Abstract

There is growing recognition that psychiatric consumer, survivor or ex-patient perspectives are not well-integrated into disability studies work and academic discourse more generally. While limited debate has focused on whether the preferred next step is an independent 'mad studies' discourse or a disability studies framework more inclusive of c/s/x voices, the broader consequences of this absence have been largely overlooked. The purpose of this review is to highlight three major consequences of the absence of c/s/x voices in US academics: The (1) relatively greater biomedicalization and (2) clinical professionalization of psychiatric disability compared with other forms of disability, and (3) barriers and obstacles to training and advancement in academia for doctoral students and faculty with psychiatric disabilities.

Introduction

Over the past decade, there has been growing recognition that the perspectives of individuals with psychiatric disabilities have not been well-integrated into academic discourse. This recognition has been prominent in disability studies (e.g. Donaldson & Prendergast, 2011; Sykes et al., 2007) and, in recent years, attention has been devoted to the question of whether c/s/x perspectives should be integrated into the disability studies framework or developed as a stand-alone discipline (Beresford, 2000; Coyle, 2012; Hewett, 2006; Lewis, 2009; Price; 2011; Reaume, 2006). 1 However, these discussions have also highlighted the fact that issues concerning psychiatric diversity/disorder have received significantly less theoretical and empirical attention within disability studies than topics related to physical and developmental disabilities and health. As Beresford (2000) notes, it is sometimes not even clear "whether or not madness, distress and psychiatric system survivors are part of the [disability rights] discussion" (p. 168) (cf Donaldson & Prendergast, 2011; Lester & Tritter, 2005; Mulvany, 2000; Prendergast, 2003; Sykes et al., 2007). Such an omission is particularly striking given the focus of recent disability studies research on other forms of diversity and intersectionality in the experience of disability, including that occasioned by race/ethnicity, gender and sexual orientation (Dyck, 1995; Erevelles & Minear, 2010; McRuer, 2008; Meyer, Schwartz & Frost, 2008; Sherry, 2004).

Many factors undoubtedly contribute to the underinclusion of 'mad' discourse within disability studies. As Lewis (2006) notes, the historical and sub-cultural trajectories of the consumer/survivor/ex-patient (c/s/x) and disability rights movements have diverged significantly, and individuals involved with both movements have at times accused each other of implicit ableism or saneism (Donaldson & Prendergast; 2011; McNamara, 1996; Wiener, Ribeiro & Warner, 2009). Additionally, with the exception of some Centers for Independent Living (CILs), for the most part both peer and professional services for mental health, on the one hand, and physical or developmental disabilities, on the other, have developed independently of one another, draw on different private and federal funding sources, and employ clinicians and providers with divergent training and disciplinary backgrounds (Mulvany, 2000; Pilgrim. Todhunter & Pearson, 1997). Mental health and disability activists are thus often faced with autonomous systems, infrastructures, and policy issues.

At a more academic level, psychiatric viewpoints have tended to play a more tenuous role within disability studies than perspectives from other social and behavioral sciences, and tensions have persisted over the tendency of psychiatrists and psychologists to view physical and developmental disabilities as abnormal, deficient or deviant (Asch, 1984; Barnes, 2003; Gleeson, 1997; Olkin & Pledger, 2003; Thorne & Paterson, 1998). Further, when psychiatric disability or "poor mental health" more generally is discussed in the context of disabilities, it is nearly always cited as a worst-case outcome of physical disability or ableism. This approach fails to distinguish psychological distress from psychological diversity (including experiences of voices, visions, and other extreme states that may be perceived as positive) and arguably further strengthens the framing of psychiatric disabilities/mental struggles as entirely negative outcomes of the ableist social environment, rather than equivalent instances of human variation and diversity.

In spite of these differences, there is also clearly overlap in many of the goals and values of the disability rights and c/s/x movements. Incontrovertibly, there is no single guiding ideology for all extant c/s/x or disability rights groups and advocates. Certain common themes, however, link c/s/x advocates, including strong critiques of involuntary inpatient and outpatient commitment, drug-centered or compliance-focused treatment programs, and reductionist biomedical and cognitivist models of "mental illness." The broader concerns that these issues raise are embraced across disability rights advocacy groups — for example, concerns surrounding the issue of involuntary treatment are consistent with the tenets of the independent living movement and its emphasis on freedom and self-determination (Deegan, 1992; Williams, 1983). Similarly, criticisms of biomedical and cognitivist models of mental illness are consistent with the repudiation of medical and moral models of disability in favor of broadly social models that acknowledge social, cultural and structural forces (Beresford, 2002, 2009a; Beresford, Nettle & Perring, 2010; Lester & Tritter, 2005; Mulvany, 2000) as well as the value of physical, mental and neurodiversity (Intervoice, n.d.,; Roberston, 2010; Roberston & Ne'eman, 2008).

