What gets called mental disorder or illness, mild or severe, shows itself as a misplaced fear of others. Personal relationships break down, followed by an inability to form and maintain new ones. The sufferer becomes progressively more emotionally and cognitively isolated. Madness results from our failure to constantly update and modify our mental map of the world. If we do not ‘test’ our predictions, beliefs, dreams, thoughts, internal dialogue, fantasies, hypotheses, plans, ideas about how the world is, and what the people within it think and feel, our map becomes rapidly out of date. If we act with an out of date model of the world - we will look mad to others, and they will treat us as mad. If others don’t share a large part of our model of reality we are emotionally and cognitively isolated. We need an accurate map; by sharing we come to have a more complete understanding than we could ever achieve alone. The ability to doubt and live with uncertainty, and hence know that we must constantly test our vision of the world - is sanity. To control and fix our view is the first step on the road to disaster and the way an unchanging outlook is maintained is by isolating oneself from any evidence that might contradict it. An unmodified and out of date model of the world is one where our thoughts and feelings are anchored in the past, hence our predictions of the future may be hopelessly wrong.



Saturday 20 November 2010

Universal emotional expression (updated 2014, 2016)

Anyone familiar with the television drama Lie to me, now in it’s third session on FOX/ Sky, will know something of the work of Paul Ekman, upon who’s research it is based. Ekman has given his support to the programme, but maintains a blog on the FOX website 



to point out where and when he sees fiction portrayed as fact. Lie to me draws mainly on Ekman’s work on micro facial expressions and their connection with deception - emotional expressions which show for up to one fifth of a second before a person can consciously try to disguise them. But it is Ekman’s work on facial expressions as a whole, and their role in expressing universal emotions (as well as individual variations) which concerns me here.

It may come as a surprise to some that there are universal emotions and that they are overwhelmingly displayed on the face, of everyone - supported to varying degrees by tone of voice, and some body movement.  It may be even more surprising to learn that Ekman and his colleagues mapped the human face (43 muscles, up to 10,000 possible expressions, about a third of which are expressed emotions) and demonstrated the way emotions are transmitted through interaction, including the universals, over 30 years ago! (FACs - Facial Action Coding System 1978) A heaven sent gift you might think for mental health professionals, but how many have ever been taught them? (The CD-Rom for micro-expressions alone has been learnt by many in just one hour). Indeed one might well think that such ignorance of science by psychiatry is positively negligent, yet as Ekman has explained, it even took the Department of Psychiatry which employed him 20 years to put his research on the medical curriculum! Such things only serve to fuel one’s contempt for the world of mental health. This was one of the issues he reflected upon in an hour-long interview for the University of California at Berkeley - available on You Tube via the UC channel


Another, was how during the process of mapping the face and identifying muscles, many hours were required in front of a hand mirror. A consequence of which was the disturbing realisation of just how easily the repeated making of an emotional facial expression can cue the persistence of that emotion, how it induced a change in mood, whether it be fear or sadness.

I stumbled upon Ekman’s work about 3 years ago quite by chance, no one ever directed me to it. I found the easiest way to digest it was through two books Unmasking The Face, and Emotions Revealed. Much of it was a shock, I simply hadn’t learnt unconsciously as a child what faces show - not unrelated I’ve come to realise, to the fact that I later spent 20 years as a client of mental health services. However, for a fast introduction, go to Ekman’s website.

Darwin said it first, of course! He identified six universal expressions of emotion and implied that it is in the act of making the expression, in response to another human, that the emotion is felt. Ekman set-out to prove it and in the process added contempt. At the outset of Ekman’s career the ‘blank slate’ or ‘culturally relative’ view of almost all human behaviour held sway. What Ekman has demonstrated is that what is personal, is specific to the context an individual finds themselves in, and is always a variation built upon the structure of universal emotional expression. What remains up for debate is the extent to which emotion can be said to be made in the moment that you physically feel the shape of your face change, how much felt emotion is cued by others, how much effective communication depends on correctly learning what you are feeling, being able to communicate it to others, and make a correct interpretation of what others are showing you. Put another way, the windows through which we can understand another’s mental distress, the extent to which we can be said to ‘have empathy’ (feel what others feel) are; the facial expressions of emotion, the tone of voice, plus some supporting cues found in the gestures which support them. But when it comes to meaning, to what a particular emotion refers to, then gestures display their principal role - and that is to support language. Nonetheless, the work of people like Paul Ekman demonstrates that non-verbal behaviour and so called ‘inter-personal skills’ should really be the spine of any training in mental health, upon which all else can be hung. The pre-occupation with non-action, with non-physical cognitive skills - is just so much talk.

The first time I tested myself for recognition of emotions I scored just four out of the seven universals, let alone anything else! How many other clients like me need a program of active learning. After the anger, it occurred to me that the lack of emotional expression amongst many in mental distress may not be so much about shutting down, blocking-out, hiding or lacking emotion but simply a failure at recognition of emotion! In fact I’m more than contemptuous of some services I’m disgusted.

However, in the last couple of years I’ve gone in search of genuine smiles that can provoke happiness and managed to find one expert amongst the mental health workers I know. Surprise, surprise, she is of lowly status, on low pay and relatively lacking in formalised training - but she has the skill of hitting you with rapid-fire full smiles, up to half a dozen times a minute. An hour and a half of that re-programmes me for weeks.

(Note 2016; There was only ever one way this post was ever going to end!)

Thursday 18 November 2010

The Recovery Movement (part two)

This is the second of three posts on the Recovery movement (part 1 - 17th January) and offers a brief history of what I’ve come to regard as a social movement - an attempt to introduce a particular set of moral, ethical and political values into the behaviour of those in the world of mental health. Here I look at the nature of the Recovery approach itself, whilst the third part will deal with it’s impact on the day to day practice of individuals and organisations. For those entirely unfamiliar with Recovery please read part one and follow the links.

As far as I am aware, I am the only person locally, who having been a recipient or ‘product’ of Recovery-focused care, has then gone on to become a critic. Bemused workers and managers have responded to my observations almost as if they were acts of disloyalty - since my mental health obviously improved over that period. My contention, as hopefully the content of this blog has begun to show, is that it was factors other than those identified by the Recovery approach which were of real importance in improving my life. Nonetheless I believe the Recovery movement is important, not least because it helps to stop some of the damage psychiatry and clinical psychology continue to do.

