Exploring the Fault Lines in Mental Health Discourse: An Interview with Psychologist Justin Karter – Mad in America

Justin Karter is a staff psychologist at Boston College University Counseling Services. He is a recent graduate of the doctoral program in Counseling Psychology at the University of Massachusetts Boston, where he completed his dissertation research on the experiences of psychosocial disability activists in the Global South.

He has served as the editor of the research news section of the Mad in America website since 2015. In addition, he has held executive board positions with the Society for Humanistic Psychology and the Society for Theoretical and Philosophical Psychology. Despite being a recent graduate and early career psychologist, he has published over 25 papers and textbook chapters on topics in critical psychology, critical psychiatry, and philosophy of psychology.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: I didnt have an interest in psychology until I finished my first masters in journalism. Instead, I have always been interested in storieshow they shape our experience of the world, and I also had an interest in politics and activism. In journalism, I learned how to listen for whats not being said in stories, to pay attention to whose stories are being told and when, and what interests they serve. While completing my degree in journalism, I was introduced to a different kind of psychology.

I took a class in Humanistic and Phenomenological Psychology with Dr. Brent Robbins. I was hooked from the start. It offered a new way of thinking about myself and the world, of articulating and exploring the sort of malaise I felt at the time. Humanistic psychology offered vitality, imagination, and possibility at a time when I was starting to worry that the world was pretty stultifying, robotic, and algorithmic.

I was also involved with student activists across Pittsburgh who were organizing and trying to make our universities more just by divesting from fossil fuels and resisting student debt structures. We also supported adjunct instructors as they unionized. But it brought us into conflict with our university administration.

When I started participating in Society for Humanistic Psychology, the APA was coming to terms with their involvement in developing torture procedures for Guantanamo Bay. Many humanistic psychologists had been calling attention to that for years. I was lucky enough to meet Dr. Lisa Cosgrove, who later introduced me to Robert Whitaker of Mad in America.

All of that reading and editing research has shaped me. First, I became aware of the fault lines in the field. There is so much we dont know about the brain, consciousness, or how people in their relational and environmental niches become who they are. These big questions and looking at all the fights kept me humble and also in awe at the complexity of our existence. They were fertile ground for different models and narratives major disagreements among experts about what it means to have mental distress or mental illness or a mental disorder and how best to treat that. Thats been its own sort of education.

My very first research review for Mad in America had a critique of Cognitive-Behavioral Therapy. I received comments and emails from people who were happy or unhappy with the piece for a variety of reasons, everything from how dare you critique a form of therapy when its the only viable alternative we have to Big Pharma to CBT and exposure is a form of thought control or emotional abuse, and your summary didnt go far enough.

Its been a lesson from the start and a constant reminder that these theories and the research we cover here have very real impacts on peoples lives. Often people are in the midst of extreme suffering, and its not just intellectually interestingthese debates have real and immediate impacts on people. As the research news team, we break down the wall between the public and service users on one side and academic writing on the otherwhats in the Ivory Tower, locked behind pay walls. We provide plain language summaries of the research so they may be useful to people when theyre evaluating treatments or trying to make sense of why theyre feeling what theyre feeling.

We emphasize research that is critical of these prevailing theories and treatments, which are often ignored in the mainstream press. We emphasize the connection between people and their environments, which sadly is radical these days. We focus on social determinants, peoples life experiences, their identities, and how that shapes their mental health. We broaden the perspective that people might bring when they think about themselves and others and why they might be suffering.

Karter: Its a sort of fault line. All these big questions like: What does it mean to have a mental illness? What is a mental disorder? What does it mean to be in distress? How do we conceptualize that? How do we understand the causes and precipitants? Most debates in the mental health field take a position on diagnosis because you have to.

At Mad in America, I was constantly exposed to different ways of making sense of mental distress. In my scholarship, I tried to find a concise way of putting together all these debates so professionals could use it to think through their position and strive for consistency. They could develop humility about these disorder categories, about what we know and dont know, and have critical consciousness about the institutions and historical factors that influence the development of these categories.

Also, it could help in thinking through how we could talk with clients in ways that honor their experience and aid them in coming to their own narrative for understanding their experience.

What is not part of the public discourse is thinking about how the presentation and the experience of different types of mental distress change cross-culturally and historically, as your work, Ayurdhi, shows. The narratives we have available to us profoundly shape our experience, and over time or cross-culturally, we have different ways of thinking and different concepts available to us. So its not just how we think about ourselves but how we experience ourselves and our world in an embodied waywhats salient to us, what we attend to, and what we dont.

If we think about disorders as discrete categories that exist in nature and were just naming them, we miss the opportunity to think about how people are making sense of themselves, of their own story, which is at the heart of psychotherapy.

Lisa Cosgrove and Robert Whitakers book, Psychiatry Under the Influence, looks at the institutional players that play a role in shaping how disorders get defined in the DSM. I mean pharma funding, physician pressures, and special interest groups. For instance, PTSD diagnosis has a lot to do with post-Vietnam War veterans advocating for their own best interest to ensure that the symptoms they were experiencing would be treated by the country that sent them to war. So it had to be defined in a way so that PTSD could be a long-standing condition.