Along these lines, several scholars have reviewed commonalities between the disability rights and c/s/x movements (for example, Beresford, 2000 or Lewis, 2006) and there is a small but growing literature concerned with applying disability studies frameworks to the study of mental health (Fabris, 2011; Ingram, 2007a, 2007b; Lester & Tritter, 2005; Mulvany, 2000; Price, 2011). This growing body of research highlights that (a) disability studies can clearly provide a forum for discussing issues concerning psychiatric disability or diversity, regardless of whether or not it should provide 'the' academic home for c/s/x perspectives; and (b) the non-biomedical academic exploration of c/s/x perspectives, particularly in the US, is in its infancy.

Our goal in this review is to highlight three reasons why c/s/x perspectives might be further developed in academic discourse by discussing the consequences of this underinclusion. These are: the relative lack of critical theoretical scholarship, exemplified by (1) the relatively greater biomedicalization and (2) clinical professionalization of discourse about psychiatric disabilities; and (3) negative impacts with respect to the training and support of students and juniors researchers with psychiatric disabilities. It is worth underscoring that these three impact areas are admittedly not symmetrical. While it is possible to draw on a variety of empirical sources concerning the biomedicalization of psychiatric disability, for example, relatively little work investigates the unique implications of clinicalization, particularly with respect to research and academic discourse about mental health. Likewise almost no empirical research has directly assessed the level of exclusion/inclusion or challenges of doctoral students and faculty with significant psychiatric disabilities 2 . This circumstance, of course, reinforces the central theme guiding this review — that further development of c/s/x perspectives in academic discourse is urgently needed.

Biomedicalization

It is first useful to compare responses to the increased scientific legitimacy of medical approaches to physical and mental health issues in the 20th century. The considerable advances in physical rehabilitation technologies made throughout the twentieth century to the present (Braddock & Parish, 2003; Longmore, 2003) have often been accompanied by increased expectations that medicine can "cure" poor health (Freund & McGuire, 1995). However, since the late 1970s, physical disability rights groups and advocates have emphatically and effectively questioned the medical field's practical limits. They have promoted an understanding that new technologies are not to be considered a silver bullet 'cure' for physical limitations, shifting attention to the prevention of illness rather than the restoration of normative health and holistic approaches to well-being that promote personal efficacy and stress management (Albrecht & Verbrugge, 2000; Braddock & Parish, 2003). These views are well-integrated in both the disability studies discourse and the fields from which disability studies derives (sociology, anthropology, etc.).

In contrast, the 20th century was largely marked by decreased confidence in psychosocial psychiatric services, in particular psychotherapy, as it increasingly became clear that early psychoanalytically-derived therapeutic approaches to treatment were often ineffective in improving mental health (Busfield, 1996; Dowdall, 1999; Horwitz, 2003). In addition, little consensus could be reached concerning what constitutes mental disorder and diagnostic systems varied dramatically between nations (Andreasen, 2007; Kendall et al., 1971). Responding to some of these concerns, psychiatric disease models that emerged in the 1950s (e.g., Lewis, 1953) and were further consolidated in the 70s paved the way for more uniform diagnostic criteria such as those provided by the non-psychoanalytically grounded DSM-III (American Psychiatric Association, 1980). Additionally, the emergence in the 1970s and 80s of new technologies that made it possible to study the brain for the first time (e.g., CT, MRI, and PET technologies) and accompanying psychopharmacological developments, swiftly shifted the focus among researchers and practitioners from psychological explanations of mental illness such as developmental contingencies and personality traits to biology (Castel, 1992; Cohen, 1993; Luhrmann, 2000; Rose, 1999, 2007). The biomedical perspective that has emerged is rooted in an understanding of mental illness as a brain disorder caused by genetic vulnerabilities, early childhood illness and adversity, or other traumas that significantly alter neural function (Read, 2005; Sharfstein, 2005, 2006). This perspective emphasizes that mental illnesses are medical illnesses akin to cancer or diabetes for which the front-line treatment should be drug therapy (Moncrieff, 2008; Schwartz & Corcoran, 2010; Rose, 2007).

