“My experiences and perspectives on the lack of empathy in psychiatry”
Nurul Fadiah Johari
Amidst the growing interest in public discourse on mental health and emphasis on fighting stigma towards mental illness, we see a dominant type of narrative emerging – one where the patient receives psychiatric treatment and regains a “normal” course of life. While this narrative is useful in challenging the idea that mentally ill people cannot lead normal lives, it often fails to examine other more fundamental issues. These include questions of what mental health, madness and recovery mean, especially through definitions which may not agree with the dominant paradigms of psychiatric treatment and recovery. In this article, I examine my own experiences of receiving psychiatric diagnoses and treatments, as well as my interactions with mental health professionals.
To me, the dominant approaches in psychiatry do not leave room for empathy towards the patients’ own understanding of their madness. What if the experiences of madness are in themselves valuable and meaningful, and not simply diagnostic indicators of chemical imbalances of the brain? The term mad used by scholars of Mad Studies, claims the experience of mental illness and tries to understand the experience of it, while mental illness is a term used by health professionals to pathologise the condition and to cure it. The diagnostic approach adopted by these professionals tend to dismiss the validity of non-rational experiences and the mentally ill person’s ability to speak for their own experiences in furthering psychiatric discourse. Madness should be empathised with and reclaimed as a human experience. Psychiatric professionals should see these experiences as such, so as not to further dehumanise the mentally ill person.
“Of course, in psychiatric circles, to pay attention to the mental content, with its ‘bizarre ideation’ in ‘psychosis,’ is frowned upon and even regarded as fruitless; in many hospitals, this is even forbidden because it is seen as harmful. I have never been in agreement with this dismissal. Once we relate to the person’s inner experience with a caring acceptance and interest, the ideation may cease to remain an assortment of strange ideas in a state of fragmentation. Instead, an inner process may soon be revealed which turns out to be entirely meaningful and about which we have much to learn.” – John Weir Perry, Trials of the Visionary Mind: Spiritual Emergency and the Renewal Process, 1999
In reading Perry, I was reminded on how little empathy I have experienced in psychiatric circles. In many ways, I feel that those working in the mental health field whom I have interacted with have refused to listen to my narratives and thoughts. By empathy, I mean the concerted attempt to understand and express concern towards one’s experiences, thoughts and emotions. It necessitates listening and comprehending; not to diagnose and not to judge. To me, there is a sheer lack of empathy towards the inner world of clients such as myself, given that the primary mode of thinking is diagnostic and based on the curing of symptoms.
The basic premise in mainstream psychiatry is problematic to begin with since the professional does not view the mentally ill person as an equal. It is a hierarchical relationship where the professional is deemed to have superior knowledge and understanding of the patient’s condition, while the patient is expected to subject her own understanding to that of the professional. The whole point of “listening” in psychiatry is for the professional doctor or therapist to determine what is wrong with the person based on a fixed set of guidelines as prescribed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), now into its fifth edition. I, the person undergoing a psycho-emotional crisis is deemed as ill, a subject to be cured.
So my meetings with my psychiatrist from 2014 to 2016 were very superficial and not really helpful, to healing from my trauma. There were many things that he failed to understand about me, and I believe that has to do with his status as a trained professional and the nature of his profession itself. When I told him, after 2 years of regular consultations, that I needed to see a psychotherapist, he was puzzled and asked why, only then to comment, “Oh, because of your anger issues, is it?” His response, to me, trivialised the depths of my emotional struggles. It was as if whatever I had told him about my inner struggles during those two years had flown past his head. I could not even think of telling him how my trauma was embedded in the patriarchal, sexist and racist society of capitalist Singapore.
A lot of my “anger issues” stemmed from injustices that I had experienced in various social institutions and in my personal relationships as someone from a minority ethnicity in Singapore – a Malay-Muslim woman whose political and religious views are often at odds with the dominant majority. How can a professional like him understand these complexities, when his training presupposes the mind as an entity detached from its socio-political environment, coupled with his privileges as a straight Chinese middle-class male in Singapore? How would he understand if I were to tell him that a significant amount of my anger stemmed from my experiences with my racist, Islamophobic and sexist ex-partner? His dismissal of my struggles simply as “anger issues” reflects the depersonalised, unempathetic and pathological outlook amongst medical professionals.
In many ways, I felt my interpretation of my own experience was not seen as valid by these professionals. I did not feel supported by mental health professionals in affirming my own experiences. The thing is, I refused to see myself as “ill”. I was going through an intense mental upheaval, and at the same time, it was full of imagery and symbolisms which were very meaningful to me. I could not simply see my experience as an indication of chemical imbalances in my brain – which was what they kept telling me.
