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Sophia: Hello and welcome to The Lancet Voice and to one of the podcasts spotlighting mental hell as part of The Lancet's 200th anniversary. It's June 2023 and I'm Sophia Davis, Senior Editor at Lancet Psychiatry. And we're going to be talking today about trauma, recovery, and justice. And I'm joined by Judith Lewis Hammond, Duane Boyson, and Angela Sweeney.

So I'm going to ask to introduce themselves to you. So it feels to me, at least, like the importance of trauma has become much more widely appreciated in recent years, both in terms of recognizing how ubiquitous it is and the ways in which it deeply affects us. I also have a background in history of science and I'm a trained therapist, so I'm aware that the interest in trauma has gone in waves in the history of psychiatry with periods where it's been confronted, alternating with those when it's been selectively forgotten.

And with the focus shifting to different understandings and also different people from hysteria in mid to late 19th century women to combat neuroses in early 20th century men to where we are now. And these shifts have been according to what's been socially thinkable and interesting. Trauma happens to individuals, but it happens within social contexts.

And the same goes for healing and recovery from trauma. Now that statement is very much informed by your work, Judith. So I would like to start with you first, if that's okay. Could you introduce yourself 

Judith: for us? Yes, I'm a professor of psychiatry at Harvard, and I'm the author of three books, Father Daughter Incest, Early in My Career, Trauma Recovery, which you referenced just now.

And just recently this year, I brought out a sequel to Trauma and Recovery called Truth and Repair, How Trauma Survivors Envision Justice. 

Sophia: Before we get to justice and recovery, I want to start with just really the basics of what trauma actually is because it's a very widely, Sometimes quite loosely used word and ideas of it have changed over recent decades of what it is, which you've been a big part of.

So you brought to wider awareness the way that trauma from combat and from rape affect people in the same ways. And also you argued about how the profound effects of prolonged and repeated trauma. Like from childhood or domestic abuse should be understood as a different category of complex PTSD, which is now widely recognized.

So you've been engaged in this field for so long, but could you start by telling us how you see it as what trauma is and how it affects people and also how your ideas have changed over time on that? 

Judith: I like to cite Robert J. Lifton, who was really one of the pioneers in the trauma field, American psychiatrist who studied.

Those survivors of the Hiroshima atomic bomb and prisoners of war who survived Chinese thought reform and Vietnam War veterans, among others, cult members. And he talks about the death imprint, close personal encounter. With threat to life or severe bodily harm, or witnessing that up close as first responders to police, firefighters.

And I think that definition has held up well over time. One of the things we did when I was on the Post Traumatic Stress Disorder Committee for the DSM IV, the American Diagnostic Manual, is we looked at unfortunate, stressful life events. That didn't include that kind of encounter, like losing a job or having a divorce or simple bereavement.

To see whether those kinds of misfortunes produced the classic symptoms of post traumatic stress disorder. And the answer was no. Lots of anxiety, lots of depression, but not the classic triad of intrusive symptoms like flashbacks and nightmares. Hyperarousal like being on alert for danger all the time and numbing feeling nothing or feeling as though one was frozen.

I think that definition has 

Sophia: held up well. So from your point of view, you haven't really changed in terms of that classic triad, but you have helped instigate this other change that I referenced earlier about bringing the idea of complex PTSD into the field. And that is now. Gaining ground or gaining recognition as something that needs to be paid attention to.

Judith: I introduced the concept of complex PTSD to argue that the effects of a prolonged and repeated trauma were different and more severe in general and more pervasive than the impact of a single traumatic event. When you have a single event, it means you can escape to safety afterwards. When you have prolonged and repeated trauma, it means that you're in a relationship of coercive control where you are under the domination of another person, and whether that's because you're a prisoner of war or because you're in a domestic violence relationship or because you're an abused child, besides the triad of classics, PTSD.