Although this perspective has served to legitimize the field of psychiatry (Mechanic, 1978), it is not entirely without its critics, and social histories of mental health care often characterize the ascendancy of the biomedical model as therapeutically inefficient. For example, Grob (1966) observed that, "psychiatrists tended to engage in a vast holding operation by confining mentally ill patients until that distant day when specific cures for specific disease entities would become available" (p. 357). Many c/s/x advocates have been particularly vocal in their opposition to biomedical models of disability and distress and have emphasized the disconnect between their experiences and journeys of recovery and traditional biologically-based theories, treatment strategies and expectations (Coleman, 2008; Fabris, 2011; Morrison, 2005; Sweeney et al., 2009). In particular, the refusal of many US psychiatrists to recognize and implement empirically documented "medication minimalist" treatment approaches such as Soteria House, Finnish Open Dialogue and Voice Dialogue in favor of drug centered treatment (Aaltonen, Seikkula & Lehtinen, 2011; Calton et al., 2008; Corstens, Escher & Romme, 2008; Romme, Honig, Noorthoorn & Escher, 1992; Seikkula, Alakare & Aaltonen, 2011) have led many to question the political and financial motivations of prominent researchers and clinical leaders (Ban, 2006; Choudhry, Stelfox,& Detsky, 2002; Lexchin, 2012; Moncrieff, 2007, 2009; Moncrieff, Hopker & Thomas, 2005 ). 3

Nonetheless, since it has become the dominant paradigm for understanding psychiatric disability, the low degree of scientific confirmation of many psychiatric disorders (particularly compared to physical disorders) has not been well recognized publicly. Additionally, there is little appreciation for the social constructionist nature of diagnostic criteria within scientific discourse, which is evidenced by the lack of specificity and changes in specificity within diagnostic criteria. White (1970), for example, long ago demonstrated that between one-quarter and one-half of patients receiving ambulatory psychiatric care were not able to be diagnosed based upon existing criteria and such ambiguity persists. While there is persisting concern about the broadening of diagnostic criteria and public acceptance of sometimes alarmist research citing the growing number of people who have a psychiatric or neurodevelopmental disorder (as a result of this broadened criteria), these discussions rarely critically question either the etiology or ontology of disorder itself, especially for more serious diagnoses such as schizophrenia. Thus, while the forthcoming DSM-5 has been criticized for medicalizing "expectable" grief following bereavement (Kleinman, 2012, Lancet, 2012), debates over a proposed new diagnosis for "attenuated" (prodromal) psychosis have instead focused on issues of predictive power and the risks and benefits of labeling and potentially unnecessary antipsychotic treatment rather than the questionable pathological status of extreme and unusual but non-psychotic mental states (Corcoran, First & Cornblatt, 2010; Fusar-Poli & Yung, 2012; Shrivastava et al., 2011) .

The nature of the discourse among those opposed to mainstream psychiatry has also been influenced by the dominance of the biomedical perspective. This is evident in that science or biomedicine has become the driving point of confrontation between mainstream psychiatry and a significant number of critical consumer/survivor groups. As an illustration, even the critical U.S. c/s/x movement's most prominent line of critique tends to adopt what Brad Lewis (2009) calls a "critical realist" epistemology—an epistemology, that is, that targets mainstream psychiatry as an exemplar of "bad science" while nevertheless continuing to affirm the basic tenets of positivist or empiricist scientific discourse (rather than generating substantive alternative epistemologies).

Furthermore, the implications of a biomedical conceptual framework for those with psychiatric disabilities have not been thoroughly investigated. There is growing evidence that simplistic biological and genetic attributions of "mental illness," particularly of schizophrenia, have in fact led (contrary to early researchers' and family advocacy groups' predictions), to an exacerbation of public stigma (including greater perceived seriousness, permanence and dangerousness) (Pescosolido et al., 2010; Phelan, 2002; Schnittker, 2008; Schomerus et al., 2012). As an illustration, public opinion research suggests decreased interest, compared to 50 years ago, in marrying someone with a serious mental illness because of possible genetic causes (Pescosolido et al., 2010). In addition, exploratory qualitative research among individuals with depression suggests a mixed picture even for this ostensibly less-stigmatized disability: although it may be common for depressed individuals to adopt a biomedical model, and even use this model to mitigate self-blame, "unintended" negative consequences also follow, including the objectification and somatization of the "illness," and the "shifting of ownership" and "responsibility for managing" the problem away from the individual, with a consequent disinvestment in self-directed behavioral change (Schreiber & Hartrick, 2002, p. 99-100).