It needs to be asserted at the outset that the Recovery approach to date has not generated any new theory of human behaviour, understanding of mental distress, of emotions or unusual behaviour, nor has it advocated specific therapeutic interventions. It is principally about the better management and delivery of care, but in this area too, it does not challenge the legitimacy of any of the existing occupational groups within mental health. In essence the Recovery approach sets out to change the way mental health services are organised and delivered in order to be more responsive to the stated needs of clients and their supporters. A set of Recovery values has emerged that are intended to inform the personal conduct of workers in their interactions with clients.

However the way the Recovery approach is experienced or encountered by the worker, client or supporter is self-reported in highly individualistic ways, only later do some appreciate the sources of their new insights or beliefs. Many talk about a journey of recovery, and of who or what placed them on that journey (see the recovery stories at http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf ) in a way that is reminiscent of many narrative approaches throughout history, particularly the notion of spiritual or religious pilgrimage - albeit with a very secular favour - as if it were a novel and unique experience. But it was never that way for me. My growing ‘wellness’ made me increasingly an outsider looking-in on the Recovery movement, which seemed to be socially constructed by people talking a language of networking.

As yet there is only a very modest evidence base for Recovery-focused care and little that could be claimed as evidence based practice. But there are many ‘interested parties’, committed to Recovery values, who are only too anxious to create an evidence base. Equally there appears to be no systematic critique of Recovery other than the reassertion of more traditional approaches - extraordinary given how pervasive the ideas have become. It is also remarkable given the context of the highly contested nature of knowledge in mental health; within and between the disciplines of psychiatry, clinical psychology, nursing and now Recovery, between competing theories of learning, and the contrasting perceptions of the providers and users of services.

With the exception of the current UK REFOCUS research project ( http://www.iop.kcl.ac.uk/departments/?locator=1073 ) almost all investigations globally have been service evaluations, and almost exclusively quantitative. A recent local example being Alison Moores Report Of The Standards And Outcomes Pilot Project 2008/9http://www.communitycaretrust.org/attachments/File/Standardsandoutcomes2008-9FINAL.pdf ). Qualitative data has been overwhelmingly restricted to collections of users’ writing. The involvement of service users as ‘researchers’ in such quantitative service evaluations is a sensitive and problematic issue in the UK and America. It remains to be seen how much influence they can assert over the current REFOCUS project.

The concept of Recovery may yet turn out to be an example of reification, but nonetheless many people do act ‘in the name of’ Recovery and in that sense it is having a very real impact on everybody’s ‘outcomes’.

Exceptional Clients and Disaffected Workers

The concept which became known as Recovery (in mental health) has its origins amongst a small number of individual consumers (users) in the US in the late 1980’s and early 90’s. Contrary to the folklore of Recovery they appear not to have rejected the medical or disease model itself, but the pessimistic prognosis offered by psychiatry. What they refused was the ‘sick role’ and the notion that they need be ‘disabled’ by mental illness. The client might continue to live with mental distress but it need not limit their ‘life chances’ or opportunities to fulfil goals or wishes. A few exceptional clients emerged who were able to wear as a ‘badge of honour’ both their ‘lived experience’ as well as their educational and work achievements. Readers may care to ‘google’ the following exceptional clients from the US - Patricia Deegan, Priscilla Ridgeway, Shery Mead and Mary Ellen Copeland. Deegan asserted in 1988 that:

‘Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. ..At times our course is erratic and we falter, slide back, regroup and start again. ..the aspiration is to live, work, and love in a community in which one makes a significant contribution’.

Even now, well over 20 years since it’s emergence there is only the broadest of agreed definitions of what Recovery is, allowing for a wide interpretation - and many welcome that. Ironically some also insist that Recovery is, what the individual decides it is. Last year Mike Slade, in the UK’s first textbook on the approach, Personal Recovery And Mental Illnesshttp://www.amazon.co.uk/Personal-Recovery-Mental-Illness-Professionals/dp/0521746582/ref=sr_1_1?ie=UTF8&qid=1290062155&sr=1-1 ) selected the following quote from William Anthony in 1993 to serve as a working definition.

‘…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/ or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’.

Unlike the anti-psychiatry movement of the late 1950’s and 60’s however, which offered new theory and practice (though now largely rejected) and the user/ survivor groups of the 1970’s and 80’s, who in their complaining and campaigning focussed on rights and entitlements - Recovery approaches were, and remain highly individualistic. Not only is it assumed, in a moral or political sense, that individuals should be able to determine their own futures, but also in terms of theory - individual determinism is taken for granted, as opposed to more social forms of learning and agency. Part of the approach is for workers to be extremely client-centred with a clear moral imperative to take what clients say at face value. This is one of the senses in which the Recovery movement is best understood as a reaction against previous forms of care, rather than a positive assertion of new insights into mental distress. It emerged in the historical context of public perceptions of what constitutes abuse becoming much wider, and in parallel with a growing sensitivity of government and academia to the use of discriminatory and gender-based language, commonly referred to as ‘political correctness’.

Individual charismatic clients were joined by mental health workers who had gravitated towards community services, having become disaffected by the rigidity of the formal mental health system. The Recovery movement spread outwards from the USA to New Zealand (google Frank Bristol, Mary O’Hagan) and the UK (Ron Coleman). By the turn of the millennium, Recovery approaches were beginning to be considered for inclusion in the formal structures of health care in most western countries.

Recovery Values

From my observations of how the values and ethos of the Recovery approach have been embodied in practice, three underlying themes have emerged, and although their meaning is not made explicit or self-evident in the discourse of workers, they seem increasingly to be taken for granted in their actions. There is of course also a contrast between policy documents (again follow the links in part one) and practice. These are social processes, of working through different ways of being with clients.

What is explicit is the language of Recovery. In the UK, ‘hope’, ‘opportunities’ and ‘social inclusion’ seem to be the emerging concepts around which the Recovery dialogue is structuring itself - indeed advocates are often quite prescriptive about individual choice and freedom of action! From the general conversation of workers I would add; 'active listening’, ‘lived experience’, ‘empowerment’, ‘self-management’, ‘personal journey’, ‘goals’, ‘control’, ‘coaching’, ‘personal story’, ‘choice’ and ‘peer support’ as key words. But the underlying processes I observe are as follows:

Having a future orientation - (hope, goals, opportunities) the promise that tomorrow will be better than today and of acceptance, sometime in the unknowable future, by a society which has rejected them. Yet alarmingly workers often appear not to realise mental distress is only experienced in the present moment and must therefore be confronted today. Hopes and expectations need to be matched to the current situation and current capabilities, otherwise the expectations of others, come to be seen as further evidence of failure. Equally motivation can only come from others, and persists only as long as the client feels some emotional attachment to that person.