What we see is that being in a relationship of coercive control erodes one's sense of identity and of what kinds of possibilities there are for a relationship. And if one is a developing child, it doesn't simply erode identity, but forms identity. So that You have much more overlap with the so called personality disorders and a much more complex profile of citizens, and that has now been recognized worldwide by the World Health Organization.

The U. S. still trails behind the rest of the world, unfortunately, and We've imported some descriptive features of complex PTSD into our PTSD definition, but we don't recognize the category. And I think it's important to recognize it as part of a spectrum. of post traumatic disorders. 

Sophia: And I think that, that classification, that recognition has opened up to really a lot of research over the past years into complex PTSD.

And thinking of this increase in research in the connection between traumatic experiences and PTSD. the effects on someone. Dwayne, let's come to you next. Could you introduce yourself first for us? 

Duane: Sure. Thank you, Sophia. So I'm Dwayne Boyson. I'm a senior lecturer at Rose University in South Africa. Clinical psychologist and doing research in the field of traumatic stress and the treatment of PTSD.

Sophia: Thinking of all this recent research, it has tended to take place in particular settings more than others. Many times in high income countries, for example. And you've written about the limited trauma research in low resource settings, as well as how the relevance of mental disorders like PTSD are contested in other areas of the world through a critical approach to psychology.

Could you tell us about this critical approach and what you think is important to consider in the research? non Western post colonial countries and what you think is needed in trauma research? 

Duane: A lot of the research that we have available, if I can call it within the global South, within the fields of mental health, psychology, trauma stems from developed countries and there are obvious historical reasons for that.

And I think, thinking about my own position as a psychologist going through my own training. And I think broadly speaking scholars and psychologists within the field, essentially in a post colonial era, started to think about, okay, the epistemological and ontological premises of these knowledge systems, that if I think about South Africa and clinical psychology in particular that it was somehow imported into a different setting and at the same time also used to perpetuate and legitimize discrimination and racism.

Through the development of time, health professionals, psychologists, psychiatrists, somehow reached a point where it was a collective point of reflection in asking, what's the relevance and the utility of these knowledge systems within a completely different setting? And I think for me, critical approaches as I, as as I look at it now, essentially questions These knowledge systems that is now being utilized within settings, context, in the most broadest sense that have slight differences, differences in terms of culture, language.

but at the same time also similarity. So a lot of reflection and questioning. And I think for me, what has to be considered is moving away and not completely away from the individualized biological system. I do think, we can't just chuck out everything, but at the same time. We have to give we have to pay attention to context, the social, political, and cultural context, and I think that's informed a lot of my research of almost walking this tight rope between and I always joke and say to my colleagues, you might say that I that I'm doing mainstream psychology if you look at it at face value, but the questions that I ask for me, And this has been inspired by critical approaches such as African psychology, such as critical psychology, community psychology, is to go beyond questions around efficacy and effectiveness.

It's good to know that something is effective and what that means, but at the same time the acceptability of it, the feasibility of it within various settings, because if one thinks of acceptability you are then forced to think of the the more social nuances of culture, of socioeconomic systems of poverty.

Yeah, so critical approaches essentially has forced psychology, psychiatry, mental health to to think more broadly and to go beyond I think what we are used to which is the case of PTSD and complex PTSD, it started at a certain point. But through the process and development of research, we've we were forced to realize that, that there's something more to this particular phenomenon that we have to acknowledge.

Sophia: Yeah, that's so interesting. I think it's always important to go try and have a really fundamental disentanglement of what a concept is and Thinking epistemologically and thinking in terms of social context beyond the individual, I think, really important to involve that lens. So let's turn to you now, Angie.

Could you introduce yourself for our listeners? Yes, my name's Angela Sweeney. I'm a survivor researcher and I'm a senior lecturer in user led research at King's College London. I was curious to hear your perspective also of different people doing the research, from different aspects of doing the research.

So you've advocated for centering survivor knowledge. Can you tell us about why survivor research is so important in the field of trauma and trauma informed care? What it means to you to be a survivor researcher, and also the challenges it can pose to psychiatry and understandings. I wanted to start answering that by saying that I've been a 20 years now.

