Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at editor@crisisnow.com.
When René Keet was in medical school in the Netherlands, he was torn between going into psychiatry or infectious disease. He chose epidemiology because studying mental health felt too close to home. When his sister died unexpectedly, he fell into a deep depression. “Also, a close family member battled with psychosis for decades,” he says. (To respect his family’s wishes, he limits what he shares.)
Keet became an AIDS researcher and traveled the world, collaborating on studies. “I was an infectious disease epidemiologist, and that had not been the plan,” he laughs. “I don’t regret my experience — it was huge to be in the middle of this major epidemic, but it wasn’t really where I wanted to be.” So he went back to residency for psychiatry.
When switching career paths, he shared his family’s struggles and his depression with close friends who worked in mental health. However, they told him to “never mention it when applying for a job.” So he kept his experience mostly to himself. “I had one colleague who also had severe mental health issues in their family, and we were open to each other but kept it hidden otherwise.”
Working with peers crystallized for Keet that his experiences were an untapped resource. “I started to see how their expertise was incredibly valuable,” he says. Also, he noticed the lack of openness among clinicians created an atmosphere where peers often felt profound loneliness in the mental health workspace. “We are in a world where most of the workforce is completely closed about their own lived experience, and yet, peers are expected to be completely open.”
The paradox was on his mind as he became the director of 12 flexible assertive community treatment (FACT) teams — multidisciplinary, recovery-oriented, and integrated outreach care for people with severe mental illness — with 450 employees. “Every year, we have a policy day, and that year’s topic was stigma,” he says. “I started thinking about my own experience with stigma.” The time had come for him to share.
“I’m no hero,” emphasizes Keet. “It’s much easier when you’re the director; you know you won’t be fired. Still, it was a major threshold for me to get over.”
In the month before policy day, he began sharing with colleagues. “Standing at the coffee machine, I’d tell someone about the struggles of my family member or me,” says Keet. He was surprised by how accepting and compassionate people were. “I realized, ‘Oh, I can be open,’ and that started a movement toward openness within the service.”
Today, he belongs to a group of professionals with peer knowledge, a term he coined that was adopted by the World Health Organization in its 2022 world mental health report, “Transforming Mental Health For All.” Peer experts are care providers who not only have lived experience but are also trained in specific skills and attitudes. “I’m not a peer expert — they’re trained to use that expertise, but I do have lived experience,” says Keet. According to the WHO, people with lived experience, including peer knowledge, “can be front-line providers of support.”
As the director of FIT-academy, which provides training and coaching to community mental health practices, Keet has witnessed a shift in mental health stigma within the mental health field. However, it remains a widespread problem in the Netherlands and worldwide. He says openness must go beyond discussions between mental health workers and into the community. That’s why he strongly supports the employment model Individual Placement and Support. In 2020, Dr. Robert E. Drake, co-developer of IPS, told #CrisisTalk that employment is the most critical intervention because “it allows people to become self-reliant.” Keet says it also combats stigma. “You work closely with your colleague and talk together,” he points out. “It’s all about contact.”
In his circle of influence, he’s tapping into exposure and normalization. “This has helped to increase understanding and empathy,” says Keet. He’s also working to shift his organization toward recovery instead of rehabilitation. “Rehabilitation is ‘I’m rehabilitating you’ while, in recovery, the client is the active person. Historically, people go through treatment, and then there’s a recovery focus.” He believes the philosophy of recovery must be there from the beginning, which is why he and his colleagues have developed a recovery-oriented intake that asks the following questions: “What happened?” “What are your strengths?” “What are your vulnerabilities?”
He then asks them to describe what their life will look like in two years, using the present tense. To Keet’s surprise, most patients have an answer to the latter question and can describe their two-year future in great detail. “Sure, sometimes they will say, ‘I want to get rid of my psychologist or depression,’ but that’s quite rare,” he says. It’s far more common for patients to say they want to have a job, a house, a partner, or that they want to travel. “We then ask, ‘So what do you need and from whom?’” The treatment teams then provide care and connect them to support.
Keet is always looking for opportunities to spark conversation, especially among those living on the grounds of the old psychiatric hospital. Some of the buildings have been turned into apartments and businesses. The old chapel houses a theater and the former canteen became a restaurant. On the property is also the “story room,” a place where people share their stories once a month. “Telling one’s story is an important part of the recovery process,” he says. People from the neighborhood are often in the audience, which creates another layer of exposure and destigmatization.
Several years ago, a client living in sheltered housing set fire to his apartment. “It was a dangerous situation, and people living in the building were understandably upset,” says Keet. However, he notes the near tragedy also created an opportunity. The man wasn’t the only client living in the building. So when Keet and his colleagues met with apartment building residents, they asked some of the clients residing in the building if they’d be willing to join them. The discussion was fruitful, and people quickly realized they had more in common than they thought. “It’s not about distinguishing between people with or without mental health problems, and exposure helps to make that connection,” he says. “We’re all human beings.”
Like many other nations, youth mental health has worsened in the Netherlands. According to a national health survey, in 2021, 18 percent of young people ages 12 to 24 were experiencing poor mental health compared to 11 percent in 2019 and 2020. “As an infectious disease epidemiologist, I was completely in favor of the Covid lockdowns,” he says. “But as a psychiatrist, I became aware of what I had not foreseen — the enormous impact, especially of isolation on young people.”
Keet uses his public health expertise in his prevention campaigns. That includes partnering with a theater program in the city of Alkmaar and people with lived experience to facilitate dialogue on mental health at schools and in the classroom. “It’s a way for us to use our expertise and train teachers,” he says. “This allows them to increase their mental health knowledge and have important conversations with children and adolescents.”