The pursuit of individualism - (self-management, personal journey, lived experience, choice, goals, peer support, social inclusion) an essentially anti-social bias; seeking equality in individual rights, entitlements and personal decision making and the formalising of relationships with peers. Clients are urged to set their own goals and needs and take responsibility - if they fail they appear to have ‘chosen’ and relieve others of responsibility. Wellbeing is judged not on the actual outcome of client’s activities, but the story or narrative they tell themselves. Individual merit and skill may be recognised but it is not given value or rewarded, everyone is made an expert to maintain an illusion of equally. Even those exceptional clients and workers who provide charismatic leadership - deny it! The social nature of learning goes unrecognised. Some claim Recovery is about social relationships, but when positive emotional attachments form between workers, clients and carers it is often seen as dependency and a failure to move on.

The illusion of a ‘self’ in control - (control, choice, empowerment, lived experience, self-management) it is one thing to argue that the client should take control back from mental health services and be in control, but this is what clients have always tried to do and been knocked-back by the reality of their situation - by evidence of not being in control. It is the ability to live with doubt, uncertainty, and not being in control, and be able to respond in a flexible way to change, that is mental health.

In short, Recovery values are the embodiment of our commonsense understandings about the place of individuals in modern western societies. They reflect the ideology of liberal democracies built upon a capitalistic economy. In so far as Recovery can be said to have intellectual antecedents then they lie in American humanistic psychology from the 1940’s and 50’s. Indeed at various times Recovery has made an uncritical use of Maslow’s ‘hierarchy of needs’! What the Recovery movement offers is highly conventional, but is offered to the one client group who are most psychologically and emotional alienated from society, the most aware of the difference between ideological valves and practical realities. The characteristics of the client continue to be seen, not as a reflection of modern society’s inability to genuinely accept difference, but of their failure to live within it. We are offered time and support to become more sophisticated conformists.

The clients I speak to every day do not speak the language of Recovery; if the subject is our own mental distress (and most often it isn’t) then we speak of the reality of the present moment and the inadequacies (or occasional virtues) of mental health services. We are suspicious of anything not grounded in the practicalities of everyday life. Workers in their stated attitudes often appear ignorant of our limited life choices. Workers wish to give hope, but do so in a situation where they get little back from the client. Equally they are anxious not to undermine the fragile confidence of the client. Yet in reality, as low paid, low status workers, they must be only too well aware of the limited opportunities of the client. As the number of workers with varying degrees of lived experience increases then the gap between potential life chances (as demonstrated by exceptional clients) and the reality of limited opportunities for most, can only become more visible.

A useful way of making sense of the activity of the Recovery movement is to see it as an example of ‘ideological work’. The late sociologist Bennett Berger ( http://www.amazon.co.uk/Survival-Counterculture-Ideological-Everyday-Communards/dp/0765808056/ref=sr_1_1?s=books&ie=UTF8&qid=1290063625&sr=1-1 ) introduced the concept - for him it was both his object of study and his method. Like myself he was initially personally involved with, and committed to, the subjects of his research, and like them wanting to provoke social change. He was interested in the tension between peoples ideals and the reality of their material existence. How the publicly stated goals of individuals or groups, realised themselves in actual behaviour. But he was also acutely aware of such a tension within himself; between his personal beliefs about the world, and what the results of his research told him. He argued that much of culture was becoming increasingly ideological, but that such symbolic structures were rarely translated into social structures. He studied people with ‘green’ values who wished to pursue a self-sufficient and communal lifestyle, but were confronted by the practical realities of agricultural labour and subsistence farming. He wanted to study the inevitable gap between what they professed and the way they behaved as they adapted to the changing circumstances of their lives.

‘…when groups are caught in contradictions between the ideas they profess to believe in and their day-to-day behavior, is their hurried ideological repair work best understood in an ironic, contemptuous, and cynical manner?’

In part three I consider how ideals have been turned into action in the Recovery movement.

Thursday 11 November 2010

Mental health services - the future

The future is unknowable, but hopefully this one-off excursion into ‘futurology’ will be of use in raising awareness and informed debate.

All the issues raised here have already been discussed on the web, but many in the world of mental health appear to have either little knowledge of them, or only just begun to consider them. Reaction within ‘health and social care’ to the coalition government has been almost exclusively negative, focusing on budget cuts and the idea of services being taken away. The development of Conservative social policy over the last five years, has been largely ignored.

The most worrying aspect however is watching workers simply waiting to be told what to do by managers from failing providers and commissioners (who’s current role will soon cease to exist) little realising that the new government want them to take the initiative at local level, and transform their own work in a more autonomous way. There will be a Conservative led, or majority government for the foreseeable future, so time and money spent resisting reform, or endorsing the efforts of others to do so, is wasted and a disservice to clients.

The ‘new’ Conservatives do have a considered mental health policy developed over many years - explore The Centre For Social Justice ( http://www.centreforsocialjustice.org.uk/default.asp?pageRef=418 ). They do not ‘cut’ for the sake of cutting or just to reduce public borrowing. As a result there are new directions which any mental health organisation can take which will receive encouragement and support from reformers in national and local government. For a fast introduction see David Cameron’s 20 minute presentation at TED last February ( http://www.ted.com/talks/lang/eng/david_cameron.html ) and this article for The Observer from April ( http://www.guardian.co.uk/commentisfree/2010/apr/18/david-cameron-my-big-society ).