And every time I'm in a room with survivors I'm struck afresh by the kind of wisdom in the room and the palpable energy often that's created when survivors come together because of that wisdom that Shared collective wisdom despite the differences amongst an iconic of mine referred to it as voices of wisdom.

And I think that you're right when you're talking about centering survivor knowledge. I think that's exactly what's important. And I think Judith's work, Dwayne's work, it centers survivor knowledge. It's based on that power of listening to people, what happens when you place people in their social, political contexts and listen to the impacts that trauma's had on them and What that means then is it's not about my research versus somebody else's research.

It's about people's ability to center that knowledge and survivor research does that, but also others do that as well. And I think I wanted to make the point as well that as survivors we can feel the inauthenticity. doesn't do that. And we feel that because it doesn't explain anything back to us.

It doesn't give us any aha moments. It it's going to cause us to frown and feel perplexed rather than heard, validated, listened, understood in the way that the people here would do. So yeah that's the first point that we need to make. And then One of the other reasons that survivor research is really important is because we're taking back control of the research process and we know that the loss of personal control is at the core often of abusive experiences.

So to be able to take that control back is a form of epistemic justice in a way. Also, because I know survivors often report quite negative experiences of research participation and I heard some. Quite difficult experiences recently from a range of survivors about people asking the wrong questions, using the wrong methods that were maybe harmful or felt exploitative, extractive.

And I think with survivor research, we, to a certain extent, have the tools to not engage with people in those ways, dependent, of course, on the kind of the funding and the time that we have to do our research. Hopefully, in the best way we can. ways we can avoid that kind of exploitative smash and grab style of research.

And we also feel the gaps in the research base quite keenly. So that means that when we conduct research, we would try to do it on the kind of things that we prioritize as survivors. So I was thinking a bit in advance about the challenges that poses to psychiatry. I would say that in many ways psychiatry can be part of that wall of silence that survivors experience in multiple domains of their lives.

And what that means then is the services don't meet people's needs because when they engage with them, they're disconnected from that social and political context. Very often they're not validated, maybe not believed, not heard, perhaps medicalized, perhaps diagnosed, perhaps forcibly treated. And all of that contributes to the wall of silence that's so damaging and that perpetuates trauma and abuse in society.

So that's some of the harms that survivors will be aware of and others will be aware of. And in some ways our knowledge, I would say, doesn't challenge because powerful institutions are going to absorb our knowledge and spit it back, back at us in a more palatable form than the version that we're trying to create.

So you might have services that re label themselves as trauma informed or people that say of course it's trauma. Impacts mental health in any way, here's a biological response and a control based response to your trauma expressions and a kind of lack of acknowledgement of some of the harms that it does see.

Sometimes you're like, reminded by my best colleagues of the need to retain a bit of hope in this situation. Judith, if we come to you again, as Angie referenced you've worked with survivors a lot and you're, Your new book, Truth and Repair, is shaped through listening to survivors.

And you've talked there about how important social justice is in healing from trauma, which is very different to this traditional psychiatry perspective of interventions and biological viewpoints, thinking of just the individual. Could you tell us about this, about the importance of social justice in recovery and how that fits together with the three stages of recovery that you had mapped out in your earlier work.

Judith: I think the basic argument of the book is that if trauma is a social and political problem, and I believe it is, then you can't just think about individual solutions. There needs to be some sort of social and political way of addressing the problem. As well. If trauma originates in an injustice in a crime, then justice is needs to be part of healing.

Part of the reason for this is that when you're talking about a crime of violence, you're not just talking about a perpetrator and a victim. You're also talking about the bystanders. For many people who've been victimized, it's the betrayal of the bystanders. It's the bystander who colluded with the perpetrator or who chose to look the other way or who blamed the victim.

That causes, in some ways, even more, because in that way, trauma isolates and shames the victim. That is true, by the way, whether you're talking about The most intimate scale of child abuse within a family, or whether you're talking about the Holocaust. Incest survivors will say, where was my mother? And Holocaust survivors will say, where were all the people who knew and did nothing?

