Overcoming Factionalism in Serious Mental Illness Policy Making: A Counter-Perspective

Who is involved in policy decision making, and with what degree of influence, is an important topic to consider. However, after reading the article by Smith and Sisti on how to overcome factionalism in policy making for people with serious mental illness (1), we have several interlinked concerns. First, by focusing on “factionalism” as a major driver of failures to adequately address the problem of serious mental illness in the United States, the authors ignore the historical antecedents that have generated profound ethical, epistemic, and policy divides. Moreover, by uncritically invoking evidence-based research (and policy) as a seemingly uncontroversial point of departure for democratic deliberation, they present their concern as one open to democratically valued differences while deploying arguments that first subsume and then expel the voices of those who, through a priori determination, seem to be deemed unreasonable. Finally, their reliance on deliberative democracy as an effective means by which to overcome this factionalism, although superficially appealing, effectively sidesteps issues of power and authority around who decides which evidence matters and who determines which voices are deemed reasonable. This approach effectively avoids acknowledging fundamental intersections of mental health policy with structural and systemic racism, classism, heterosexism, and broader forms of ableism. By coupling the “problem of factionalism” with an appeal to deliberative democracy, the authors explicitly signal the political nature of psychiatric discourse and mental health policy while implicitly reinforcing the very politically charged conflicts they seek to resolve by appealing to a seemingly uncomplicated evidence base.

We unpack these concerns herein. We argue that Smith and Sisti’s invocation of factionalism and their reliance on deliberative democracy as a means for overcoming it, although superficially appealing, mask the historical antecedents that have generated profound ethical, epistemic, and policy divides and are more likely to continue to perpetuate power hierarchies in the context of serious mental illness than they are to move us collaboratively through them.

Deliberative Democracy: “Rationality,” “Equity,” and Evidence-Based Policy

Although the typical researcher or clinician working in mental health services may not be familiar with formal writings on deliberative democracy, within political theory, deliberative democracy is a controversial “ideal” political approach with limited empirical backing (2). (See also references A1–A11 in the online supplement to this commentary.) Specifically, political theorists of various orientations have critiqued deliberative democracy for the way in which it ties political legitimacy to rationality (3–5) (see also references A7–A9 in the online supplement) and neglects the exclusionary and paternalistic operations that are historically and structurally ensconced in such deliberative approaches (A5, A10, and A12 in the online supplement).

Without offering a comprehensive review of these criticisms, we quote Cheryl Hall (4), who eloquently states,

Political philosopher Seyla Benhabib adds, “Institutions of the polity (under deliberative democratic theory) are so arranged that what is considered in the common interest of all results from processes of collective deliberation conducted rationally and fairly between free and equal individuals” (our emphasis) (6). Here, in addition to deliberative democracy’s problematic fixation on rationality, invocation of the “free and equal individual” should give us pause. As anyone versed in the history and politics of psychiatry in the United States is likely aware, service recipients, particularly those most deeply disenfranchised, rarely (if ever) enter the policy arena as “free and equal” as those who have traditionally held power in these spaces. And the historical, structural, and political inequities in play do not simply disappear at the door when an otherwise disenfranchised service user steps into a meeting room (A5, A8, and A10 in the online supplement).

Inequities hold not only at the level of the individual service user, but also at the level of discourse on research, evidence-based practice, and policy. As health services researcher Trisha Greenhalgh and colleagues have argued in a series of papers, patient and caregiver experiences and values have been systematically marginalized in evidence-based medicine and subordinated within hierarchies of evidence (7) (A13–A23 in the online supplement). Systematic areas of bias include the general subordination of qualitative and more overtly user-directed evidence, the failure to prioritize and study user-led interventions (such as peer-run crisis respites in the United States), and the dependence of clinical trials on help-seeking individuals who overwhelmingly do not represent the typical public-sector mental health patient (i.e., individuals who disengage from services, discontinue medications, or engage with services only in the context of emergencies or under court mandates) (see A13 in the online supplement). Overall, as thinkers as diverse as Michael Walzer (3) (and A2 in the online supplement), Iris Marion Young (5), and Chantel Mouffe (see A8–A10 in the online supplement) suggest, the equality of individuals—and the necessary regard for epistemic plurality—required for deliberative democratic practice is often more presumed than actual.

Deliberative Democracy: Factionalism, Power, and Voice

We next turn to the issue of deliberative fairness. As Smith and Sisti note, difference in voice is a vital part of political and democratic life, but it is worth remembering that when Madison penned Federalist 10 to address factionalism in government, his intent was to enlist a republican strategy as a countervailing force that would protect the interests of democracy against the democratic “mob.” It was a strategy meant to temper majority rule through an institutional structure that would give power to a governing elite (see reference A24 in the online supplement). We worry that such a committee would, similarly, function more as an elite advisory body than a democratizing one.

Some hint of how such exclusivity enters into a supposedly inclusionary democratic body is present in the authors’ explicit concerns about stakeholders, whom they describe as “unreasonable” or “antiexpertise” or as those who “only selectively read the evidence.” These concerns not only are a nod, however unintentional, to the trope that links “irrationality” to “madness” and “unreasonableness” to individuals with a history of significant psychiatric disability but also fail to acknowledge the substantive arguments and contrasting views that have in fact animated debates around many of the very issues that Smith and Sisti single out (see A9–A19 in the online supplement). The authors, for example, take up the example of opposition to addressing a putative shortage of inpatient beds as a seemingly obvious instance of the “selective use of incomplete evidence,” but they cite only a single electoral policy platform from the 2020 Bernie Sanders presidential campaign. They do not mention the substantive debate in Psychiatric Services in 2019 on precisely this topic and involving Bazelon Director of Policy, Jennifer Mathis, and Sisti (see references A25–A26 in the online supplement).

The authors’ oversimplification of a particularly fraught issue flattens a nuanced and multifaceted set of relationships and concerns. These concerns include overuse of involuntary psychiatric holds and hospitalizations, the contemporary reduction of hospitalization to “medication stabilization,” and the risk that the so-called inpatient bed crisis diverts attention from, and potentially operates as a political alibi for, the need for substantive policy reforms and efforts to meaningfully address underlying social and structural determinants of health. As Mathis argues in her debate with Sisti, policy discussions about bed shortages and the IMD (institution for mental disease) exclusion must also consider the indirect yet significant ramifications of such policies; for example, such discussions should take into account the role of the IMD exclusion as a legal and policy driver of federal shifts toward community-based services and should be cognizant of the risks posed by dismantling such a driver. These highlighted concerns beg the question of how a deliberative democratic process will legitimately overcome factionalism, whether there is an a priori constraint on which purported “factions” (or stakeholders) are invited to participate.

Conclusions

Ultimately, it is dogmatism, not factionalism, that must be overcome. The dogmatism that is of concern to us appears not only within disability rights and mental health advocacy but also in biomedical and clinical psychiatry and mainstream medical ethics. Pluralism is democratizing; top-down decisions about who can or cannot participate, and on what grounds, tend to instead support authoritarian regimes—when dogmatism is an issue, deliberation easily defaults to power.

Finally, although Smith and Sisti conclude that we must act now and not wait for slower, more distributive changes designed to address key sources of structural, political, and epistemic inequality, we underscore that we have no real choice but to act now, albeit slowly, methodically, and critically (4, 6) (A27–A30 in the online supplement). Equality and democratization will ultimately come not from a closed-door committee but from converging, distributive change, inclusive of a diverse range of stakeholders and perspectives—research, policy, practice, and critics—that compose the fields of mental health and social services.