We take for granted that symptoms that are listed in the DSM are somehow core symptoms to the experience of that disorder. But network research suggests otherwise. For instance, with major depressive disorder, symptoms in the DSM-5 have more to do with what historically has been defined as depression in the DSM than whats consistently reported by people as their experience of depression.

Karter: The idea was to produce a way of thinking about diagnoses that could train professionals and help them think critically about when and how theyre using it. What that actually looks like with a patient depends on who that person is, what theyre bringing in, etc. Culturally, there are a lot of models of madness circulating rapidly. People talk about mental health on TikTok, Instagram, and Twitter. People are learning about the neurodiversity movement, DSM definitions, and psychotherapeutic and psychoanalytic ideas.

Were cobbling together a model for ourselves to understand our own behavior and the behavior of others, drawing more than ever from the psy-disciplines. Its confusing for a lot of people, and rightfully so. Amid all the uncertainty, we tend to cling to something that seems the most concrete.

But this is also an opportunity to think creatively. Without an obvious answer, were forced to get creative in combining and creating a new language to understand ourselves and others. When somebody brings up a diagnosis, I hope to work through it, talk it through, and get to a place where we create a new language for that person. It should make sense to them or help them explain something theyve been wondering about, providing a way forward.

Karter: I did this work with Dr. Cosgrove. In 2016, the United States Preventive Services Task Force recommended screening everybody above 13 for major depressive disorder, especially in the postpartum period for women. This sounds pretty benignits one more piece of paper to fill out. Its a great thing. You catch people who would have fallen through the cracks.

Unfortunately, thats not what the evidence suggested. We found Canada and the UK had decided not to implement mandated screening for depression because there wasnt sufficient evidence that it would improve care. But the US decided to do it. So we reviewed the available research for screening collaboration with Dr. Brett Thombs, an expert on this topic. We found, as others had seen, that there wasnt evidence that implementing these screenings would lead to improved patient outcomes.

And there are risks. Other countries might have made a different decision because, with government healthcare, youre cautious about wasting resources. You pay more attention to the false positive problem and identify people at risk who arent actually at risk. In the US, the system is quite different.

So, one risk is that we treat people who otherwise wouldnt need treatment, which diverts resources away from others. Also, through diagnostic overshadowing, it distracts from other things that might be going on. We are not denying that people, especially in the postpartum period, struggle or have depressive symptoms.

We didnt find evidence that a questionnaire will lead to more support than having a skillful clinician check up on a struggling patient. In fact, a screening instrument makes it less likely that a clinician will have that conversation in a human way because it has been outsourced to the piece of paper which makes the decision for you.

It provides concreteness that isnt always justified. If somebody scores above the threshold on a PHQ-9, which was developed by Pfizer and has a high false positive rate, were likely to think, this person has depression, and this is what we do for depression. If we have a clinical interview with somebody and they tell us how theyre struggling, not feeling how they thought they would after birth, not getting social support, nervous about their relationship, having trouble finding foodthen that points us to other solutions that might be more supportive. Screening lets the system off the hook.

We wanted to attend to womens distress in a way that allowed for a broader conceptualization of what might be happening to them and provided a broader menu of support.

Karter: A number of studies find that the groups screened for the mental disorder have worse outcomes than the control group. That raises the question of the Nocebo Effect. Is it helpful or harmful to think about ourselves in terms of I might have a mental health problem?

Karter: Theres the movement for Global Mental Health and then the emerging movement for a global human rights-based approach to mental health. This one has a different identity category, Psychosocial Disability, with different assumptions about mental distress. I was curious about how people under this identity or advocating under it thought differently about what it meant to have mental distress or madness and how people with lived experience participated in research, policy, and practice in the movement for Global Mental Health.

The movement for Global Mental Health was a call to scale up services for mental disorders worldwide, especially in the low- and middle-income countries or Global South. It has been criticized widely for assuming that we can take the conceptual, diagnostic, and treatment approaches to mental health from the West and apply them in a top-down way in the Global South. This is without any critical reflexive analysis about what works and what doesnt, about how we think about mental health here in the Westlike our outcomes are wonderful!

That was being critiqued by service users. The consumer/survivor/ex-patient body of literature is remarkable and often ignored by mainstream psychology and psychiatry, but thats slowly changing. Because of the move towards psychosocial disability, therere now legal frameworks on the rights of people with disabilities. Rights-based organizations demand that people with lived experience be part of the process of developing research, practice, and policy in the psy-disciplines.

Suddenly, because of the Nothing About Us Without Us pressure, the movement for Global Mental Health was pressured to include people with lived experience. My participants were leaders in different psychosocial disability movements, had been involved in activism, and were from other countries and cultures. The majority identified at some point as having what was labeled a psychotic experience by mental health professionals, but they had come to make sense of it differently over time.