There are a few simple principles behind new Conservative thinking, which though often confused with Thatcherism actually come from an older tradition, and provide a certain logic to forthcoming policy:

a) You impose as little as possible on people’s freedom to act, minimising legislation and the bureaucracy it creates.

b) Governments do not seek to lead change in society, but enable individuals, communities and business enterprises in their chosen pursuits. There are no inherent, or permanent, ‘rights’ or ‘entitlements’ which people have, and which it is a government’s duty to bestow or uphold - rather it is expected that individuals and groups will lobby, vote and negotiate in their own interests to change the law to fit current social needs.

c) Governments tax and spend as little as possible, leaving the maximum amount of wealth and resources for people to use as they please.

d) You encourage anything that will sustain family and existing communities and devolve decision making to the lowest level possible.

e) Work (purposeful, productive or contributory activity) is undertaken on behalf of families and the community and is the principal way in which people maintain their self-esteem, achieve status and reward. It ought to lead to a fair exchange of labour, goods, services and education such that the costs and rewards match the real demand within a community - rather than being dictated by government.

f) You don’t reward failure, or reward people for doing the wrong thing (so in 2008 it was wrong to bail-out the banks, but right to guarantee personal savings). Equally risk (and a willingness to fail) is accepted as an inherent part of creating both wellbeing as well as wealth. Therefore seeking to regulate for most risks is folly, leading to a false sense of security, greater vulnerability and a less flexible response when the unexpected happens.

Social enterprise and social entrepreneurship

The idea of shared ownership amongst the workers and users of a business plus the principal of not taking profits out of an organisation has been around for a long time and taken many forms. The new Conservatives enthusiasm for social enterprises to take over services previously provided by national or local authorities is not so much ideological, since ‘public service‘ has always been part of their ethic, rather a result of it becoming lost in public bodies through the seemingly unstoppable process of bureaucratisation. Public organisations which set out with equality in mind, have ended-up offering a hugely inefficient and impersonal service, and often the people working within such organisations don’t realise how rule-governed, inflexible and risk-averse they have become. For an explanation of what is meant by social enterprise and social entrepreneurship see the website of Oxford University’s Skoll Centre for Social Entrepreneurship ( http://www.sbs.ox.ac.uk/centres/skoll/Pages/default.aspx ).

The new Conservatives don’t seek to impose how much health and social care is provided - that’s a matter for individuals, families and communities to decide. Nor indeed how it is financed, what mix of public and private, as long as it is responsive to public demand, and the public get value for money. What is paramount is an equitable relationship between provider and consumer. Therefore any form of business organisation may provide the best service in a particular location if it is responsive to local needs.

The idea that general practitioners should oversee the commissioning of health services in their locality arises solely from the observation that they are in the best position to assess need. It is a re-assertion of the idea of a family practitioner and an acknowledgement that a GP already acts as a ‘gatekeeper’ to services. Even today the most important decision affecting the outcome for a person in mental distress is probably their choice of G.P. Mental health professionals often assert that the average GP knows very little about mental health. Well - yes and no. A GP knows that many of their patients present with psychological problems, and they know about the psychology involved in the doctor-patient relationship. What they know little of is how mental health services are organised and what they actually do. What little they have seen, usually some parts of NHS mental health trusts, they don’t much care for - they know services rarely deliver because their patients tell them so. More worrying still, they know they’re boxed-in - forced to refer to services they have little confidence in because they know their patients have problems that go beyond their own level of expertise to treat. And herein lies the greatest opportunity for mental health organisations that are willing, and flexible enough, to go with the government rather than against it.

Mental health organisations

Despite being over-worked general practitioners do want to influence commissioning in their local area, they know of local needs but lack quality information about alternative providers.

(The principal purpose of making available government and local authority information and statistics, is to give anyone the opportunity to bid for contracts to provide public services).

Voluntary and ‘third sector’ providers, given that they tend to be smaller, more community based, flexible, efficient and the first to try-out more innovative practice, may well be better placed to form direct relationships with general practitioners and later the commissioning consortia they oversee, than the existing statutory providers. However a third sector organisation needs to pause and think twice about it’s existing collaborative practices in what will become a more competitive environment; existing open sharing of information and expertise, the informal ‘hands-off’ agreements based on geographical areas, deferring to the presumed expertise of statutory NHS mental health trusts etc. Smaller providers have often taken on trust the information and priorities handed down by commissioners. However there is already the opportunity for more equitable relationships given the amount of existing information and data placed on the web - but often their lack connectivity, coupled with an attitude of not needing to know, means they just don’t know they don’t know.

The larger statutory organisations have repeatedly shown over the last twenty-five years their lack of ability to reform themselves. The managerial bureaucracy cannot imagine that much of what they do is unnecessary. Eventually the only option is to cut-off the money. However, one common strategy of NHS managers to avoid reforming themselves is to ‘mothball’ one service in order to introduce another, with the consequence that the only increase in actually activity is amongst themselves. For the observant client the hypocrisy is staggering, for mental health professionals will daily be encouraging them to take more risks, be pro-active, and drop the routines and habits that have failed them!

The answer being proposed is in essence to personalise the process, whereby the person taking a decision at any level (in smaller, more local and devolved organisations), is placed in direct face-to-face contact with the people affected by their decisions - where the consumer has access to the same information as the provider. To be personally connected to an outcome. This also implies a radical change in the concept of expertise - which will be the subject of future posts on this blog.

A relatively good example of a current third sector provider, with which I was personally connected as a client, is the Community Care Trust ( http://www.community-care-trust.co.uk/ ) Although still unknown to many local general practitioners, it has a track record of reforming itself towards a recovery-focused approach, of being cheaper and smaller (more efficient) than it’s competitors, of understanding social networks (though it lacks knowledge of just how the web can facilitate this), and of introducing more flexible working practices that respond more to an individual client’s needs. It’s major weakness however is the lack of up-to-date IT skills and personal connectivity amongst most staff, plus a few who remain habituated to deferring to traditional expertise in mental health.

Mental health clients and carers

There is a common myth that most mental health clients don’t use the Internet, that they would be at a major disadvantage if they did because many lack conventional ‘functional skills’ (numeracy, literacy and IT) and besides they’re ‘vulnerable’ when online. This of course just tells us about the ignorance of mental professionals and the eagerness of conventional educationalists to make work. I’ll just note in passing that there is no reason why the technology which produces World of Warcraft cannot teach mentally healthy skills - fast! See Pandora’s twitter list for a sample of (200+) global mental health service users online ( http://twitter.com/serialinsomniac/mentalists ).

Public reaction amongst UK users of mental health services to the new government has been largely one of fear, panic, anger and outrage at the perceived desire of the coalition to take away financial benefits and services they believe they have an inherent right or entitlement to based upon a diagnosis of mental illness for which they believe there is limited treatment and from which they are likely to suffer for the rest of their lives. They believe themselves to be amongst the most vulnerable in society and that government has a permanent and comprehensive duty of care towards them. But they also believe that their disability should not prevent them from fully participating in society and that any government has a duty to facilitate this.

