Sometimes I think therapy practitioners and mental health administrators don’t really think about what they are doing when they adhere to industry standards in trying to promote mental health for those marginalized in the mental health system. Whether working in the mental health system, administering mental health programs, or working out of their own psychotherapy office, practitioners are presumed via education and experience to know how to help. Many of us learn how to tout what the research says about the problems we encounter.

There is a presumption in mental health that help must be scientifically proven to be valid. At least there should be journal articles and laboratory results that validate what you have to say as a therapist. Many of us have participants who will ask for what the research says. Many of us feel compelled to keep current and familiarize ourselves with the latest trends. When we are faced with things we don’t understand perhaps we read up on it and seek training.

Thank goodness we also are all trained to think that it is appropriate to be curious and let the participant teach us things when we encounter a cultural issue. However, not often enough is this applied when a practitioner works with people who have experienced psychiatric incarceration in jails and hospitals, deprivation on the streets and shelters, or marginalization in board and care group housing. Here, practitioners with master’s degrees who have not been incarcerated, abandoned and deprived themselves need to do a lot of cultural exploration. Too often, rushing to the books to understand psychiatric oppression is likely to provide one with dehumanizing medical model constructs and eugenic beliefs.

As a practitioner with a twenty-five-year career working with marginalized populations, I am writing to emphasize an emerging trend in counselling theory and practice. In this article, I will argue that counselling theory is increasingly headed in the problem-focused direction. Additionally, I will emphasize the importance of letting this trend be guided more by culture and lived experience and less on evidence-based research.

Basing A Mental Health System on Evidence-Based Practices:

 I was once warned in the county in which I work that I could not tell anyone that I don’t believe in evidence-based practice. Indeed, in Alameda County in California, mental health recovery was once thought to be achieved through a researched method that is imposed in a top-down manner by experts who have established fidelity measures. In other words, evidence-based practice has been researched elsewhere and found to best work in a prescribed manner that must be replicated. All workers learn a practice that is taught to administrators (who must replicate it in the prescribed manner) and then the learning trickles down to the mental health worker who is taught through workshops and on the job training.

Much of the reason I criticize the roll-out of the evidence-based practices in this manner is that I worked in a failed project as an administrator. The Choices project rolled out in exactly this manner. We had three evidence-based practices going at the same time and were supposed to work together seamlessly so we would learn all three practices to a certain extent. I like to think that it did not take a researcher to know that recovery did not trickle down in this manner. But the expensive program did have researchers who helped end our collective misery after six years.

These best practices were the employment-based best practice developed out of Hanover New Hampshire (IPS Model,) the corporate peer counselling model represented by Recovery Innovations out of Phoenix Arizona and the housing-first model out of Seattle Washington, that suggests that if you rescue people from homelessness, mental health problems tend to fix themselves. As a staff, we were told that the established fidelity measures were proven to work across cultures.

Having gone through what I went through on that job, I don’t understand how best practice notions are thought to be able to cross cultural barriers. My biggest take from the terrible associated experiences was that best practices, like movements or revolutions, need to arise out of unique cultures by people who are targeting those cultures.

Evidence-Based Counseling Theories That Cross Cultures:

Back in the olden days, evidence-based research was considered an imperative part of developing counselling theories. In my master’s studies, which ended twenty years ago, the theory seemed to be touted as being functional to cross-cultural divides much as evidence-based practice is today. I learned many good theories as such that were proven to work across cultures, from Freud to Albert Ellis to White and Epstein.

For example, when I was young, structural family therapy could help children of the slums: European, African American, African, Asian, Latino and Indigenous. Across the nation, and the western world, not only slum families but also families with psychosomatic conditions such as anorexia or childhood diabetes could benefit. Anorexia was more often found in the suburban private schools, than in urban areas so the practice was statistically proven to cross cultures.

As a young therapist, I had the occasion to use some of the techniques rest assured they would work across the cultural divides. Of course, back when I was in school and learning from books than with my young twenty-something look and undiagnosed Asperger’s, I wasn’t too good at holding onto clients. But I did apply many of those intense techniques for better or worse because they were battle tested.

But were those techniques truly able to cross all cultural divides? I only needed to consider my own experience with them to know. Those techniques had ripped into my family support and resulted in the emotional cutoff. For example, being bullied into eating by my father may have worked to reveal family dynamics, but it really traumatized me that exacerbated my condition.

My parents were private school teachers and were not used to hearing that they or their kin were remedial in any way. Suddenly, it seemed like in their cultural tradition, it was more customary to throw the misfit off the lifeboat. My family had a member who has given a lobotomy a generation ago and who then disappeared into institutions. Suddenly I might be the next victim?