People journeyed through different models of mental health and initially thought about themselves through a biomedical approach which they found initially sometimes helpful. It connected them to resources and provided a narrative for making sense of their experience, but over time felt like it was missing things or was actively harmful. In addition, it justified having their rights restrictedthey suffered inhumane treatment. Over time they became reformers of the field and became aware of the UNs Convention on the Rights of Persons with Disabilities.

The psychosocial model suggests that disability emerges in an interaction between a person and their environment. The environment does not make accommodations, and that lack of ability to make room for that person in the world leads to a disability. This changed the frame and led them to push for more social determinants approaches to mental health.

Also, participants talked about having an a-ha moment where they started to think of themselves less as somebody who is suffering a deficit, but instead as somebody who was a rights holderthat I am a person who has rights that need to be respected, who can make certain demands, and speak about my needs, which I found empowering.

Karter: Participants spoke about being stuck between a rock and a hard place where they would be invited to participate in a project. Sometimes theyd be invited from the beginning, which is whats recommended, that you include people in even the brainstorming and study design process. Sometimes theyd be called at the end to rubber stamp a problematic policy.

They felt they were being asked to provide their testimony or rubber stamp a policy so that the researchers or the policymakers could say they had lived experience input. They were aware if they turned that down, if they said, no, this is not CRPD compliant, or Im not going to participate in this process, that some researchers and policymakers would shop around for somebody who would rubber stamp it. Theres a diversity of perspectives among people with lived experience. You could shop around and find somebody who was more friendly to forced treatment and still claim to have lived experience input.

Karter: Participants in the Global South were aware that most of the researchers they interacted with in the movement for Global Mental Health were western-based researchers with institutional power, often White, from the US, Canada, the UK. They saw this as an extension of colonialismthe idea that we, the West, know the answers, the objective truth, and were going to advance the rest of the world and force them to use what we use.

One of my participants brilliantly said this is the grandchild of the colonialism of 500 years ago. She explained, In Latin America, weve had dictatorship after dictatorship, extractivism, free trade agreements where workers are paid under minimum wage, have no rights, they count the times they go to the bathroom. She said that the movement for Global Mental Health operates from the same logic as these other policies brought to the Global South by the Global North: Its a newer manifestation of that White supremacism, egocentric view.

She made an explicit link between the Global North extraction of resources through slavery, mining, ongoing exploitation of labor in her country, and the way the movement for global mental health was treating her (a person with lived experience)coming to mine data from her to pursue their donor funding and support their academic careers on her back.

She told the story of a psychologist who opened up a peer support group that they led and charged money for people to enter. This was infuriating, a travesty for her. It was a sort of perversion of her goals, of what she was trying to offer the community. This co-option is doing the same thing that people with lived experience are doing, which is offering peer support or group psychotherapy, but doing it from a Western researchers perspectivecharging money to get in and spreading their own narratives about psychosis to the groupchanging how safe people feel to explore different explanations.

Karter: There are also many possibilities right now because there are so many shifting narratives around mental health. There are some big cracks that the public is becoming more aware ofas in the narrow chemical imbalance theory and the DSM.

But as narratives shift, the forces and systems were operating within are trying to take advantagefor example, the right-wing authoritarian pickup of the chemical imbalance theory. Critics have pointed out that the chemical imbalance theory served neoliberalism and the right-wing political agenda because it depoliticized stress. Now that were seeing the serotonin hypothesis fall away, the right will try to use it as justification for defunding mental health treatments. As were questioning these narratives, they are going to be used to justify existing injustices.

Karter: The field of psychotherapy is under threat by the neoliberal culture that wants to turn it into an AI chatbota set of flowchart responses that will lead to a corrective thought. Whats fundamentally countercultural is also whats healing about psychotherapy, and thats the experience of being a version of yourself that can come forward because of another person. Thats the process of psychotherapy for me.

Its hard even to articulate this because our language is built in a culture that thinks about people as individual beings. But in therapy, thoughts, feelings, or embodied sensations emerge in an inter-subjective space because the other person is contacting something within themselves thats powerful that you also feel. Theyre also reaching that because of something that youre able to put into the room. So you get to experience yourself as a relational and open being over time. So if a good psychotherapy process is allowed to unfold, you get to be a different kind of self that our culture keeps telling us we cant be.

Karter: Its seductive because its challenging to get to the edge of what you can be certain about yourself and step over it because were under pressure from others to be consistent. It requires a lot of energy and vulnerabilityto be open to being a different version of yourself.

Karter: I think we need different types of stories. I love finding a good piece of literature that captures a different way of being a selfseeing people who carry multiple selves with them or have their ancestors voices in their heads. Hopefully, these stories will help us think about ourselves differently, with the ultimate goal of not just feeling better but of being the kind of subject that is unruly and ungovernable.

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Exploring the Fault Lines in Mental Health Discourse: An Interview with Psychologist Justin Karter - Mad in America