One objective of those who think in a new Conservative way is to reconnect the users and beneficiaries of public services with the people in society who’s productive work has paid for them. Many clients and carers do not seem to make the connection that other people's tax payments, combined with loans secured with that tax revenue, has in relatively recent history, allowed for the benefit payments, services and housing they consider to be their’s by right. Some younger clients seem to believe that a government has a free hand to provide or take away a public service, or indeed the power to create a prosperous economy. Equally, the protests of clients and carers in recent months appear to take no account of the fact that the entire population is facing cutbacks.

The new Conservatives believe the mentally ill need not be permanently dis-abled and dependant - that it’s financial support should be an incentive to be more independent from the state, more in the community. For them the tragedy of de-institutionalisation has been that unconditional financial benefits, better services and social housing have had an unintended disabling effect, a deskilling of social skills, leaving individuals isolated ‘in the community’. Their ‘model’ of provision comes from observation of people with physical disabilities, whose work prospectus and integration into the social life of the community has proved greater over the past 30 years than that of people with mental health problems. They have no problem with paying DLA for transport and to provide support at home to someone who is already doing some form of contributory work, paid or not, for just a few hours or full-time - which will boost the moral of a client, their acceptance by others, and be a public demonstration of a willingness to contribute to the wellbeing of all.

All of the above is of course my attempt to get inside the ‘mindset’ of new Conservative thinking. My own political views, as someone who has been permanently ‘on the sick’ for sixteen years and was a client of mental health services for twenty years, I’ll leave for another time.

Thursday 4 November 2010

Walking meditation

My preferred form of meditation is to walk.

The basic elements occur naturally, one following-on from another. By focusing first on the breath, it will dictate an open upright posture, and balance will come from knowing that the centre of the body resides in the diaphragm along with the breath. In motion the focus shifts when the eyes are allowed to rise naturally to the open horizon; not a point of constant attention, but the place they come back to, again and again, as you let-go of distracting emotions and thoughts - from a past which is gone, and a future that is unknowable. With the eyes to the horizon and with good posture, then the feet will start to follow the contours of the ground and as if by magic, a ‘bodyscan’ occurs all on it’s own, as the right muscles are stretched, then relaxed along with stressful feelings and thoughts. A ‘mantra’ can be found in the pace and rhythm of the stride, but it must be flexible enough to change in an instance, for walking consistently and repetitively down a ‘made’ road may bring a kind of temporary bliss, but will soon narrow the horizon and an open future.

Tuesday 2 November 2010

So what is wrong with me?

The short answer is that 16 years ago I was diagnosed as manic depressive (now Bipolar 1). If you’re satisfied with that as an explanation then either you are an official (who needs a label and no more) or a fool. Of course I had been diagnosed several times before that. In the seven years after my first meeting with a psychiatrist in 1987; it was first a reactive depression, then a psychotic episode, then severe depression, a short gap of normality, then schizoid affective disorder, and more depression before it settled upon Bipolar.

My perception of my problems, or acceptance of such labels, changed over the years too. Before entering the mental health system I was quite clear psychiatry was the ‘dismal science’, but within days of my first admission I’d lost track of what I felt my problems were. I’d entered a new world of psychological interpretations, but had also begun to be influenced by the clients around me. The end result was that over a period of a decade I became completely converted to defining who, and what I was, by the use of psychiatric labels. I came to the belief that ‘bipolar’ explained myself, to myself. And for a few years more, no doubt with much confirmation bias, I remained thoroughly dis-abled!

It wasn’t until six or seven years ago, when I radically changed my ‘world view’, that I had to then set about revising my view of myself. I began to view the world, from minute to minute, as well as over millions of years, from the point of view of Darwinian evolution by natural selection, and that let me step-out of ‘the preoccupation with self’ that seems to paralyse so many people in mental distress. Viewing all human activity in evolutionary terms, including all social and cultural activity, allows you to see ‘before your very eyes‘ the unfolding of human psychological behaviour on a daily basis - how the interaction between people (including mental health workers, clients and carers) usually reproduces, and only very occasionally transforms, relationships. All of which has led to what verges on contempt for the world of mental health, as evidenced by many of the previous posts on this blog.

Of course an expression of contempt is hugely powerful, if you see it in the face of a partner, then the relationship may as well to over. I haven’t been a client of mental health services for three years, I’ve ceased almost all ‘involvement in Involvement’ or participation, refused for six months now to meet with anyone in an official mental health building and severed links with mental health academics.

I’m now left with two kinds of explanation of myself, between which I flip from time to time. The less common one might be titled; ‘How the hell should I know what’s wrong with me?’ For the sorry facts are that I’ve spent my life not getting the jobs I wanted and being largely unemployed, and unemployable - unable to live to a set routine, accept authority or responsibility for others. A life of not sleeping with the women I really wanted to, but having a succession of short-term relationships with whoever would have me, plus long periods of living alone. And despite all the studying I’ve done, I still don‘t know why I’m largely ignored by the rest of the world. For example, not so long ago I wrote;

‘Just had one of those horrific moments of despair (thankfully they never last long) when I realise that by being honest and true to myself I’ve lived a life of broken relationships, unemployment, mental illness and academic rejection. As a result what blissful moments there have been have largely been experienced alone. And yet any outsider looking-on would conclude that although the day began and ended alone, it was full of good company and worthwhile activity. The more ‘well’ and socially skilled I become, the more angry and isolated I feel.’

So one kind of explanation is that insight has brought me nothing, but that should not be unexpected with someone so unable to understand others. In this sense the question: ‘So what is wrong with me?’ is for others to answer.

