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    AvatarSanjana Mishra

    Reflection on Mental Health: January 2021
    Sanjana Mishra

    “As you say, there have been significant developments of this sort [postmodern thought]. However, I am not at all sure that these have gone very far in challenging the hegemony of the pathologizing discourses, which are undergoing constant processes of revision, refinement, and elaboration.” (Michael White in conversation with Ken Stewart, “Psychotic Experience and Discourse”)

    Somewhere in all our undergraduate classroom debates about whether psychology is an art or a science, we leave out an equally important question—are we the mental health field, or the mental health industry? To me, this seemingly innocuous difference in language signifies planes of difference in what is important to mental health practitioners in the current day. The psychology and the therapy we are traditionally taught emphasise an “expert” position, one that privileges the opinion of the practitioner and leaves the consulting person to simply accept the diagnosis and/or therapy handed to them. As pointed out in this conversation between Michael White and Ken Stewart, we may be bringing more postmodern approaches (such as those of narrative therapy) into therapy rooms (and other relevant mental health spaces). However, what is the impact that they are having in the face of the “hegemony of pathologizing discourses”?

    In thinking about mental health, an essential question that arises is about who gets to define what mental “health” is. What does a mentally “healthy” person look like/act/do, and who decides that? More than just a broad philosophical question, this question is essential to our work as therapists. I’ve found myself asking myself this as I think about closing therapeutic work with certain clients. In the past, I had an idea that one closes work with a client when they are “fixed”, so to speak—when the problem they are struggling with has been overcome. Slowly, I’ve been recognising that there is no cut and dry indicator of when to close work. For some people, their problem may ‘disappear’ (although I am yet to see this for myself). More often than not, people walk away from therapy with the problem still in their life, but feeling better equipped to cope with it. This could mean coping through new skills we have discovered together, but my learnings in narrative therapy have helped me see that more often than not, it is the skills and knowledges people come in with that truly help them work through or deal with their problems. Why, then, is so much focus given to teaching people the “proper” skills to “cope” as a hallmark of “good” therapy?

    Through the course of this year of narrative therapy learnings, I’ve found myself deconstructing and then rebuilding notions of mental ‘health’ and psychology. I’ve found myself grappling with notions of “effectiveness” and “evidence-based practice outcomes” in the face of actual work in therapy spaces and how much practices like externalisation have helped while working with people I’ve been struggling to work with for a while. A young person I worked with for about 4 months, J.B., reached out to me last week to let me know they would like to pause our work for now. We had spoken the previous week about shifting to fortnightly sessions, as I also felt they were in a space to reduce the frequency of sessions, but their choice to end our work came as a surprise to me—I began to question our work and wonder if I had done something to make them not want to come back, because in my head we still had work left to do. I wrote them an email checking in, and received a beautiful reply. They wrote, “…I’m in a really good space now and this is probably the happiest I’ve been in a while. thanks to therapy, I’ve finally reached a stage where the problems I have are manageable on my own”. While I felt we had more to work on (having just recently begun working on externalising gender dysphoria and beginning to identify gender euphoria, moving away from the Anger Cube and Anxiety), J.B. spoke about realising they were non-binary as a massive milestone, and about externalising the Gender Dysphoria Gloop as something that was proving to be extremely helpful to them. This brings me back again to the idea of challenging the hegemony of pathologizing discourses. Somewhere, in spite of my efforts to take a decentred position as a therapist, normalising judgements of mental ‘health’ do seep into my work. My surprise at J.B.’s desire to close work was an indicator to me that I was still thinking of their mental ‘health’ through a semi-expert lens, and perhaps that I was privileging my knowledges of therapy as an indicator that I would be the one to make the decision to close work. Perhaps that is why I am writing about closing therapy in a reflection that is meant to be about mental health as a whole, because there is no doubt that the mental is political and there is power entrenched in our therapy spaces. I had simply not considered that something like closing therapy work would be so tied in to questions like “who decides what mental ‘health’ is?”

    In my efforts to learn and critically engage with the mental health field/industry/complex, I have also found myself turning to user-survivor accounts of psychology and psychiatry to answer this critical question about mental ‘health’. In the interest of centering the experiences of the people who consult us, I wonder how different things would look if the experiences of user-survivors had been taken into account while shaping how we look at the mental health field today. I once read a tongue-in-cheek descriptor of the DSM as a “Chinese takeout menu of disorders”, and I sincerely feel that is the most befitting description possible. I can also honestly say that moving beyond the CTM (Chinese Takeout Menu) and towards a space where we get a chance to privilege the experiences of the people we work with has been something that has brought a lot of fulfilment to my work. I think the missing ingredient (so to speak) in our retelling and reworking of the mental health field inevitably has to involve bringing forward more questions and critiques, and turning more and more to users of mental health services to answer them—bringing expertise back to where it belongs, if you will.

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