Perhaps, the structure that was unwittingly imposed on our Quaker boat was viewed as militaristic. The Argentinian, Minuchin, had worked with the Israeli Army. Maybe, in fact, it was a bad cultural fit. While the therapist didn’t initially let my parents throw me off the boat, I failed to gain weight and those ever-mysterious results from the psychological evaluations came back.

In fact, I have been to many therapists of very different orientations both before and after this experience and slowly I learned more about myself during the psychological evaluation of my soul. For example, I eventually learned that I had at least two distinct neurodevelopmental disorders that helped to explain my torment. I did not respond well to other schools of thought that just were pathologizing and added to the negative thinking in my head.

How Evidence-Based Counseling Theories Helped Me:

Twelve years later, I engaged in a rebellious political battle in a drug zone as a social worker. I found myself a ward of the state, confined for three months to a state hospital. I could only reflect on the way I had a series of powerful therapists use their culture to impose reality on me. I’d had to undergo quite a journey to realize that a history of having reality imposed on me resulted in degradation and a loss of sense of self. When, I was moved from the observation ward to the chronic unit, for example, I was essentially being trained for a life of degradation and abuse. I was forced to learn subservient behaviour to get off the unit, behaviour that makes it hard to be around the privileged culture of therapists.

I feel that imposing a behavioural change that isn’t wanted or isn’t possible for the subject results in subjugation and resentment.

Of course, there are many therapeutic traditions that function contrary to the view I assert above. In Uncommon Therapy, when Jay Healy explores the work of Milt Erickson, an alternate view is clearly explored. In such a model an exceedingly powerful therapist has figured everything out and knows how to trick the participant into behavioural change. Several theories work to impose a behavioural change in like manners.

Just because I have experienced a sense of feeling culturally dominated by powerful theories, doesn’t mean that other people may not benefit from them. And, so, particularly with culturally diverse people, I identify my own experience and how many therapies did not work for me. And then with a sense of curiosity and inquiry, I explore what the client’s experience has been and their view of their needs. I am not averse to an occasional paradoxical technique.

The Development of Problem-Focused Treatments:

 Since therapists have a shared history of studying western therapy movements, I think that therapy movements (or theories) are also important to explore culturally. In fact, as I have practised crossing cultural divides among marginalized individuals, I have often found that I must reflect on social circumstances about what made the therapeutic movements work to make what I know useful!

Ten years later when I dove back into the study of theory to pass my licensing requirements, I recall arguing to one of the few licensing teachers I trusted that I felt it was good that therapy theory was moving in the direction of what I called problem-focused treatments.

By then, I stopped treating counselling theory as a proven fact. I considered: firstly, who the theorist was culturally, and who their subjects were; and secondly, who I was, and who my client was cultural. Before I applied the techniques, I was thinking about how to transmit them. I figured some would fit in some contexts, but not in others. I put people first. I had learned that working eclectically with theories that matched the situation led to more success.

At the time I was leading DBT groups for individuals who suffered from complex trauma. There was a specialized treatment for addictions: AA and motivational interviewing. And there were also emerging treatments for trauma, like EMDR, Internal Family Systems, Emotional Freedom Techniques. I studied WRAP to help consumers across diagnostic divides work together to avoid public warehousing and watched it become an evidence-based practice. I figured there was a similar need to teach other therapists how to work with things like psychosis.

By then, I started to see many DSM diagnoses more as oppressed cultures that required specialized theoretical focus. I felt that different problems could be deconstructed and redefined in solvable components. This would help therapists and clients alike work together to better understand what was going on.

So, in my mind, problem-focused therapy is the new direction in which psychotherapy needs to head. The trick is to turn problems (or social phenomenon’s) into cultures, reconstruct those cultures into solvable definitions and bring people together across DSM cultural divides to work on them. Ten years ago, I could see this was being done for many problems already, just not for psychosis.

Respecting Lived Experience and Culture:

 Back when I was award in a state hospital, I was diagnosed with “schizophrenia” and given a poor prognosis. As a young social worker who had worked with “schizophrenic” clients for seven years, I could not accept the diagnosis. Misguided individuals tried to impose that diagnosis on me, but what I was going through had nothing to do with the “schizophrenia” I had observed and studied up to that point. It clearly had nothing to do with what they thought “schizophrenia” was either.

I experienced so little empathy and such hard conditions, I did not realize that anybody else could possibly have endured what I believe happened to me. I did not imagine at that time that many people across diagnostic categories really could relate to what I was going through. I never knew that one day I would see how it all went together.

For the last ten years, I have held specialized group therapy for psychosis and I have redefined what psychosis is through sharing my story and hearing the stories of others from my culture. This work has not been based on clinical trials, but a rather anthropological observation. I may be able to research journal articles and run experiments that prove what I am saying. Maybe one day I will. But what has helped me most throughout this time was my lived experience with myself and my ability to cross cultural barriers.