Our primary purpose in rehearsing the current state of affairs with respect to biomedicalization is to underscore the extent to which the absence of an academic and empirical discourse guided by c/s/x experiences has allowed a strongly pathologizing approach to and conceptualization of "mental illness" to proceed largely uncontested within academia (and, hence, given the power and status of academic discourse—in the eyes of the general public). We now consider the implications of clinicalization in greater detail.

Greater Professionalization/Clinicalization

A second key consequence of the absence of an academic branch of the c/s/x movement can be located in the greater professionalization and clinicalization of psychiatric disability and the absence of more substantively cross- or transdisciplinary work. By professionalization and clinicalization, as distinguished from medicalization, we mean to describe the process whereby the power to generate knowledge about particular phenomena is allotted not just to credentialed academics, but academics that have specifically been trained to "treat" individual abnormality or pathology. 4 While disability studies researchers herald from a wide variety of clinical and non-clinical disciplinary homes (including sociology, anthropology, English, communication, public health and education, as well as occupational and physical therapy and medicine), mental health research in the US remains almost wholly dominated by clinically trained investigators.

Consequently, while much work in disability studies celebrates and explores such themes as disability culture, disability history, disability and the arts, disability identity and disability theory, the literature on psychiatric disability tends to revolve around clinical treatment and rehabilitation. Even those non-clinically oriented US social science texts that address broader sociopolitical issues (e.g. Coleman, 2008; Estroff, 1981, 1993; Luhrmann, 2007; Morrison, 2005) nevertheless tend to ultimately focus on clinical sociopolitics as opposed to, for example, explorations of mad culture5 This trend arguably also extends to work on consumer-run organizations and mutual support groups, which tend to be investigated in terms of their impact on clinically-relevant outcomes rather than, for example, their effects on identity and spiritual expression or their contribution to the development of shared political and (sub-)cultural narratives (Brown & Wituk, 2010).

Another consequence of clinicalization lies in the instantiation and reinforcement of the belief that only individuals with highly-specialized training can help, support or understand individuals with psychiatric disabilities. Thus a student experiencing a first psychotic break may find herself suddenly abandoned by friends and colleagues (who have absorbed the cultural message that they should simply defer to professionals) precisely when she needs them most. Several reviews of the rehabilitation literature (e.g., Anthony, 1993; Young & Ensing, 2010) suggest that this orientation may also be problematic to the extent that it supports rehabilitation models that are inconsistent with the actual experiences or desires of people with psychiatric disabilities. For example, qualitative work among people with psychiatric disabilities emphasizes the importance of self-care, which Young and Ensing (2010) find is largely absent from the recovery literature, perhaps because, as they note, "self-care is simply not perceived as very interesting or informative" from a clinical standpoint (p. 24).

This orientation may also undermine more emic or indigenous forms of self-understanding inasmuch as it encourages (or even requires) patients to embrace the language of clinical diagnosis and various institutionally proscribed semantic delimitations of psychiatric symptomatology in order to speak to clinicians and/or obtain culturally appropriate "support". As Rose (2001) notes, this clinical or therapeutic discourse is inherently positive in the sense that it produces new possibilities of experience and selfhood, but possibilities whose unintended consequences may prove to be significantly damaging. A patient, for example, might be taught to distinguish between "normal" and "delusional" thoughts—the former properly hers, the latter the consequence of cognitive or neural dysfuntion—potentially leading to the experiential dis-integration of the otherwise assumed connection between agency and "her" conscious mental processes. While clinical control of diagnostic language may not be wholly negative or destructive, socioethnographic work amply documents the dangers of "engulfment" in a clinically framed 'chronic patient' role or identity (Estroff, 1989, 1993; Link, 1982, 1987; Schur, 1971).

Moreover, there is little acknowledgment in the mainstream clinical rehabilitation literature that the relationship between clinicians and patients is also a relationship almost irreducibly marked by asymmetrical power relations (Rose, 1996). Clinicalization, that is, reinforces not only the belief that only sanctioned clinicians can understand and attend to psychiatric disability but also that this assistance can only be accomplished through a very specific, and in most cases intrinsically hierarchical, relationship. On the one hand, the clinician—whether biomedical, behaviorist or psychodynamic in orientation—remains neutral, objective, and aloof, while the patient "confesses" his or her emotional (subjective, raw, naive) problems (cf Butchart, 1997; Foucault, 1978; Hook, 2007). Through processes of guided subjectivization—the patient's identification both as the subject that speaks and the (psychopathological) subject of speech—his or her self-experience is thus brought in line with the "norms of psychological expertise" (Rose, 1996, p. 96). Both quantitative and qualitative research in the clinical disciplines makes this relationship even more explicit: the consenting research subject at once symbolically concedes "understanding" of his or her disorder to the academic researcher while at the same time reifying his or her position as an informant or provider of data that will only become 'externally valid 'once it has been combined with dozens of other narratives, reports or data points and 'transformed' by expert clinical scientists (Rose, 2009; Turner & Beresford, 2005).