Justice, I think, for survivors involves healing that relationship between the victim and the bystander. The survivors that I interviewed 30 survivors of various forms of gender violence. What they all wanted, first and foremost, was acknowledgement. Not primarily from the perpetrator, but from the bystanders, from the community in terms of the bystanders acknowledging the harm and saying this was wrong, that vindicating the survivor by saying, you are not to blame, this should never have happened to you, this was a crime.

And that's what And when people get that, it really helps with recovery. 

Sophia: And how do you, just to come back to the idea of how it fits with this, the three stages that you had mapped out before of needing safety and. Looking at their memory and forming connections, how do you see them fitting together?

Judith: About the stages of recovery, generally, this is not a kind of a forced march, this is more a set of guidelines for the focus of treatment. You start with establishing safety, which is very much a social issue because if a person is still under threat, they're still going to have PTSD.

They're not going to get better. And safety is always, involves other people. So you start there, and then when people are reasonably stabilized. They will have a base, a sort of a defensive base, if you will, in the present from which they can revisit the past and say that was then, this is now, that happened, but it doesn't control my life anymore.

And that's when people can make meaning and grieve the trauma. And then the focus shifts more back to the present and future when people can be more expansive or, imagine the future and imagine being understood even by people who haven't been through exactly the same kind of trauma and see that there's lots of injustice and lots of suffering in the world.

And maybe even find a survivor mission that Robert J. Leston's germ of. Making new, transforming the meaning of their trauma by making it a gift to others and joining with others to make a better world. And I think it's really at that point, when one is making a larger meaning of the trauma and joining with others, that one is really ready to seek justice.

Of course, our justice system, imposes its own rules and often ends up re traumatizing people in numerous ways. So the testimony of For survivors, I interviewed, it's really an invitation to imagine different and better form of justice. It's interesting what you 

Sophia: say about how the different stages, they're not just concrete 1, 2, 3, and how different things happen at different time, but but they're all Still, there is the need for safety in the beginning, and Dwayne, if we come back to you and your work with trauma therapies, you've looked at whether trauma therapies like prolonged exposure therapy, what you work with, how they can help people with PTSD who are living in a trauma.

adversity and continue to be exposed to trauma, which is a condition, not of safety. Can you tell us what you've found in your work, both for health care workers and the people they're working with and how, what you found could help to inform. services. 

Duane: Sure. So that focus of research, I think for me at the early stages of my PhD, which was too long ago, looking at the field of traumatic stress and PTSD and really looking what's been done over the last three to four decades.

Being cognizant of of the debates that's been, that's been going on, which I think is not necessarily a bad thing. I think it's a good thing that there is. Active engagement around what's happening within the field. But looking at PTSD and the development of empirically supported trauma focused therapies and essentially asking the question, Will these treatments, for example, prolonged exposure therapy, work?

within a country like South Africa and similar countries, and almost taking a position of of ignorance. Asking myself, okay, so let's see, let's implement it and at the same time, as I said earlier, still being mindful of the critical discourses and debates to some extent rejecting mainstream treatments.

I felt that, let's still do the research because I do think it's necessary. Let's see what comes, let's see what comes back. So for me looking at the effectiveness of a prolonged exposure therapy, but specifically within settings of ongoing adversity. So working with participants and clients that struggle on a daily basis with poverty, having done some research within the Cape Town area, that's unfortunately experiencing, increased levels of gangsterism with people living on the Cape Flats where there are so many social difficulties and social ills.

And the question for me around safety is, to some extent we don't have in certain instances, we don't have the luxury to to say, let's get this person safe first, because the resources aren't always available. So for me, it was important to say, okay, what can these treatments do irrespective of the challenges, the real world challenges.

that these individuals are encountering. Currently, we're working at a trauma center with a group of refugees from the DRC and Malawi, and essentially piloting prolonged exposure and working with a group of social workers, which has given us a lot of rich, qualitative data around working with individuals who, and, Unfortunately, they had to flee their country of birth due to political instability, going to a different country with the hope of having a form of life and a quality of life.

