Written by Philippa Lund Frederiksen, psychologist, & Mads Bruun Pedersen, psychology student.

This article was originally released in the danish media POV International and as such it has its footing in the context of the current and growing psychiatry-debate which has become prominent in Denmark in later years. However, it is our belief that this debate is both applicable and relevant to many other countries as well as the UK. The mental health crisis is unfortunately in no way a localised, Scandinavian phenomenon – and neither are the outdated systems with which we attempt to handle it. The psychiatric monopoly on mental health treatment has become ubiquitous in western society;  and thus we believe that though this article is written in the context of current issues in Denmark that it nonetheless could apply much more broadly to any state which ostensibly aims to provide security and mental health support for all its citizens. 

Intro:

The psychiatric system is largely the only state financed system in Denmark which has the mental wellbeing of people as its primary purpose. Thus, psychiatry is the only system in which a citizen can partake in if they wish to enjoy the benefits of governmentally subsidized treatment. This results in a systemic bottleneck where people are being herded into one particular framework for understanding mental distress – that being the psychiatric model which often relies on biomedical explanations for so-called mental illness and, as a logical extension of this view, often resorts to psychopharmacological interventions aimed at treating supposed biological imbalances and deviations. Discussing the flaws of this approach is not the aim of this article (this has been done many times elsewhere). Instead, we argue that it is problematic to let the psychiatric system be the only state financed mental health system having to shoulder the entire responsibility for the mental health of all citizens. As we will argue in this article, it is our claim that this monopoly runs the risk of leaving many suffering people alone with their suffering.

Although many people share accounts of having experienced improvements in their lives after receiving psychiatric treatment, we should not remain blind to the fact that there are also people who either don’t get better-, are harmed from-, or simply do not want psychiatric treatment. We pose the simple question: What do we actually have to offer these groups of people? We argue that the current system continually and unequivocally fails them. 

It is well documented that the efficacy of mental health treatment is closely tied to the degree that a particular treatment makes sense to a client as well as them having their treatment preferences accommodated. It thus appears rather meaningless that we currently only offer people one singular framework for understanding themselves and their mental health – i.e the biomedically based model of psychiatry.

We therefore aim to explore how systemic alternatives to the psychiatric system might look if we were to put the individual’s rights and lived context at the epicenter of any and all treatment.

For this purpose, we suggest that we bracket psychiatry for a moment to allow space for a new discourse; one which is centered around the building and testing of valid alternatives that could embrace those people who slip through the cracks of modern day psychiatry.

Suspending psychiatry/psychiatry in brackets

The Danish psychiatric system is built upon a biomedical foundation. Mental suffering is by and large understood as illness or disturbance, often accompanied by claims of biological pathology. Despite the fact that psychiatry formally works from a bio-psycho-social model, where social and biological factors are regarded as interacting, it is not our experience that this is reflected in the reality of psychiatric practice. Often, psychopharmacological interventions take precedence, whereby other forms of intervention take a backseat. In 2023, the WHO and the UN published new guidelines for the handling of mental health. Herein, they “call for a significant shift from biomedical approaches towards a support paradigm that promotes personhood, autonomy, and community inclusion.” The WHO and the UN point out that the biomedical paradigm keeps the mentally suffering in outdated and reductionist understandings of their own suffering. It creates and maintains a power imbalance, in which marginalized, traumatized, and otherwise crisis-stricken persons are regarded as dangerous or untrustworthy. This mistrust of the citizen can thereby justify violations of the citizen’s rights. This happens, for example, through forced treatment and other coercive measures. In result, there are many people who do not benefit from psychiatric treatment and the accompanying conceptual framework. 

We have to face the consequences of not accommodating the people that are currently being failed by the psychiatric system. One consequence of this is that psychologists who specifically work non-pathologically are sought out by people who have been harmed by psychiatric treatment. We encounter people daily who have returned suicidal after psychiatric treatment, wherein they have been denied their autonomy, self-understanding, and processes of meaning-making. We see numerous clients who have experienced that their reactions to suffering have been interpreted as pathological, and documented as such in their medical records, which subsequently have been used against them. Thus, the interpretations of the mental suffering done by psychiatric workers end up being used as justification for coercion and neglect of people experiencing mental distress. Many post-psychiatric therapeutic trajectories could have been avoided if these people had been offered alternatives to psychiatric treatment in the first place.

We argue that the time has passed for the idea that psychiatry can or should stand alone as a mental health system. By working toward the establishment and testing of alternative systems, we can better ensure equal access to qualified support for all people. However such a systemic alternative may come to look, it should be based upon a set of core principles that safeguard every person’s right to autonomy, inclusion, and dignity. We will now present a proposal for how such an alternative could take shape in the mental health care of the future. The aim is to show that an alternative system is not a utopia, but rather a realistic and achievable addition to any welfare state . What follows is one such proposal.

Welcome to the future Danish Mental Health system (DMH)

At DMH, we safeguard citizens’ human rights, and therefore all staff are trained in human rights as well as the Convention on the Rights of Persons with Disabilities. Every staff member must be certified in WHO’s QualityRights program, ensuring a solid understanding of human rights and the practical tools needed to protect and uphold them. The program also helps to balance out power dynamics that can lead to coercion, violence, and degrading treatment. DMH is built on close interaction with the citizen’s broader life context. It is grounded in investments and a restructuring of schools, childcare institutions, and our social safety net as a whole. This shift was not about efficiency, but about creating a sustainable welfare model where citizens and their immediate context form the central focus.