The second explanation is the academic one, the alternative to psychiatry, the more neuro-scientifically flavoured one:

a) There is natural variation in the limbic system (which regulates emotion) between the brains of individuals living in any particular environment; my inheritance is that I’m more highly sensitive to my environment than most others. Such sensitivity is occasionally useful, but when the majority in my environment are less sensitive, my emotional reactions look to others like rapid and consistent overreactions. Equally, I’m likely to quickly become over-stimulated and feel the need to socially withdraw. Such reactions occur over the whole range of emotions, which the crude psychiatric category of ‘mood’ hardly begins to encompass.

b) So when it comes to nurture (social learning) individuals bring their particular genetic inheritance to learning in particular environments. But whatever the background and context, the outcome is that we learn (using the inherited capacity to imitate) varying degrees of empathy (the ability to feel what others feel) and a ‘theory of mind’ (knowing how others think). Bringing the consequences of a) to my own particular environment, my ability for empathy and to a lesser extent to share a theory of mind were blocked. I even have problems recognising the universal facial expressions of emotion. So when psychiatry focuses on something called ‘depression’ they are attempting to treat the consequences (rejection or ejection from normal purposeful social interaction) rather than the cause.

c) Finally there is a third process which even neuroscience, let alone psychiatry, hardly recognises and about which I’m only aware of the consequences - and that is handedness. I am very left-handed, instinctively a southpaw, but I also want to move anti-clockwise, often transpose figures and letters - all in a world designed by right-handed people. But of course I’ve known no other world and I am well adapted. Nevertheless I have the horrible suspicion that these instinctive ‘reversals’ happen all the time when I try to relate emotionally to others - and if they do, what must others feel about me?

However one of the implications of the above, and much of the content of this blog, is that a search or journey for conscious explanation is merely a ‘story we tell ourselves’, after the fact and of no causal consequences, and so must be of no importance when attempting to transform one’s own, or anyone else’s behaviour - our routines, rituals, habits and addictions. One should of course be asking what does Nick Hewling do, and ‘how’ does he do it?

I like to think of myself as a mental health peer supporter. I have much greater confidence in my understanding of people when they’re crazy than when they’re together! I almost always know how to react in a useful way. I’ve done my 10,000 hours and some of that learning has become instinctual. On the one hand I’ve always despised those workers who don’t live in the area in which they work and therefore don’t know a client’s territory, who believe their work can be professionalised by impersonal rules of best practice and imagine therefore they can use some different psychology than in their ‘personal’ lives. But equally I’ve come to mistrust the kind of peer support that has been turned into work, formalised and made ‘intentional’ - which rapidly comes to resemble the kind of talking therapy it was intended to replace. I’m accountable only to myself, my rules of effective and ethical conduct have evolved over two decades. I can operate when I like, where I like. To my mind you cannot be an effective helper unless you can do it standing up in the street, or in a bus queue with an audience of ordinary people. What the person in mental distress needs, is support to feel at home in normal social spaces. And I don’t mind occasionally looking crazy to outsiders in order to build a rapport with someone who is being activity avoided by others. Confidences can be offered and received when necessary in the normal way, in close proximity with appropriately lowered voices. Of course such informal peer support is increasingly facilitated by web-based social networks.

What workers think they achieve in one hour in an isolated consulting room I cannot imagine, I’m often with clients before and after such an appointment and actively undoing their work. Having lived in my local area a long time I’m now quite conspicuous, but have come to know the routine of so many clients that I can have as many ‘chance’ encounters as I like. My activity is also purposeful in another sense, I do ‘set the stage’ a lot, contriving the time, location and activity - so as to create an atmosphere conducive to new learning. Motivation can only come from others, and in pursuing people one purses knowledge and skill, I practice social skills like I practice rolling and smoking a cigarette. I know what others want from me; warmth, confidence and competence, humour, to feel what strength I have so they can feel safe and good about themselves. They want my ability to be serious without making heavy talk. I do it by turning my fear and judgement into curiosity, confidence and competence, doubt into accurate assessment, the desire to control into the ability to live with change and uncertainty. I model, verbally and more importantly non-verbally, more effective ways of being with.

Monday 1 November 2010

Homelessness and mental health

Sometimes you just have to be outside.

Those who are homeless and have mental health problems, have different needs from those who don’t. Like other people who are homeless they are highly likely to be users of street drugs and alcohol, they may have been forced from home due to various forms of abuse, relationship breakdown or for economic reasons. Nonetheless their priorities are often different, and almost certainly different from those charged with helping them.

Social workers, social services, the police and more specialised outreach workers often just don’t ‘get’ why someone wouldn’t want even the most basic of accommodation. But that’s not to say they don’t welcome the right kind of help.

Mental distress and a sense of confinement go together. The opportunity to escape, sometimes at a moment’s notice, for longer or shorter periods may be paramount. For some that requires physical space and even an open horizon.

Prior to the current recession the homeless had been becoming less visible than at any time in the last thirty years or more, not simply as a result of economic prosperity, but because of concerted efforts by various authorities to tidy-up social spaces - 24 hours a day. A combination of the police moving the homeless on from town and city centres, plus government and charities providing more hostel beds and more flexible forms of social housing, meant that to be on the streets by choice became more and more difficult. Rough sleepers had to become more discrete. Road and railway cuttings, embankments and bridges - rather than railway stations and town centres. In fields and hedgerows, rather than within the village.

Despite the impression often given in the media, most homeless people/ rough sleepers/ young runaways/ missing people tend to stay within their own territory. And although the population is much more mobile than it once was, it is still the case that a homeless person is likely to remain within a few miles of the home they felt forced to leave. A runaway from a Devon village is quite likely to meet an ex-Royal Marine whilst kipping on a south Devon beach! (Although some younger people undoubtedly do head for the capital, most of London’s rough sleepers are Londoners. At one point people joked that there were more outreach workers at London mainline stations than runaways).

Now the homeless population is growing again - but are they really more conspicuous or less easy to ignore? It is often argued that the general population becomes easily desensitised to their presence. Well, we can block-out all sorts of things, and when we do, that simply forces the rough sleeper to seek out better locations for spot-begging. The portal of an ancient church, which just happens to be en-route for some of the more well-heeled commuters at eight in the morning in my local city - is much favoured. Enterprise is often rewarded. But for others, crowded streets are as much a nightmare as a spacious night shelter may be - too confining by virtue of the company you’re forced to keep. But just to be seen alone is perceived as a threat by some, and a reason for others to impose help. A trusted companion may be welcomed at times, but only for certain things. Physical freedom, in town or country, in order to pursue any activity, unaccompanied or unsupervised, is at an all time low. Space is not free but certain spaces are left vacant at certain times of the day and night. Rough sleepers will commute into towns to beg from commuters and just as purposefully leave again.

Most helpers want to put back together that which is perceived as having fallen apart. Most obviously in the case of children there is the insistence on returning them to the source of their distress after they have taken the constructive step of removing themselves from perceived danger - which often leads to worsened circumstances. But the same thinking is applied to adults too, albeit through ‘expert’ advice rather than the force of the law. People make themselves homeless when there is ‘nowhere else to go, and no one left to turn to’. But when life at ‘home’ becomes impossible and individuals feel forced to leave, family and professional helpers do conspire - made possible by the distressed person’s inability to explaining themselves to others.

