling this the mental health accountability crisis.

In many mental health spaces, there's been acknowledgment, which I support, that external factors are quite often the original root cause that led to a person now experiencing high levels of emotional distress as trauma. For example, the advocacy and resource sharing network PACEs Connection was founded on a goal of recognizing the impact of a wide variety of adverse childhood experiences (ACEs) in shaping adult behavior and health.

On the face of it, that seems like it's not blaming the sufferer, right? And it partly isn't. The subtle and critically important point is that it's not blaming the person for their past. But groups like the PACEs community (and hundreds of other similar groups) frequently promote a view of holding the individual accountable for their future. It is that view which is very much having the effect of blaming the emotionally distressed for being emotionally distressed. We set an expectation that the individual can success through a combination of personal effort bracketed by some form of support. With the support exclusively focusing on supporting or coaching individual skill building and personal effort and nothing more. This leads to a situation where, if the person fails to improve, the clear message is that is was an individual effort failure. What is never discussed is external social accountability for ongoing external sources that can and do lead to extreme and undue emotional distress.

With Blame the Poor, as this article explains, an objectively false narrative is created. One that claims that "people are poor because they are lazy, irresponsible, averse to work, sexually promiscuous, criminally inclined, or simply stupid."

With Blame the Emotionally Distressed, an objectively false narrative is created. One that claims that people's emotional issues are wholly a result of a lack of effort on their part to get better.

We can see this individual blame is such offerings as this phrase which is widely circulated in emotional distress support groups - "“Trauma is not your fault, but healing is your responsibility." Can read more about the circulation of that phrase and why it's problematic here

What we're doing here is always asking the individual to do something different than they currently are. Any "treatment" that is focused on the individual doing something different than they are is a form of blame.

We are not holding others and society, not at all, partly accountable for sometimes changing itself and only itself in response to the emotional distress of a given individual. We do this to the poor. And we do this to the emotionally distressed.

What could be done instead? Change others. Change society. If a person is crying, what was done to them. Instead of asking them to stop crying, ask what around them is making them cry, and point accountability there. At least in part. Maybe point most of the accountability that way. But that's not how the vast majority of mental health systems approach emotional distress. The entire underlying notion is always and only about "empower individuals" while ignoring and denying that "fix external causes" might be an option as well.

This framing is justified by two powerful supporting myths that are much more (thought not entirely) myth and very much not a statement of actual reality...

1) Help almost almost always exists

2) That help will be effective

Very akin to blame the poor, we tell people the reason they're not getting better is that they're not trying hard hard enough. For decades now the mental health movement has championed the "reach out, seek help" message. While at the same time, completely ignoring the decades of evidence from the lived experience community of help often either not existing at all. Or times where something was labeled as "help" but the impact was anywhere from ineffective to outright harmful and/or abusive. 

The individual responsibility would feel a lot more justifiable if effective help actually was real. Even then, we're still distracting from even asking if a person should be the only one held accountable versus others or society. But the myth is that a person can do better by holding them accountable and making them put in their own effort with a goal toward relief from emotional distress. Support may be on offer, but support in this context is meaning "support you on your own effort" versus "support through accommodation without effort on your part". 

This "put in the work" theory has, time and again, been shown to fail more than it succeeds. Not every time - success stories do exist. But the failure is immense. The amount of help actually existing, and the failure rate of that help, is vastly out of line with conventional narrative. We can replace the quote above about the poor with the emotionally distressed.  

The false statements about, and type of language used around, emotionally distressed people needs to become as taboo, as clearly bigoted, as with any other form of systemic prejudice. When we hear it, we need to call it out."

 Below are five examples of accurate reality being reported on. I have hundreds more. These aren't "one-offs", "one bad actor", or "one unfortunate instance". These are representative samples of widespread failure to provide effective help under the "put in your own effort" framing and moralizing of demand placed on individuals with emotional distress. 

1) How CBT Harmed Me: The Interview That the New York Times Erased
"The article reads as self-congratulatory, biased, and anti-opioid, going so far as to say that therapists are providing a “powerful salve for suffering” despite later admitting that most research only shows one-third of participants experience significant improvement. They removed the quotes they had from actual patients who received CBT and found it unhelpful or harmful."