Having, and they're not sued after that, they are faced with the reality, the sad reality of continuous trauma. Where these participants need to navigate socioeconomic issues of not gaining employment because of their refugee status. They have to navigate the, I want to say, daily threat of xenophobia.

So it's a complex, prolonged very complicated trauma history that now sits with these providers. Trying to do and implement prolonged exposure therapy. And in our weekly provider supervision, And what comes back is, I almost want to say, a very hard work in terms of untangling almost everything that's happening, whereby participants are coming back saying that I've been assaulted again.

We received messages on social media that all refugees and foreigners living in this particular neighborhood or area shouldn't set foot outside of their houses. So that has forced us to think on a theoretical level and also just in terms of how these established treatments work and don't work and how they really have to work very hard To, to make very small improvements, which, and sometimes they don't, which raises the question around, what we have in terms of psychotherapeutic treatments have been developed within a certain setting, with a certain type of diagnostic thinking.

But we are at a point where the data that's coming in is really revealing that, these treatments They are up for further revision and development and progress, which is a wonderful thing for me to see. Okay to see these treatments, how they've been established. But if we take them into different settings with different trauma presentations and history the findings that we are sitting with really makes us think quite hard.

I just want to say one last thing around social justice. Working with social workers, what they constantly say to us. As clinical psychologists, the minute they hear all of the adversity that these participants are going through, they want to jump and put on the human rights, social justice hat and go out into the communities, engage with the authorities around the rights of these human beings, irrespective of nationality and status.

And there's a whole discussion that we have around What do we do first? Do we engage in social justice first? Do we heal and recover the person first in order to engage in that very difficult process, which is such a, which is such a, I think, thought provoking discussion for me, coming into the field at such an early stage.

So a lot happening in terms of implementing these evidence based treatments manualized treatments, and essentially, Asking the question, will it work in the same way? Will it still be feasible? Will it still be acceptable? And then if not let's then see what's the next step. I see. I see.

Dr. Hermann. Do 

Sophia: you want to reply directly to that, Sadie? 

Judith: Oh I see you nodding. Yeah I can't imagine how prolonged exposure would be effective. Thank you. In those circumstances, even in much safer conditions, the dropout rate is very high. A lot of people find it re traumatizing rather than healing.

I do think we have similar refugee problems here in the U. S. And in many countries, of course. One of the things that I think has proved much more effective is group therapy. And it doesn't have to be exposure focused. It can be psychoeducational or there's also a three stage group model. There's a psychologist in the US named Mary BUNN, who's published a paper called Sharing Stories, eases Pain about.

group work with refugee survivors and how it becomes really a bridge to new community. It helps people with shame, with isolation, and with all the disruption and loss of community that they have suffered as refugees, not to mention the violence. So we're big fans of group therapy. I think there are good data, good outcome data on trauma groups.

We also have more of a stage one model that's really a psychoeducational short term group with topics for discussion, like what is PTSD and how does one take care of oneself, that sort of thing. And then a more trauma focused, exposure focused, if you will, type of group for people who have stabilized and are ready to do more intensive.

But I, I really do think that. When you're dealing with such a difficult social context, individualizing treatment may not be the way to go. 

Sophia: It's interesting. It's interesting in terms of thinking how much the context matters, like you've been saying, but also in thinking in general, how much we need to think in terms of how we can consider the individual level.

But we must also consider how individuals can change within groups and how individuals can change if we look at societal change and Dwayna can relate to that. I can understand that must be a difficult question. We've mentioned a couple of times the idea of trauma informed care and this keeps being brought up recently and you've written about some misunderstandings about what trauma informed approaches are or should be.

Can you tell us about some of the Misconceptions and about what as essential to foreign formed approaches. Before we do that, I just want to respond to Judy and just really reiterate what you're saying about groups, because I think that power of survivors coming together in groups that I talked about at the beginning.

