Experiencing and treating ‘madness’ in the United States circa 1967–2022: Critical counter-histories

Abstract

Over the past 55 years, in the United States, we have witnessed shifts and changes in mental health treatment practice and policy focused on ‘psychosis.’ Alarmingly, in this same period, neither in its social location nor its clinical outcomes, has psychosis, particularly multi-episode psychosis, shown much substantive improvement (Hansen et al., 2022; Huxley et al., 2021). Epidemiological studies of stigma have documented the worsening of perceived dangerousness and desired social distance (Pescosolido et al., 2010, 2019), while long-term trajectories include extraordinarily high rates of incarceration, homelessness, and unemployment (Lin et al., 2022; Ramsay et al., 2012; Wildeman and Wang, 2017). Disengagement from “services” viewed by users as unresponsive to the user's actual needs and values is thought to be part of the problem, although it is not clear that those who do engage do better (Hansen et al., 2022). Written from the first-person perspectives of current/former “users”—people who have experienced psychosis and “used” services—this paper leverages critical counter-history, conceptual analysis, and autoethnography to ask how and why treatment policies and practices continue to fail so many persons labelled with psychosis in the United States. Outcome, we argue, hangs on much more than clinical effort. We thus explain widespread “treatment failure” as a consequence of interpersonal misunderstanding and misrecognition as well as entrenched structural and institutional ableism, racism, and classism—factors to which clinical services and individualizing narratives alike consistently fail to adequately respond. On a more hopeful note, we trace histories of activist (user/survivor) resistance. This includes efforts that may appear fledgling or transient, but that have nevertheless sustained a distinctly different vision of what might be possible.