The authority of the clinician has been further naturalized in both clinical practice and the psychiatric research literature through the elaboration of the construct of "lack of insight" or anosognosia (Amador & David, 1998). In this discourse, mere disagreement with a psychiatric label and/or the legitimacy of a past or current hospitalization is often recast as a neuropsychiatric deficit or further sign of underlying psychopathology. An example of this can be found in the Beck Cognitive Insight Scale (Beck et al., 2004), which counts disagreement with the statement "other people can understand the cause of my unusual experiences better than I can" as an example of a deficit of "insight." In order to prove his or her mental health, then, patients must learn to accept the clinicians' semantic, diagnostic, and psychological authority.

To the extent that scholarship on psychiatric disability continues to be controlled by researchers whose expertise is defined in large part by virtue of their neutral and objective second-hand observational knowledge and explicitly clinical expertise, it is not difficult to appreciate some of the barriers to the inclusion of either psychiatrically disabled academics or academic or "scientific" perspectives that are explicitly informed by first-person experiences and narratives. To some extent, that is, the very premises of clinical expertise are uncomfortably challenged by the potential counter-authority of direct (lived) experience.

In disability studies, conversely, the importance of first-person perspectives, as well as the integration of disability with other aspects of identity, including academic identity, is well-accepted. Indeed, disability studies has been characterized as a place from where "crips strike back" (Davis, 1999). As an illustration, Zola's (e.g., 1981, 1982) often autobiographical and cross-disciplinary writings revolutionized our understanding of the sociopolitical and personal aspects of the lived experience of physical disability. However, the equivalent to this type of work in American psychiatric disability research is largely absent; what is more, the prevailing research environment, as we explore in more depth below, may in fact actively inhibit the emergence of such scholarship.

Consumer/Survivor Researcher Academic Climate

Ultimately, the greater biomedicalization and clinicalization of psychiatric disability/disorder reviewed above has resulted in an academic environment that many cite as inhospitable to scholars with psychiatric disabilities (Jamison, 2010; Jones et al., in press; Karp, 2002). Evidence indicates that the academic environment is problematic throughout the typical academic career trajectory, from graduate training through tenure. While part of this inhospitability may stem from a general discomfort with disease and disability of all types (Goodwin & Morgan, 2012), much empirical research documents the high prevalence of profoundly negative and yet widely socially accepted stereotypes regarding individuals with significant psychiatric disabilities (Corrigan, Markowitz & Watson, 2004; Pescosolido et al., 2010; Schomerus et al., 2012). Hinshaw (2008) explores some of the reasons why such stigma may actually be particularly pronounced within clinical mental health disciplines, leading to a culture of silence and non-disclosure. As Price (2011) and Reiss (2010) discuss, the consequences of stereotypes centered around dangerousness and unpredictability have recently become particularly salient in the wake of a series of widely-publicized school shootings as well as more general acts of violence in which students or faculty with some form of psychiatric disability were implicated. These include the Virginia Tech, NIU, Jared Loughner and Aurora shootings, and the recent murder of a graduate student by a faculty member with a diagnosis of bipolar disorder at the University of Idaho. While legitimately motivated by concerns for both student safety and legal liability, academic institutions, as Reiss (2010) notes, have responded to the danger posed by 'mentally disordered' academic community members through an array of initiatives designed to screen, redirect and/or monitor "risky" individuals. This discourse of risk, in turn, may further legitimize the public's fear of mental illness, and strengthen the objectification of students and faculty with psychiatric diagnoses.