It’s more difficult to jump trains (fare-dodge) than ever before. And of course it was never possible to be a ‘hobo’ on the UK rail network (jump freight cars and be a seasonal agricultural labourer - outside, and on the move). Equally the ancient art of hitching lifts on roads has died-out, unless you are clearly identifiable as a fellow member of a very small number of occupational groups. Railways however have a traditional, although dwindling connection with homelessness in the UK. And that connection is linked inevitably with the number of suicides that have occurred on or around railways. I’ve written elsewhere on this blog about suicidal thoughts and actions, but there is one exception to the views I’ve already expressed and that is what has become known as ‘suicide by train’. My sympathy goes out-the-window when someone attempts or succeeds through such a method. If you are determined to make life as unpleasant as possible for the largest number of people by your voluntary death, then suicide by train is the way to do it.

Choosing suicide by train in the mistaken belief that death is both instantaneous and easy; the track-walker, platform or bridge-jumper, when successful, dismembers themselves and leaves the greatest possible mess for others. And when the British Transport Police, for it is their formal responsibility to clean up, euphemistically refer to the ‘torso’, they simply mean the biggest bit they can find. Of the many people potentially traumatised by such an act, the train driver often suffers the particular experience of witnessing the before, during and after of an act in which they are both involved but powerless. There have been some initiatives in the UK to provide counselling for drivers, and training for station staff in suicide prevention. However the modest amount of research into suicide by train has principally been undertaken in Canada and Sweden.

But what is really missing is an appreciation that homelessness is not just a precursor to suicide for many with mental health problems, but a process in which an individual my progressively loose their adaptability to modern living and revert to more fundamental and natural behaviour. For although suicide may be unnatural, choosing the time and place of one’s own death may not be. The suicidal person often expresses the belief that they have become useless to their nearest and dearest, that those they care about most, would be better-off without them. They cut themselves off, mental and sometimes physically, becoming outsiders to their own group. In this way someone, whatever their age, may in their thoughts and actions come to resemble the elderly. Equally, there may be parallels with our ancient ancestors. In modern Christian mythology, death is about ‘crossing the river’. In a hunter-gatherer ‘form of life’, a natural lifespan comes to an end when you can no longer cross the river without endangering the lives of your family and group. I’ll end therefore with a quote from Jacob Bronowski in The Ascent of Man, reflecting on an incident recorded whilst filming the nomadic and pastoral Bakhtiari of northern Iran in 1970.

‘Who knows, in any one year, whether the old when they have crossed the passes will be able to face the final test: the crossing of the Bazuft River? Three months of melt-water have swollen the river. The tribesmen, the women, the pack animals and the flocks are all exhausted. It will take a day to manhandle the flocks across the river. But this, here, now is the testing day. Today is the day on which the young become men, because the survival of the herd and the family depends on their strength. Crossing the Bazuft River is like crossing the Jordan; it is the baptism to manhood. For the young man, life for a moment comes alive now. And for the old - for the old, it dies.

..What happens to the old when they cannot cross the last river? Nothing. They stay behind to die. Only the dog is puzzled to see a man abandoned. The man accepts the nomad custom; he has come to the end of his journey, and there is no place at the end.’


Support Railway Children http://www.railwaychildren.org.uk/?lpos=fromtheweb - a charity started by UK railway workers, which raises funds for projects principally in India, East Africa and the UK. Includes help-lines, outreach work, family support, education programmes, the recruiting of former street children as peer supporters, plus in the last few years, research. For the Off The Radar (2009) report, 100 experienced UK child rough sleepers were interviewed; 2 out of 3 experienced violence on the streets, 1 in 10 had been sexually abused at home, 2 out of 3 had mental health problems, and almost all had been excluded from school.

Sunday 12 September 2010

Mental health in Groups

Groups went out of fashion in the world of UK mental health for more than twenty years. Now they are re-emerging in a looser form, often as part of wider social networks - an inevitable, if unacknowledged recognition of their role as basic units of society. The new form they take is a reaction against their perceived over prescriptive character in the past, particularly in psychodynamic psychotherapy. However, although the need for group work has become explicit again, those who construct them remain largely ignorant, as in other areas of mental health practice, of progress made in the life sciences, on understanding natural human groups and the ‘social brain’.

My first taste of group work was in 1988, a year after my first admission to a psychiatric hospital. The clinic was a converted country house several miles from the city centre. It was traditional group therapy, in a relatively controlled environment. A large living room, in which 10 easy chairs placed in a circle fitted easily, in a quiet and remote location. It was thought a virtue that we were away from a normal environment, but actually it was so untypical that I soon came to question its relevance to our real world problems.

I realised almost immediately I’d need time, both before and after the weekly one and a half hour sessions, to adjust to the difference with the outside world - sometimes up to half an hour to get my head together. It began as a closed group of 8 clients with 2 nurse therapists as facilitators (smaller groups were thought too intimate, larger increased the likelihood of two conversations developing). When someone failed to turn-up the empty chair was left as it was. The facilitators were there when we arrived and stayed seated until we left. They sat across from each other - an obvious way to ‘cover’ the room and cue each other! (It was easy to start thinking like that because they were so ‘non-directive’, many of the clients in contrast were actively looking for advice and direction). They rarely intervening, but most members wanted explanation, insight and leadership. The group didn’t remain closed for long however because people steadily dropped-out. For newcomers it was more difficult to join an established group. I remained for eighteen months.

The idea of a Group as presented to us was that in such controlled circumstances, the masks we presented to the world, or screens we hid behind, would be removed; problems we hid from ourselves and others would be revealed, the unconscious forces that led us to replicate mistakes exposed. We would be encouraged to express both positive and negative feelings as they occurred, and have those thoughts and feelings accepted by the group. We would be helped in learning how to express emotion.

I discovered later that the therapists had been trained in a psychodynamic approach, although there were no explicit references to transference relationships (let alone counter-transference), defence mechanisms or indeed a group dynamic. We were however gently reminded of how we might be bringing past and present relationships ‘into the room’ replaying them or acting them out. We all found it difficult to articulate problems in front of the group and cope with the reaction of others, but the desire to ‘do archaeology’ (dig-up the past) was strong, in preference to confronting what was happening between us in the ‘here and now’. But it always remained the assumption of the therapists that what we were doing was seeking insight, and that that in itself would provoke behavioural change.