I can really see how that can be fostered in group therapy and also in peer support. So many survivors will advocate for peer support approaches, trauma informed peer support groups. It's a very similar, I think through our knowledge, we've got to a very similar place that Judy's got to with her knowledge, I would say.

It just struck me, but there's a lot of similarities there. If I think about what is essential trauma informed approaches, I think it probably to a certain extent would vary depending on the day that I answer it. At the moment, I'm thinking about creating the ability to form healing relationships as being essential.

So whether that be with a provider or in a group, but services that are structured and organized and delivered in ways that allow those healing encounters, those healing relationships to happen, that to a certain extent has to be fundamental to trauma informed approaches. I think that's the essence of it.

And then the policies and the procedures and all of that can be reviewed for the extent to which they enable or prevent that from happening. Bringing in kind of principles of safety and mutuality and survivor partnership and. cultural and gender awareness and empowerment. All those kind of principles get brought in, but it's fundamentally to enable those healing encounters or healing relationships to happen, I think.

And what do you see as being central to a healing encounter? I said at the beginning, I've been a survivor researcher for over 20 years now. And one thing that comes up repeatedly is how a single person can, often a healthcare provider, not always, but often a healthcare provider. can change things for a person, because they listen, they validate, they humanize, they care, they believe and they give time, and those things can really mark a pivotal change for somebody, they can really help somebody on their journey to recovery.

So when I've interviewed survivors, often they'll talk about that person. and what they did. It's about having, I think it's about having those really human encounters. I don't know if that sounds a bit too wishy washy but people coming together as humans listening, caring. Yeah.

And what would that be in, in contrast to that you think really must be avoided or that, Or that are misconceptions about what trauma informed care should look like. So when survivors talk about that pivotal person that listens and cared, often that's juxtaposed with the norm, which is staff who are very busy, who don't have the time to give, and often survivors can be quite understanding of the structural pressures in terms of the systems and the way they operate to prevent those humanising encounters.

It can be feeling processed like a number to be. process through a system and not as a human being, not being seen, not being hurt, all those things can prevent those healing encounters from happening. The misconceptions that I've written about in the past are, so I'd say that there's something of a tension in trauma informed approaches in that if you define it overly, you then prevent systems from becoming trauma informed because they're sticking rigidly to a process.

procedure, which may or may not work in that context. And Dwayne's talked a lot about the importance of that social and political context. So that means that misconceptions are quite understandable because it has to be somewhat fuzzy to a certain extent. Trauma informed approach advocates say that everybody has experienced trauma, which I'm not sure is quite the case, or the opposite, that trauma is just child sexual abuse and the other forms of trauma that we experienced don't really count.

We're not really thinking about those. And whereas in actual fact in trauma informed approaches, the kind of traumas that Duane's talked about are really critical to understand poverty and racism and xenophobia, all those experiences are critical to understanding what a person's experience of trauma is.

I think the most dangerous misconception is the idea that we do this already. We don't need to know this. We've been trauma informed, it's just another buzzword. Or maybe a service will change its name to say we're now the trauma informed service when, they don't make any other changes.

But actually countering that, I think, is the fact that control and equation is still very much the fundamental operating principle of psychiatry and mental health systems. And no service that has that at its heart can really be trauma informed, I think. And this is why I wanted you to spell it out, what the problems were about exactly this idea of, oh yeah, we do that already, we already know that.

Judith: Could I just add that this is not wishy washy there are, that the most powerful predictor of successful psychotherapy outcomes. is the relationship between the quality of the therapeutic alliance between patient and therapist. And that there, we have abundant empirical evidence of that. And that is true regardless of the brand of therapy that is, or the school of thought of therapy that is practiced.

That is the most powerful predictor. There is no pill that is equally powerful for PTSD. It's the quality, the humanity of the therapy relationship that is the strongest predictor of successful outcome. 