In addition to such general psychiatric stereotypes, stereotypes more explicitly directed at the mental or cognitive (in)capacity of academics with psychiatric disabilities may be particularly destructive. Price (2011), for instance, discusses a myriad of ways in which individuals with mental disabilities—disabilities that affect intellectual energy and socio-academic relationships in addition to intellectual function—are specifically stigmatized in the context of academic work. Although no existing empirical work has directly assayed the prevalence of academic stereotypes among faculty and students within doctoral training programs, a study including both undergraduate and graduate student with psychiatric disabilities found that among those who sought academic accommodations, a full 56% reported feelings of embarrassment or shame, the same number (56%) reported a fear of being stigmatized by faculty due to their requests, and almost half (42%) reported actual negative experiences with accommodations such as faculty member's unwillingness to cooperate (Salzer, Wick & Rogers, 2008). In addition to the negative consequences of academic stigma among members of the university community, recent research has documented the damaging effects of psychiatric-specific stereotype threat on academic performance: college students subtly primed with their psychiatric status, that is, were found to significantly underperform un-primed controls on academic tests (Quinn, Kahng & Crocker, 2011). These academic forms of stigma are perhaps most likely to negatively impact doctoral students, pre-tenured and adjunct faculty, whose success depends so strongly on successfully projecting an image of academic confidence and competence.

In the context of higher education, stigma and stereotyping may also constitute a threat to perceptions of the quality of individuals' research. Thus even if an aspiring academic with a psychiatric disability makes it through a doctoral program and obtains a university appointment, his or her research may be suspect due to assumptions of additional bias, subjectivity, personal overinvolvement, weak boundaries, or a general lack of rigor (Rose, 2003, 2008, 2009; Saks, 2007, 2009; Sweeney et al., 2009). Arguably, such stereotypes, as suggested above, follow from the medicalization and clinicalization of mental health discourse to the extent that these discourses tend to privilege neutrality, emotional distance, and second or third-hand observation. Further, in fields in which explicit activist scholarship is rare, researchers' commitment to the advocacy community runs the risk of being viewed as proof of such academics' "compromised" science.

In addition to concerns about the social consequences of requesting accommodations, there is also concern surrounding the fact that accommodations specific to psychiatric issues are often inadequate, particularly among graduate students and faculty, for a variety of both practical and legal reasons (Jones, Harrison, Aguiar & Munro, in press). Thus, although students with psychiatric disabilities now represent the single largest disability sub-group receiving campus disability services in the US (Government Accountability Office, 2009), many disability services offices are far better equipped to deal with cognitive and physical disabilities than psychiatric issues (Collins, 2000). In addition to these immediate institutional barriers, legal research suggests that individuals with psychiatric disabilities are often significantly less well protected by key legislation such as the ADA compared to other disability groups, particularly in the context of education and employment (Stefan 2000, 2001; Swanson et al., 2006). In a comparative paper, Sahlin (2009) even more specifically unpacks many of the difficulties involved in obtaining faculty accommodations for psychosocial impairment in the US, given the often excessive legal deference granted academic institutions regarding determinations of "unfair advantage," "undue [institutional] burden" and the "essential functions" of academic employment.

As an illustration of several of these issues, Saks (2007), in her autobiography about her experiences completing graduate work after being diagnosed with schizophrenia, details the lack of accommodations offered by the university where she studied and open discomfort exhibited by faculty whenever she acknowledged symptoms (exemplified in a tendency to simply suggest she go directly to a mental hospital). As a consequence, and to avoid being viewed as incompetent, she overcompensated in her graduate work to such an extent that her thesis was deemed by her examiners to be of a quality equal to what is typically expected in a doctoral dissertation —also notable is that it was completed while, unbeknownst to others, she was experiencing auditory hallucinations so severe they led to her hospitalization (Saks 2007).

Inadequate accommodations and stigma also pose a threat to many faculty members with psychiatric disabilities, as other personal histories demonstrate (Jamison, 2010; Karp, 2002). Jamison (2010), for example, highlights the vulnerability of junior faculty who choose not to disclose a psychiatric disability in her depiction of a chancellor's garden party she attended in the midst of a manic episode: While she thought herself to be having "a fabulous, bubbly, seductive, assured time" (p. 26), it was later pointed out to her that she was dressed provocatively, wearing much more makeup than usual and seemed hysterical. Karp (2002) additionally describes the profound sense of loneliness occasioned by his vulnerability as a junior faculty member prior to tenure, describing sleepless nights accompanied by the knowledge that his intense teaching load could not be reduced even though he was experiencing clinically-significant symptoms.