Many major figures in mental health have admitted that they used lived experience to develop their work. Consider evidence-based movement leaders such as Bill W., Bob Smith, Albert Ellis, Marsha Linehan, Mary Ellen Copeland, Bessel van der Kolk, Francine Shapiro, Marius Romme and Sandra Escher! I bet that others who have contributed significantly to the development of best practices have started with their own lived experience.

As a person who spends all my work day at practice, it feels odd that my work is often discounted. I did run a successful research grant to prove the validity of my approach but many of the marginalized participants I worked with were unwilling to fill out surveys. Perhaps it is a lot to ask marginalized people to partake in an experiment. I would have objected to it when I was not well.

I believe that my lived experience and curiosity has created something of value. I think these elements are more important in the development of counselling theory that the research which somehow doesn’t trickle down to serve marginalized people. I think it is time counselling theory and therapy practitioners who work with marginalized people to look to them for help in what they are doing. Really, this is already happening for many of us who effectively work with the disenfranchised. It’s just slow to see institutional change.

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A Need for Providers who Specialize in “Psychosis.”

I was hired straight out of college into work in the counseling field. I started to work with an adult mental health population at my second professional job at the age of twenty-three. Since that time I have been increasingly focused on how to make therapeutic engagement meaningful when working with people in “psychosis.” In the field there are many who will say or imply this is not possible. They may argue that the mental health system is the best we can do. This story is for the providers who think more can be done to help individuals who have anomalous experiences.

***

Working my way through graduate school, I can still remember struggling to get my dumb-ass footings as a professional counselor. I remember thinking about how ironic it is that they start you out with the most sophisticated of problems.

“Oh, you’re good,” said this vagabond homeless man who sticks out in my memory.

“What do you mean?” I asked perplexed by how he could affirm me with such confidence.

“Well, I can tell because you just asked me what was going on with my schizophrenia, like you really wanted to understand it.”

I did a little double take on this man standing before me. I couldn’t understand how when he lived such a deprived, sunburned, and sweaty existence that he could respond to this young, privileged and nervous person in front of him by being supportive. I didn’t sense that he was doing this to butter me up.

I recall making an internal commitment to him on that day. Hence started my desire to learn about and heal schizophrenia. I felt I owed that man something for his kindness.

***

By the time I got my degree so that I was promoted to a case management position, I found it a wonderful opportunity to get a picture of what life was like for the schizophrenic clients on the streets, in the boarding homes, away from the clinic. It was not a pretty picture, but I reasoned that now I could provide a service to earn their rapport. Then, I could use my little theoretically informed counseling skills to get at their truth. In many ways, I did not actually know what to say other than, “Did you take your medication?” However, I was happy with the arrangement.

Meanwhile, in my personal life, I got tired of being in and around my hometown. Sure, I went to school in a ghetto and had built up the rental history to take up a lease on a suburban flophouse with some acquaintances. Sure I fled that shelled-out place into a pad in the city. But, somehow this plus getting dumped in all the female relationships that I barely managed to make wasn’t enough for me.

***

I switched coasts and accepted underemployment in a new city where I could pick up where I left off at understanding schizophrenia. Here, I really wasn’t expected to do therapy as I monitored well-tended housing for clusters of mentally ill adults, but I did anyway. My supervisor, whose standard care I often challenged, found me difficult. My better than average handwriting was targeted as being a problem.

It’s true the clients seemed to have it pretty good in the west coast city. The facilities I monitored were much nicer than the ghetto ones back east. But within six months, after another heartache, I took a promotion in a pilot program setting up services in a notorious section eight housing authority complex.

I must admit as a kid who grew up in a private school, the streets and the ghetto, much like schizophrenia, had always been a lure for me. I love other cultures. I set up shop in the notorious section 8 housing project. I got some real exposure to what people who end up homeless and destitute due to schizophrenia deal with. Let me tell you, it wasn’t a very safe holding environment.

Six months in, I was talking with a resident I trusted very dearly. He had once told me who the for-real drug kingpin was about the complex. He paused a minute and said, “You know, one time we had a person like you work for us before, someone who really cared and fought for the residents. That person, ended up losing his job and having to come and live with the residents. I just don’t want that to happen to you.

I looked at this schizophrenic resident who worked a minimum wage job. It was true that since I had leaked stories to the media about some of the suspicious violence and fear that the residents were subjected to, that I had been picking up on random threats and feeling very unsafe.

***

Within a week, things escalated into my personal life. I got threated by someone who really did have a nefarious past. I started getting interesting takes on mainstream movies.