To me, my experiences, albeit intense, were personally meaningful, yet none of the specialists I met helped me make sense of them nor affirmed the depth of meaning that my madness had. They seemed to be concerned about me somehow moving on from those visions I had and to simply forget about them, since to them, I was simply just unwell. I only slowly started making sense of the symbolisms in my visions after doing more reading, which was a privilege I had, since I had time and the access to books in my university’s library. I read about Joseph Campbell’s hero’s journey, and works by Carl Jung, John Weir Perry among others, and even on themes of the divine feminine, which I felt appeared in my visions as well.
The words of these writers and thinkers affirmed me as a person – much more than my mental health professionals ever could. How could my experiences be simply reduced to a mere pathology? That invalidates my experiences and my ability to make sense of them. I still cannot accept this up till today. To me, the first step towards healing from trauma and growth is about the affirmation of one’s experience, and then to be able to own and define those experiences. I affirmed my experience as a form of inner rapture that I needed to go through before I could heal from my past trauma. I was not healing from a mental illness, but from the residual pain from traumatic experiences. I also believe that the discussion of mental illness must be centred around the person’s history of trauma, as opposed the diagnostic approach based on symptoms. It is so much more empowering than being subjected completely to the judgment and diagnosis by the professional.
When a mental condition is reduced to mere symptoms as likened to a physical ailment, the patient is treated in a non-empathetic and non-humanistic way. While the patient is going through the intense throes of psychic upheaval, what is most needed and most therapeutic, as Perry had discovered in his studies, is for her to be heard and to be understood. Once patients find that their thoughts are being understood, they become less overwhelmed and will soon regain their normal sensibilities. Perry even saw that some of his patients emerged from their experiences “even weller than well”. RD Laing, the so-called father of the anti-psychiatry movement also made this observation. A psychotic or schizophrenic person mostly needs to be understood and embraced as completely human. They do not need their experiences to be dismissed and invalidated as wrong or symptomatic of an illness. Their experiences, regardless of how they challenge conventional reason, must be affirmed as a valid part of their reality.
I still remember the utterly dehumanising experience of being sedated and tied down to my bed, as though I were a raging beast that needed to be tamed. I was forcibly restrained though I was not acting violently against myself or others. And when I tried free myself, I was slapped by a nurse. I remember the belittling ways in which nurses speak to mental patients, without any regard for their dignity as human beings. And although Singapore is not exactly the worst place for mental patients (I’ve heard of worse treatments in other countries), I know that it is also not the best. We cannot deny that there are still abuses and dehumanising practices in mainstream psychiatric institutions in Singapore, which includes restraints and forced treatments.
For starters, the over-reliance on medicalisation and the neurobiological model is highly problematic as it overpathologises mental illness. What we need is not more medication to suppress our non-rational thoughts or odd behaviours. What we need is empathy and support, and the mind can heal itself. We need spaces where we can freely express our deepest or most repressed thoughts, no matter how irrational they may appear to most people. We need people to listen to us as we share our fears, insecurities and joys; the highs and lows that make us completely human.
The common identification of the person going through a mental crisis as the patient, is highly problematic. It assumes pathology on the part of that person, and is being subjected to the diagnostic authority of the professional. The new term, now often used in mainstream institutions is ‘client’, presumably to counter the stigma of being labelled as a mentally ill patient. This retains the detached and impersonal relationship that mental health professionals have with the people whom they are treating. As a client, I am essentially paying for a service from a trained professional who has authority to decide for me what my condition is and how to best live my life, without even knowing much about me. My relationship with the professional becomes merely transactional, where power lies with the professional.
I attended a focus group discussion late 2015 and again in 2017, which were conducted by the Early Psychosis Intervention Programme (EPIP), which I have been made a part of by my psychiatrist since my first episode in the previous year. It was a research study on case management, and we as ‘clients’ were asked to give our thoughts and feedback. There were various opinions shared, and mine were generally very critical of the psychiatric practice as a whole. My main points were how the whole notion of case management is largely professionalised, how there is a severe lack of transparency of information by the professionals (especially the doctors) and how there are many abuses and violations of human rights in psychiatric practice. The researcher was noticeably very uncomfortable with my feedback. She kept turning away from me. I truly wonder if they actually took our views seriously. I was quite offended when the researcher – a psychiatrist – spoke to us in simplistic language, as though we were incapable of engaging fruitfully in a more mature, adult discussion. I tried to mask my angst under a veneer of calm and distant rationality.
The hierarchical, detached and impersonal relationship between the specialist and the patient which is the dominant approach means that the person who has a mental health diagnosis is made dependent on the decisions and judgment of the specialist. The specialist does not relate to the patient’s personal experiences, rather he defines for the patient how to make sense of their own experiences, regardless of how deeply personal these experiences may be. It does not matter that the specialist does not know the patient personally, because she is just another medical case.