While such personal accounts highlight the barriers and challenges of succeeding academically as a researcher with psychiatric disabilities, it is noteworthy that these issues are almost wholly absent from the research literature. Our review indicates that the only published discussions of these themes in the U.S. have been limited to select reflections on the inclusion and exclusion of students with psychiatric disabilities from undergraduate and master's level social work programs (GlenMaye & Bolin, 2007; Stromwall, 2002) and, to a lesser extent, doctoral programs in psychology (Jones et al., in press). Even in texts in which the plight of academics and students with disabilities is discussed more generally, issues specific to psychiatric issues are often not mentioned. For example, while Olkin (2002) very helpfully unpacks the potential difficulties experienced by doctoral students with disabilities enrolled in clinical psychology training programs, she makes no mention of any issues or concerns—particularly pronounced in such contexts—regarding the unique challenges that might arise in the context of psychiatric disability (including potentially significant barriers to licensure).

Mentoring is another area in which individuals with psychiatric disabilities may be disadvantaged. While the value of mentoring minority doctoral students and junior faculty has been well-documented and discussed (Jeste et al., 2009; Shavers et al., 2005; Smith, Smith & Warkin, 2000; Waitzkin, Yager & Parker, 2006), discussion of the mentorship of junior colleagues with psychiatric disabilities is virtually non-existent. One implication of this lack of discussion is that people with psychiatric disabilities may face not only many of the same challenges as other visible minority groups but also the additional burden of sorting through complex issues of disclosure and identity (particularly in the face, as discussed above, of substantial socially acceptable stigma) (cf Goodwin & Morgan, 2012; Saks, 2009). Although it would be problematic to suggest that non-disabled senior faculty cannot appropriately mentor junior colleagues, given the frequency with which "like me" faculty are often sought as mentors (Rockquemore, 2011), the double invisibility of many researchers—invisible due both to the nature of their disability and their decisions not to publicly disclose—arguably decreases the pool of recognizable mentors even as it reinforces an academic culture of silence. It is, therefore, perhaps not surprising that even a figure as prominent as Marsha Linehan, the esteemed developer of dialectical behavioral therapy (DBT), waited until the very end of her career to publicly disclose her own struggles with borderline personality disorder (Carey, 2011, June 23).

Although we have thus far discussed many of the challenges that face graduate students and faculty in academia, this discussion has excluded the arguably more basic issue of graduate admission. In addition to abundant (but anecdotal) stories of discrimination in the doctoral admissions process, a recent survey of psychology graduate admissions directors led to the categorization of disclosures of personal mental health issues as a "kiss of death" (KOD) in the admissions process (Applby & Applby, 2006). The authors explain:

The discussion of a personal mental health problem is likely to decrease an applicant's chances of acceptance into a program. Examples of this particular KOD in a personal statement included comments such as "showing evidence of untreated mental illness," "emotional instability," and seeking graduate training "to better understand one's own problems or problems in one's family." More specifically, one respondent stated that a KOD may occur "when students highlight how they were drawn to graduate study because of significant personal problems or trauma. Graduate school is an academic/career path, not a personal treatment or intervention for problems."

The authors further warn prospective graduate students to "avoid references to…mental health [because] such statements could create the impression you may be unable to function as a successful graduate student" (Applby & Applby, 2006, p. 23). Psychiatric disability, these authors suggest, may more or less directly imply some level of academic incompetence or risk regardless of one's academic record, at least for some admissions directors. (Notably there were, to our knowledge, no public outcry concerning these findings, a situation that seems highly unlikely were race or sexual orientation likewise implicated as a "kiss of death.")

Clearly enough, graduate students and faculty with a range of different (physical and mental) disabilities and chronic illnesses face significant barriers and an often inhospitable climate in higher education. The development of disability studies programs and curricula, on the other hand, has clearly led to at least pockets of explicit support for and acceptance of academics with disabilities. To the extent that both psychiatric disability as a research area and students and faculty representing the full spectrum of psychiatric disability are significantly under-represented in disability studies, however, academics with psychiatric disabilities are arguably at even more of a disadvantage. They have, that is, no disciplinary safe haven.

Conclusion

The narrative of the consequences of the absence of c/s/x perspectives in US academic discourse presented here paints a disquieting picture: While there is increased interest in bringing c/s/x perspectives into the academic fold, biomedical models of psychiatric disability dominate, cross-disciplinary research remains rare, scholarship largely revolves around clinical interests and goals, and the aspirations of academics with psychiatric disabilities are often thwarted by the current academic environment. Given the increased attention paid to issues concerning psychiatric disability and diversity in the disability studies literature specifically, it is worth highlighting two potential courses of action for scholars within this discipline.