2) 'It's torture': critics step up bid to stop US school using electric shocks on children
"The Judge Rotenberg Center has been shocking young people with special needs to control their behavior. Now opponents are demanding action to end ‘state-sanctioned child abuse’"

3) Saving Our Own Lives A Liberatory Practice of Harm Reduction
"Lying helped me to understand that hiding was an essential part of navigating systems, because to be transparent about my whole life meant denial of treatment and facing possible criminalization."

4) It’s Not Me, It’s You. Leaving My Racist Therapist
"I knew it the first time she made me feel uncomfortable in my skin, and the second time, when her white fragility kept her from taking responsibility for it."

5) Nation’s Disability Services At Breaking Point
"Programs are closing, people with developmental disabilities are being turned away and providers are failing to meet federal requirements, according to the analysis out this week from United Cerebral Palsy and the American Network of Community Options and Resources, or ANCOR."

Note at this point that I have never stated that all help attempts are failures. That's a strawman counter-argument that deflects from the main conversation at hand. The fact that we sometimes do actually help people is not a valid excuse for the widespread harms and failures detailed below. 

Also note the constant patterns in stories like these of how, when the Emotionally Distressed question these systems, they are belittled, attacked, and dismissed. Survivors and help-seekers know we're getting it wrong more than we're getting it right. We can prove it. So why are we here in the first place and what can be done? 

How Did We Arrive At This State of Misinformation?


It is very trendy and of-the-moment right now to talk about mental health and trauma-informed care, and yet the messaging is so brutally wrong. What trauma-informed should mean is that emotional responses are valid. Humans have emotions, and one reason we have them is to warn us about things that are problems and might need to be changed. It could be things we need to change about ourselves. It could be things that need to be changed about our external physical and social environment. Both our interpersonal social environment and the broader social structures of larger society.

The success of the modern mental health movement is that we've started acknowledging that many people suffer from undue and extremely excessive emotional distress. And that it's a moral and ethical failing to let that suffering go unaddressed. The massive crisis and failure is in how we're attempting to address is. We are dead-set focused on framing suffering as individual failure and only ever discussing things we that individuals might need to change about their own selves. We ignore, and at times loudly reject, the second half of true trauma-informed understanding - that things that need to be changed about our external physical and social environment.

How and why did that messaging come to be? For now, I'll leave that as an article for another day. A teaser for that discussion is systemic disempowerment. It's an topic I'm still actively working on and researching. What I can also share are some preview notes, thoughts, and initial observations.

One thing I've noticed is that there seems to exist an almost pathological need and desire in the mental health provider and research community to ignore and/or loudly reject evidence showing times where treatments aimed at changing our own individual selves failed. This goes beyond mere positive success reporting bias (though that's an issue unto itself). My theory is that what's often happening is a hijacking of an otherwise wonderful trait we humans possess - having compassion for others. We want to help. We at times will badly and desperately desire to have a person we've met not suffer. In such a mindset, evidence of "the treatment isn't working" can be immensely distressing. It is an admission of failure. Not a failure of intent (though people often take it that way), but a failure of impact. Some people, and ironically this can hit the most compassionate among us the hardest, seem to have such a fear and intolerance toward compassion-driven assistance failure that they'll defensively attack any evidence, even clear and objective evidence, of failure of impact. Of failure to help. But those denials of failures of impact are one of the greatest acts of oppression and harm we inflict upon the emotionally distressed. It's a distortion and denial of reality. We need to be honest about when things aren't working, and we need to believe survivors when they speak up about it.