I tried to get to the Canadian border to seek asylum and ended up getting separated from my car. Eventually I surrendered to police in a ditch while ascending a mountain pass. They took me to State Hospital where I resided in barracks three months. Just when I was starting to come to terms with this ridiculous black market sea of poverty I was cast into, I was transferred to the most chronic ward where the overcrowded conditions were comparable to the worst of what I’d ever seen.

I spent two years after that trying to overcome homelessness and underemployment in a full-blown psychotic episode.

***

What I had learned about schizophrenia at that point was that most people had absolutely no interest in it. As a mental health patient, I found that no one was any longer interested in my story or what I had to say. The five-word phrase, I had been trained to use, “Tell me more about that!” was replaced with a famous five-word question: “Did you take your medication?” Nobody believed a word I said no matter how real I was being. And no longer did anyone care what I was subjected to.

For example, during my “psychosis” I believed the mob or the government was following me. The only job I could find despite hundreds of applications and two relocations was at an Italian Delicatessen, I had needed to bike twenty miles and catch a two-hour long train ride, daily. Nobody had cared that I was in back pain through the all of it. I was still the last to go on break. I was blamed and framed for anything that went wrong. There were constant threats against my job. There had been no acknowledgment for my efforts, only complaints about my service from upper-class people, and punk-ass ridicule from my teenage co-workers. Finally, I agreed to take medication.

How was I to transition from being treated like that—from being locked outside the ward mental patient in sub-zero temperatures freezing like the cow patties in the field while the staff returned late from their lazy lunch break—to being a fully entitled therapist? Finally, I could understand why someone who was even a little bit interested in what it meant to be a schizophrenic was a good worker.

***

To be honest I knew I was not a good worker for a little while. I was just barely-making-it, overworked, highly insecure, and protecting myself as I worked two jobs and an internship with a half a day off every other week. When I earned my way back to working with people individually, I was a little better at getting rapport and experimenting with helping out with schizophrenia. I heard a lot of, “Oh you’re good,” comments. At least I knew enough not to approve of the word schizophrenia. It took me six years and a number of side jobs to get my license and be fully grounded in a staff position.

Throughout the training for my license, I had not disclosed to anyone what I had been through. Always too busy to make friends, most colleagues tended to think I was younger than my stated age, and perhaps a little over-anxious about making rent.

I soon found among licensed marriage and family therapists that most presumed that there was not much value in treating individuals who had schizophrenia. Some individuals forced into working with them characterized them as just lazy and unresponsive to instructions. Those who picked up on my insecurity said maybe there was a future for me in providing “just” case management services. I often heard it said, that it was debatable whether there was effective treatment. Sitting in licensure lectures, we were taught that in coming across a person with “psychosis,” the standard of care was to hospitalize and refer to programs.

When I passed those sucker licensure tests in spite of my learning disabilities, I was tired of leading groups full of good people who had experienced “psychosis,” and not talking about what was really going on. I decided to get to work creating my own treatment strategies for schizophrenia. I had heard about the hearing voices network movement in Europe and decided to create a curriculum that deconstructed “psychosis,” and emphasized recovery skills. I took WRAP training, and finally started to experiment using my own story with all its minute details.

***

Learning how to navigate the profession as an identified schizophrenic has been full of challenges. A co-worker found a copy of my curriculum, and turned it over to the manager with grave concerns. Another left insulting cartoons on my desk. I had occasion to hear myself being referred to as, “Crazy Tim!” I ignored these and persisted. Eventually, I took a job where I was identified for two years, advocating for change in the county. My name and unhealable condition spread like wild fire throughout the county. In team meetings, I was accused of being against medications. One person who defended me end up getting written up and eventually fired. When I returned to my hospital job, my primary boss, who, thank god, has been supportive of me throughout, once let me know that when I went over to the county’s ward to run groups, that I had little red dots following me on my forehead.

My groups, my popularity among people who I help, and my own little paranoid vigilance has helped me survive the past nine years and thoroughly develop my own eclectic theoretical approach towards helping who I prefer to call message receivers in group and individual settings.

Things have gotten a lot less hostile for me at work. I now know what to do to help out that vagabond homeless man I met two decades ago. Additionally, I wrote a grant a proved that message receivers could be paid as outreach workers, tell their story to providers, and transition to being group leaders, and mental health professionals while they attracted and motivated individuals who might not have otherwise been motivated. I serve on the board of the local hearing voices network.

I believe uniquely talented specialists are needed. We need outreach specialists with lived experience who can meet sufferers wherever they are: at home, on the streets, in the board and care homes. They can deliver messages of hope and referrals to bolster a system of self-support, like the hearing voices network. And still for others who need it, referrals to therapy specialists, who might have the training that hasn’t yet penetrated academia programs. Perhaps, one day, other interested parties can learn to become a specialist in work with “psychosis” without having to face quite as much pain. It is a very sorely needed specialty!

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