As alluded to in our introduction, the differences between disability and c/s/x discourse are not insignificant and, thus, the question of how best to address some of the negative consequences we have described—i.e. whether to work toward an independent 'mad studies' discourse, encourage the disability studies establishment to more fully include psychiatric issues, advocate for the expansion of critical and interdisciplinary approaches within traditional disciplines such as sociology and psychology, advocate for the expansion of the medical humanities, or some combination of these—is unclear. Developments outside the US, for instance in Canada, where 'mad studies' has made more significant inroads in disability studies (e.g. Reaume, 2006), or in the UK, which has seen the emergence of a strong social science user/survivor researcher movement over the past decade and a half (Beresford, 2002, 2009a, 2009b; Chandler & Hayward 2009; Sweeney et al., 2009; Rose, 2008, 2009; Rose, Thornicroft & Slade, 2006) suggest the viability of several different paths.

If c/s/x perspectives are to be more fully considered in the context of existing academic disciplines (disability studies or other), meaningful critical self-reflection seems a necessary prerequisite. Departments, that is, including prominent US disability studies programs, need to honestly examine the extent to which they currently employ researchers (with or without personal experience) who approach psychiatric disability from a holistic, non-pathologizing perspective. Hiring faculty with such interests, in turn, would help create a pipeline encouraging applications from students both with and without psychiatric disabilities with significant investment in these issues. Likewise efforts might be made to fund and organize mad or psychiatric disability focused symposia, conferences, and research initiatives, as well as special issues of relevant journals, in order to promote and encourage progressive cross-disciplinary scholarship on psychiatric disability and madness.

Even in the absence of the formation of a full-fledged mad studies discipline, steps can be taken to address some of the issues specific to the often stigmatizing academic climate in the US, as well as the lack of targeted supports for doctoral students and junior faculty with psychiatric disabilities. With modification, programs already in place aimed at promoting the success of students of other historically disadvantaged groups (including special summer institutes, research fellowships, and additional mentoring opportunities) might be implemented for students with psychiatric disabilities. In addition, steps could be taken to empirically evaluate and implement effective academic accommodations specific to doctoral students and faculty—i.e. accommodations involving not only coursework, but also modifications to duties and expectations in the areas of teaching and research. The absence of any existing research into "advanced" accommodations highlights the need for further attention to this matter, and suggests that any such efforts might be limited if they do not openly acknowledge and target the full range of psychiatric disabilities, including more highly stigmatized and potentially complex disabilities such as schizophrenia.

As Cook (2000) notes, "some have argued that institutionalized discrimination against people with mental illness" is in fact "one of the last socially-acceptable, government-sanctioned threats to the rights of a large class of vulnerable individuals" in the United States (p. 199). In this review, we hope to have made the case that the c/s/x community also remains one of the last large sociopolitical groups to be substantially excluded from academic discourse and community in the US. Open acknowledgement of this underinclusion and its causes and consequences is the necessary condition for change.

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Endnotes

  1. Note that while we cite non-US authors throughout our article, our focus is on US academia. In many cases there are in fact substantial differences between the US and non-US countries in terms of mental health research, mad studies and user/survivor research. Discussion of these differences, however, would significantly exceed the scope of this paper.
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  2. As Price (2011) notes, there is little consensus as to the best or most emancipatory term with which to reference "mental illness," "disorder," disability or madness. In the context of this paper, we generally use the term "individuals with psychiatric disabilities"–currently the "progressive" standard in psychiatric rehabilitation research–but recognize that some may prefer other terms or even explicitly object to our use of "disability" inasmuch as such a move arguably reduces madness to a form of disability.
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  3. It is worth emphasizing that we are in no way claiming that psychiatric disability has no neurological basis; all psychological phenomena are clearly connected to neural events and function. Nevertheless, as in other areas of human experience such as love, empathy, and creativity, this does not mean that these experiences can or should simply be reduced to neurological events, divorced from the interplay between the brain, individual agency and the sociocultural environment. Furthermore neurobiological differences, even if consistently found, do not necessarily represent neuropathology, a distinction the Autistic Neurodiversity movement has capitalized on.
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  4. Biomedicalization and clinicalization are nevertheless certainly closely linked; a recent review and metaanalysis by Schomerus and colleagues (2012), for example, demonstrates a strong positive correlation between population-level increases in biomedical causal attributions for mental illness and belief in the value or necessity of engagement with psychiatric professionals.
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  5. Notably, outside the US there is a growing multidisciplinary literature on psychiatric experiences with a broader focus on history and cultural theory. See, for example, Woods (2011) and McCarthy-Jones (2012).
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