Another weakness of our systems of help is the colossal failures of how define metrics of success in behavioral health. This is a topic that deserves its own article series, but is worth touching on here as it's also another way we improperly blame and oppress the emotionally distressed. One brief example of this is how high-ranking autism researchers (including such institutions as Stanford University) still frame the act of not making eye contact as a social deficit in need of repair and through "fixing" the individual by training (i.e. forcing) them to make more eye contact. This is a form of blame through prejudice and ableism. It is completely possible to have a mutually satisfactory and successful social experience with someone else without making eye contact. Ever participated in an enjoyable phone call? Great, then you've experienced successful social interaction without making eye contact. We can instead come to understand that eye contact is, in reality, just a social norm and a preference. It is perfectly valid if eye contact enriches your personal social interactions. It is also not necessary. To say otherwise is means you're enforcing your preferred standard on others. And to claim that people who don't meet your preferred standard are broken and medically deficient is an astounding act of hateful prejudice. Likely one borne more out of ignorance than personal malice (though sometimes malice). And the ignorance goes so far as to believe that "fixing" such individuals is compassion. The compassion here can be real and genuine. The effect however is enacting hateful abuse justified through a grossly distorted an inaccurate understanding of reality. 

The third and final note to touch on is the continued exclusion of lived experience perspective in the design of mental health support systems and health knowledge. There shouldn't be a need to justify why that's important. It's seems like a blindingly self-evident notion. But if you do need an evidence-base for it, some of it is already out there and some of it is well-known but not yet researched. One such resource is the Co-Production Collective Resource Library. And there's hundreds of examples of lived experience (or, more accurately, Expert by Experience) perspective exclusion or cooption. As one example, from this recent National Institutes of Health report, 

 Although 27% of U.S. adults live with a disability, only 10% of science, engineering, and health doctorate holders, and less than 2% of researchers funded by the National Institutes of Health, report having a disability. Inclusion is even lower among professionals with disabilities from underrepresented racial or ethnic groups in science, technology, engineering, mathematics, and medicine fields.

Concluding Thoughts


Both you, the reader, and me myself have been taught these myths about emotional distress our whole lives. One could rightfully call it a form of cultural gaslighting. Research can continue as to how we arrived at this point, but ultimately what seems most pressing to me is that we acknowledge that it's happening and is a pressing and harmful crisis of misunderstanding that needs to be remedied. 

I feel compelled to mention that thus far journey of working to resolve this crisis has been an absolute living hell. That too is probably a story best left for another article, but I refuse to leave it out of this article. Even though it's sometimes strategically more beneficial to not mention the toll the journey as taken thus far (what a gross aspect of modern reality that is). Suffice to say, bringing this article and information to you came at immense personal emotional and physical cost. I do believe it will get better eventually. I'm not asking for pity, nor guilt. I do need it understood that this work was not a "passion" or a "delight". What would be a delight is finding others who want to embrace creation of more accurate depictions of social reality openly and willingly.

Toward that end, one thing I can offer as a final hopeful note is this...

A lot of these realities being discussed here are unpleasant. Help not helping? Why so negative! I'm often accused of focusing only on the glass being half-empty instead of being half-full. Which isn't true. I only talk about and focus so much on the empty half because no-one else seems to want to. I want to know why the cup isn't full and I don't why that's an offensive or negative question. There's room for it to be filled, so why aren't we filling it? I'm not trying to complain about my cup size. It's the size it is. And I'll push back against anyone trying to tell me to be happy with the half-full (or even less) portion I've been given when there's room for more and there's water right over there in the distance. Demand to be happy with what you have is what the "be resilient" movement often tries to do. And sure, that's a strategy to use in battlefield situations. It often causes long-term until we can get a society back to offering "full-cup" portions. But when we try to teach people to make do with half-full or less portions, that often leads to attempts to convince you to shrink your cup down and accept less. I'm babbling too much about cups here and the takeaway  point is this - it is okay, natural, and I'd argue downright healthy to point out when cups aren't full. That's not "pessimism". It's an act of working to depict reality correctly. Depicting reality correctly is not an act of those lacking or avoiding hope. I find it to be one of the most positive and uplifting experiences on offer. 

Climb out of the gaslighting. Identify the real problems so we go work on real solutions.

Put another way, here's how Bernice King (daughter of Martin Luther King, Jr.) puts it...

"Being truthful about the state of our nation and world does not equal losing hope. Hope sees truth and still believes in better. That which dismisses or does not seek truth, but grins, saying "It will be okay," is naiveté, not hope.""

This article is a ask and a plea to come join in working toward hope instead of naiveté. I promise, it's more fun that you'd think. And it has a much higher success rate of creating help that actually helps. 

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Photo by Karthikeyan K on Unsplash

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