Autonomy
Citizen autonomy is a top priority at the DMH. For this reason, the large psychiatric wards have been closed in favor of smaller, local residences and clinics with free entry and exit. Here, individuals in psychological crisis can receive immediate support without a referral from their general practitioner. The clinics are guided by the person’s own wishes and needs. If the person is unable to express these, staff follow their advance planning document that lays out preferences and boundaries for crisis management. If a person’s consent regarding crisis management is breached, they are automatically offered trauma care, and the violation triggers a formal complaints process. The clinics work in a context-oriented way, tailoring support to the individual’s life circumstances. A wide range of services is available, including outpatient therapy, trauma care, hobby and community activities, legal and financial counseling, as well as somatic health care. Psychopharmaceuticals may be offered as temporary relief, but only with true informed consent that explains effects, side effects, and tapering options. This is not only ethically sound, but also increases the likelihood that the individual will experience improvement as a result of treatment.

Dignity

A person’s dignity is preserved by involving current and former users of DMH in the development and maintenance of their services. The clinics serve as hubs for various forms of support, including social support groups in which the person participates on an equal footing with others. These support groups provide local mutual care, giving all participants the opportunity to be part of a meaningful community. This offers the person stable and attentive developmental frameworks, without pacifying them in their own path to recovery. Additionally, the clinics are open, allowing the person to maintain work or home life if they wish. There is no bureaucratic barrier between the person and the help they need, so referrals are not required. The clinics are also overseen by independent oversight bodies. 

Inclusion
As the clinics are locally operated, they are also designed with an understanding of local culture. In most cases, this means that a person can speak with support staff in their native language and receive help that is sensitive to diverse understandings of suffering, including spiritual perspectives such as djinns and ancestral spirits, psychiatric models, social and societal explanations, and other culturally specific approaches. This ensures that support is experienced as meaningful and respectful, regardless of individual background.

Inclusion requires that support be accessible to everyone, regardless of economic situation, gender, sexuality, ethnicity, religion, disability, or place of residence. Therefore, services are free, easily accessible, and distributed proportionally across the country, complemented by outreach teams. Finally, combating stigma and discrimination is central. DMH actively works to change society’s perceptions of people in psychological crisis, shifting from viewing them as ill or dangerous to recognizing them as people with the same rights and opportunities as everyone else.

To illustrate how the principles of autonomy, dignity, and inclusion can be applied in practice, three examples of people in different life situations are presented. These examples demonstrate how DMH can tailor support to an individual’s needs and life context while respecting the person’s rights. These cases are not templates, but rather reference points for how support can be provided.

1 – The Child in Their Context
Sophie is 11 years old. She has always enjoyed school, but suddenly begins experiencing stomach aches every morning. She struggles to focus on her schoolwork and eventually refuses to attend school. The teacher is concerned, and the family feels powerless. At DMH, Sophie and her parents can visit their local clinic directly, without waiting time or a referral. They are met by a multidisciplinary team that engages in dialogue with Sophie, her family, and her school to understand the root of her distress. Is there something in the classroom dynamics that is causing insecurity? Does Sophie need a calmer environment or more support to establish her role in the classroom? Does the school’s teaching style not match Sophie’s temperament, or are there issues at home? Flexible solutions are offered, which may include additional support, interventions at school, access to extracurricular communities, and/or counseling for Sophie and her family.

2 – Hearing Voices in a Life Perspective
Mehdi is 27 years old. He has not slept for days as he is hearing voices telling him to harm himself. The voices are frightening and violent, and he feels like they are taking over his life. His family contacts their local DMH clinic because he is shouting and appears aggressive. At DMH, Mehdi is received at an open clinic with no locked doors or coercion. Staff sit with him and reassure him that he is safe. Mehdi is supported in making sense of his current situation and is offered temporary accommodation where he can sleep and receive support around the clock. In addition, Mehdi chooses to have sessions with a trauma therapist and participates in meetings with a peer support group from the hearing voices network. In the group he meets others who have had similar experiences. He also receives assistance with finances and housing, ensuring that practical concerns do not add further stress.

3 – Alternatives to Forensic Psychiatry
Aida is 35 years old and is in pre-trial detention following a violent incident related to a relapse in her substance use. At DMH, she is offered a specialized program that focuses both on safety and on creating a pathway back into society. Aida and her close network want strong support around her during this period, so they meet with a team of clinicians, social workers, and peers from the community. She seeks help managing her substance use and has opted for trauma-informed addiction care as well as legal support. Although DMH is based on autonomy and freedom, it takes into account persons whose psychological crises have led to legal offenses. For this reason, the residence where Aida is detained resembles a communal living environment rather than a psychiatric ward. There, she participates in cooking, cleaning, and community activities, gradually rebuilding trust in herself and others. The court can still impose requirements, but all interventions are based on consent, with reintegration rather than confinement as the primary goal.

What these examples have in common is that the solutions possible within a context-based, multidisciplinary system are difficult, if not impossible, to achieve within our current psychiatric system.

Conclusion
This is only one example of what an alternative system could look like. In practice, such a paradigm shift does not happen overnight. It requires both time and financial resources. But most importantly, it requires the willingness to take action. Establishing and testing systemic alternatives to psychiatry is not only feasible and practical, but also an ethical necessity for a welfare state like the one we have in Denmark. Moreover, it is unlikely to be more costly than our current society, where record numbers of young people are assessed as permanently disabled, increasingly attributed to mental health issues. It is, after all, extremely costly to skimp on people’s mental health. To quote Deficit by Emma Holten: “Economic surplus can be a smokescreen that conceals human deficit” (pp. 228). If we want to deserve the label of a “welfare society,” we have no choice but to confront that smokescreen.