Sophia: It's interesting, isn't it? That the humanity of it and that comes back to what you said, Angie, about, a human encounter, that's a healing encounter.

It's difficult to find other words than to say. So that's at the crux of it. 

Duane: Just thinking about, thinking about trauma informed care and understanding trauma and how we can provide care and support to the consequences of traumatic experiences. I think, for me what's also become evident is that they, there are many different approaches and many ways of conceptualizing.

How to support those individuals. And I think you're living within a post colonial setting. We, some of the debates has been, a real push and pull in terms of almost. Pledging allegiance to a certain camp for me, I've been quite resistant to, to, to just, stick something in the ground and say, this is how one gets about doing it, but to remain open if again, if I think of my context, if if one looks at racism, And the ideas around historical trauma and how indigenous communities have, I've had to endure the experiences of trauma, in the broader sense and how those communities, whether they know it or not, are left with if I can think of one thing specifically is a sense of shame of who they are and what that process of discrimination of colonialization and the mechanics of those systems had done to those individuals to have the humanity to connect with those individuals and to to create a relationship in a space where they do not have to feel ashamed about who they are, where they come from, how they look, how they speak and I think the wonderful field of traumatic stress and trauma and the field at large is that.

We are finding these different ways of working towards the same, if I can say end goal, and that is really to help one another, get through the difficulties of life. And unfortunately, some of the difficulties that we ourselves Impose upon one another. 

Sophia: I've got loads of questions that I'd love to ask both of you.

One of them for Judith, I was revisiting some of your work this week, and you talk about that kind of historical ebb and flow, the move towards rumour and then the pulling back, and I wondered how you see the time that we're in now, and what you think's going to happen. I wanted 

Judith: to ask the same question you guys.

I see the time we're in now as one of very heightened conflict worldwide, if you will, between the forces of tyranny and the forces of democracy. On the one hand, you really have a worldwide movement of oligarchies to impose various forms of dictatorship, whether you're talking about, the monarchies or the religious dictatorships of the Middle East, or the sort of proto fascist regime Putin's Russia, and you certainly have, then, within Europe, the spinoffs of those, and within the U.

S., very active anti democratic authoritarian groups. And on the other hand, the hopeful sign to me is the Activism that we've seen in the U. S. around labor, around race, around gender around the climate. And I do see these as all interrelated I, and I think the traveling field has always depended for its existence on these broad human rights movements, whether they were for abolition of slavery.

Slavery for the establishment of secular democracy, for women's rights, for women's liberation. They ultimately, you're talking about two templates of relationship, one of tyrannical control and one of mutuality and shared responsibility and shared dedication to the common good. I fear for my children and grandchildren.

Because it does seem very existential, but I am heartened by liveliness of these worldwide human rights movements. Now, it's interesting to distill it down to the, 

Sophia: the different forms of relationship that are at the heart of it, which is about different forms of power, what how power is used.

Exactly. Exactly. It's interesting that we relate back to what you were saying earlier, Angie, about that at the heart of psychiatry, there is still a coercive tendency. And Judith, I've heard you saying elsewhere that psychiatry is broken. I'm just wondering if anyone wants to reflect about power within psychiatry.

Great 

Judith: question. I'm just thinking as I speak. I could rant on that subject for a long time, I think. In the U. S., we have a very dysfunctional system in which the profit motive has pretty much taken over medical care. Unlike many other wealthy countries we don't consider health care as, or mental health care as a right, it's a commodity.

At this point it's really a disgrace in our country. Mental health care for people with severe mental illness is the prison system. And people with severe mental illness are generally found either in prison or on the street because we closed our asylums but did not provide the community mental health services that we need.

We're supposed to replace them because they don't make profit. I think we are in a pretty extreme case. We have worse public health statistics than many poor countries. Again, if you're talking about an oligarchy, that drains resources upwards for profit, you're not going to have good healthcare.