In fact, the detached and impersonal relationship is the dominant approach and seen as ideal in contemporary psychiatric practice. The patients may reveal everything about their inner lives without ever receiving the same level of depth of sharing by the trained professional, whose knowledge is mostly acquired through studying and job training. Nevertheless, the professionals are recognised as authorities in their ability to identify and diagnose the problems faced by the patients who are reliant on them.
The peer support model, which is increasingly popular in mental health circles even in Singapore, tries to adopt a more patient-centric perspective. Nonetheless, it is not without its problems. I think the biggest issue in Singapore is its co-option into mainstream institutional psychiatry. The peer support movement started out as a radical criticism of authoritarianism in mainstream psychiatry. But in Singapore, where peer support is still subsumed under the dominant mental health establishment, it ends up propagating the same outlook and direction as the institution. The preoccupation with recovery, for example, necessitates that the mentally ill person eventually aligns herself back into capitalist society, with the aim of finally being gainfully employed. Professional peer support workers still rank below psychiatrists and therapists in the institution. The unequal power relations still remain, only made more subtle by turning peer support into a paid profession.
Empathy can only happen in an egalitarian relationship, which does not happen as a matter of course in the professionalised and institutionalised setting where psychiatry is practised. Developing critical reflection on dominant paradigms is one; recognising ‘us’ as co-producers of knowledge and involving ‘us’ in ways that are not belittling are important ways in which we can begin to challenge this. This means that the accounts of mentally ill patients are as valid as the observations made by professional psychiatrists. Psychiatrists should also be made aware of their privileges, as well as the limits of their knowledge vis a vis their patients. I believe that has to happen from outside of the mainstream institutions. Collective efforts from mental health advocates are necessary. Models of peer support based on the principle of mutual aid independent of mainstream psychiatric institutions have been adopted in other countries and should be replicated in Singapore.
Importantly, liberation from psychiatric domination and abuse has to happen alongside other struggles for social justice, such as institutional racism, sexism and economic injustices. In this respect, mental health advocates need to also adopt an intersectional perspective on their struggle, that mental well-being cannot be divorced from the liberation from oppressive forces in society. Thus, there has to be greater cooperation and solidarity with activists working in other fields. Greater empathy and an egalitarian relationship between mental health professionals and the patients must be fostered so that the perspectives of persons with mental illness would be continually affirmed for healings to take place.
Nurul Fadiah Johari is a researcher, and is active in groups advocating for Muslim women’s rights in Singapore. She co-runs Penawar, a support group for women raised in the Muslim community, dealing with negative experiences from patriarchal interpretations of religion. She has also written pieces in local publications such as Perempuan: Muslim Women in Singapore Speak Out (2016), Growing Up Perempuan (2018) and Budi Kritik (2018). She is currently interested in examining the intersecting problems of patriarchy, capitalism and racism, and their implications on mental health and trauma, especially in the lived experiences of minority women.
Editor’s Note (15 September 2019)
This editorial note provides clarification following feedback from the public sent to s/pores on 9 September 2019 on Nurul Fadiah, “My experiences and perspectives on the lack of empathy in psychiatry”.
As Menzies et al. (2013) write in their introduction to Mad Studies, madness/mental health/mental illness is itself a multi-vocal field with many differing views and perspectives. In her essay Fadiah Johari draws on her own personal experiences to point out the lack of empathy and the hierarchical imbalances in the relationships between patient and doctor in psychiatry. We have received a letter from the public highlighting that Fadiah’s main argument focuses on how approaches in psychiatric treatment lack empathy because of an emphasis on mental illness as a chemical imbalance in the brain.
I would like to reiterate Fadiah’s main points to make them clearer for the reader.
Drawing on her own experiences undergoing psychiatric treatment, Fadiah argues that while current paradigms prescribe the treatment of mental illnesses, it is also important that psychiatry pay attention to the experiences of the mentally ill and not dehumanise those that are treated. Here she makes the important point that psychiatric professionals need to respect the human experiences of the mentally ill, and not view the mentally ill simply as objects of treatments.
Fadiah makes suggestions for mental health to improve as a practise in Singapore: rethink the hierarchies in psychiatry, adopt models based on peer support in other countries which recognise those with mental illness as co-producers of knowledge, recognise the intersections of mental health issues with other kinds of oppressions in society such as race, sexuality and economical status, and professionals fostering greater empathy with their patients.
Fadiah has expressed her thanks to the member of the public for their correspondence.
Menzies, Robert, Brenda A. LeFrancois, and Geoffrey Reaume. 2013. “Introducing Mad Studies.” In Mad Matters: A Critical Reader in Canadian Mad Studies, 1-22. Toronto: Canadian Scholars Press.