Sophia: I'd love to hear you talk more, Judith, about why you think it's a broken system. I think that would be really fascinating. Globally as well as within the states. From a survivor perspective, often we talk about with trauma informed approaches, how often people will say we do this already. But actually People aren't generally involved in decisions about their care.

In the UK, we have something called a community treatment order. I don't know if you have the same in your countries, but we have those here. And that means that people can be forcibly treated within the community and community settings. Use of restraint is very widespread, particularly against women and girls and people from racialized communities.

And they include the risk of death and people voluntarily on wards are often there under the threat of sectioning. So whilst it appears voluntary, actually, it's So there are huge aspects to, to the coercion and control that's at the heart of psychiatry that's often denied, strangely, and not recognized.

And I just wanted to draw attention as well to this report that's come out of Australia, I don't know if you've heard of it. It's it's called Not Before Time, Lived Experience Led Justice and Repair. I just came across it this week. And the Department of Health commissioned advice for the Minister for Mental Health in Victoria about how the government can formally acknowledge the harms in the mental health system.

It's a really fascinating read and it details the different forms of harm. And the different forms of reparation or justice that, that could be enacted at governmental level. And what they end up recommending is that there's a truth and reconciliation process followed by a formal apology to quite fascinating to see that emerging there.

Whereas often I think it feels like there's a denial that's happening. 

Judith: Oh I was just going to say, it's very sad because we had in the U. S. a deinstitutionalization movement precisely to address the overly coercive aspects of mental health care. A lot of people with chronic mental illness don't need to be locked up.

They can be treated much more humanely and actually more cheaply in a community A good spectrum of services is provided, including resident, community residences, day treatment, sheltered workshops. Those treatments require a very serious investment. And in our country, psychiatric patients do not have a strong lobby with the legislature.

So they. are stigmatized and neglected and basically abandoned to their fate. There is a coercive mentality within medicine generally. We speak about patient compliance. I hate that term. We're not looking for patient compliance. There is also a democracy movement within medicine that talks about things like informed consent, and those, and that dialectic is still very active.

And it's especially important in the context of children because of needing to 

Sophia: reinstate a sense of autonomy and control. Exactly. Elaine, you had something to say a moment ago. 

Duane: Thank you, Sophia. I think just to just echo the point that Dr. Herman made, I think investment, investment and to prioritize mental health.

If I look at South Africa in terms of our Mental Health Care Act we recently had a revision of our mental health policy framework and everything looks very well on paper. But when it gets to the implementation of it and how governments essentially prioritize healthcare and mental health care you don't see, you don't see it operationalized to the point where.

We've had a process of deinstitutionalization and taking the heavy load away from psychiatric hospitals and focusing on community based mental health care at a primary care level and if necessary to go to a district level and then if absolutely necessary go to a tertiary level. But yet, the funding that, that's required, the training that's required Again, it comes down to what do the people in power essentially prioritize and don't prioritize.

I think a lot can be done if I almost want to say if the minimum resources are given, but it seems like for the most of the time, very little to nothing is given. So investment and prioritization of it. As they say, there's no health without mental health, so, yeah. 

Sophia: I think we'll start to wrap up the discussion, but before we do any of you have anything else that you would like to say, that you've come here and you couldn't say so far?

I would love to urge the Royal College of Psychiatrists in the UK to read the Australian report, which is the one on lived experience led justice and repair. and to consider a restorative justice approach here in the 

Judith: UK. I'd just like to thank you for bringing this group together. It's been a very interesting and informative discussion for me.

I'm very happy to participate in it. 

Sophia: You're very gracious. The honor is mine. Thank you. Thank you all for participating as well. It's really wonderful to have your perspectives from different points of view and different parts of the world. I really appreciate bringing your different ideas all together in one space.

So we'll stop there and to our listeners, you can find a collection of articles for The Lancet's 200th anniversary in our mental health spotlight online now at thelancet. com. So just remains to say thank you again to Judith and Duane and Angie, and thanks to all the listeners for tuning into this episode of The Lancet Voice, which you can subscribe to wherever you get 

your podcasts.