Pre- and post-group meetings between members were not allowed, but they took place nonetheless. Indeed these encounters led in time to my being a guest at the family home of one of the older male clients on several occasions, and to my meeting outside the group with one of the younger female clients. Also, with a third member, I had one of those moments of disbelief upon meeting someone you have heard talked about incessantly, in this case the person’s partner, and immediately concluded they’re not a bit like you’ve been led to believe!

I found the therapy sessions often quite exciting but emotionally draining, a tension between what I was observing and feeling. People would try to sit in the same seat every week, and become quite disconcerted when I didn’t. The ninety minute sessions were not at all egalitarian, clients competed for time for themselves, some tried to ‘hog the limelight’; others more subtly, would seek to shift the conversation in the directions they wanted to go, some sought alliances, some to mediate, some seemed to just want to belong, others to be accepted as they were. Within a session there were short periods of half an hour or so when real work seemed to be done in a mutually supportive way. But the events within the group were much less dramatic than those recalled by the members from their lives outside it.

My sense of mental wellbeing certainly improved whilst I was in that first group and for almost a year after. Since then I’ve been part of dozens of groups intended to have some sort of therapeutic effect, and structured and managed to varying degrees. I’ve come to prefer the more informal groups one can contrive for oneself with ones peers. The first thing to emphasise is that it is the activity, or the making of relationships themselves, which is important rather than some imagined product or outcome.

An old, but illustrative example from inpatient wards is what might be called, The Art Room Versus The Smoking Room; it is common for the outsider to view The Art Room as an area of calm, purposeful activity with a definite outcome. They may express surprise when after an hour’s absorption in making a painting, a client simply walks away discarding their individual effort. They may seek to praise the client’s work, suggest it be kept, or put on the wall. The client shows no interest in this - it is the hour away from his or her intrusive thoughts that is important. In contrast The Smoking Room is viewed by the outsider as the antitheses of healthy activity; dark, poorly ventilated, clients indulging their habits for nicotine and caffeine, sitting around in unfocused, purposeless conversation. Yet flow, the loss of self-consciousness first experienced in childhood, often occurs in one-to-one conversation (occasionally with more). From the client’s point of view here is the opportunity to talk to each other about the very things that they are unable to express to staff, and which other clients are better able to understand. (It’s worth noting in passing that clients will often ‘protect’ staff psychologically, by not discussing issues and behaviour they have come to know will disturb them).

Secondly real facilitators do not teach. The term has been much abused. It does not refer to someone who arrives in a group with an agenda, with things they will teach or seek to demonstrate. (They would certainly not stand-up, use a flip-chart and lecture to a group!) A proper facilitator is a member of the group, and is unlikely to intervene until they have come to know the group. They seek first and foremost to be fully in the room, sensitive to the feelings of both the group and the individuals within it. Interventions occur when they seek to redirect conversation or activity towards areas which their experience suggests are useful. Thirdly, groups always have a ‘star’, but they are not leaders appointed or accepted by the group, but the person who appears to be get most from the group, changing or benefiting the most. Other members often respond positively to that person as an example or role model, but sometimes negatively as yet another example of how they are failing!

Fourthly, since the activity of the group is all - and the ‘here and now’ a group’s proper concern - it is important to what extent someone is in the room, living in the present moment, able to let go of thoughts and feelings about the past and future and fully participate. For example, one person sits alone in a corner of the room; are they agitated and their thoughts miles away, or are they calm, quite and possibly acutely observant? Alternatively, is the person calmly absorbed in an individual task, or agitated by their observance of what is happening in the room? The person who is not participating remains an outsider. Often clients are forced to remain outsiders despite being in groups. Staff are usually part of a fixed group outside of the activities they devise for clients. They have their own professional competencies and ‘codes’ of behaviour. In so far as they bring such ‘values’ to the group, they prescribe/ pre-determine group activities and relationships before it even starts, and so always exclude clients. But staff of course then remain outsiders to the shared concerns of clients. Clients have informal codes of behaviour too, and confidences which they share only with each other - not just because they may feel misunderstood, or wish to protect, but because of the practical consequences of giving information to the mental health services which may be passed on, recorded and acted upon. Clients often form self-help groups of ‘like’ people - they gain the emotional bond of shared experience, but they also share the same strengths and weaknesses.

Fifthly, as in any social encounter what the participant remembers or ‘takes away’ from a group is rarely a precise memory of what was said. What is remembered is the atmosphere or mood, whether it was a good experience; relaxed and friendly; or anxious, hostile or perhaps aggressive - a general feeling of like or dislike for the other participants. Finally, practice has taught me that the more mobile, less routine and predictable a group’s activities can be the better; but all change, good or bad, is stressful.

However, even the very basic level of interpretation I’ve given to group activities is often frowned upon these days within the mental health industry - giving choice to the client and upholding ethical and sometimes political values, means not seeking to understand social processes. (The very antithesis of what this blog is about). Social networks are thought okay and their voluntary nature emphasised, but at times even encouragement to join is thought too prescriptive. If only mental health professionals were more aware of the content of genuinely peer organised activity, or indeed online activity! But the basic drive to belong is recognised, and loose open groups with no fixed location guard against dependency and institutionalisation. Changing your environment and finding new people to motivate you, are the only elements that will break old habits by replacing them with new more useful ones - the brain is just like that.

Throughout recorded history there can be found observations by the socially curious on what might be the natural or optimal size of a human group. At the lower end groups begin at around 5 - the basic family unit. More than that and two ‘conversations’ emerge, at around 8 to10 a group begins to have divided loyalties. At the upper end it has long been noted that where people live, work and play together then at between 100 and 130 they will split into two new groups. Doomsday Book gives you an average size for a village of 130, recent archaeology offers a similar figure for earlier Anglo-Saxon settlements. The necessity for battalions, the imposition of a chain of command to control numbers larger than the basic unit of a ‘company’, emerged in Roman times. Today, some isolated religious communities with long traditions will anticipate a split, and plan for the division of resources, as their numbers approach 100 - one of the new groups will relocate locally, but separately. Promising small businesses which expand rapidly are notorious for failing when the number of employees exceeds about 130 if they don’t radically devolve away from the ‘hands-on’ day-to-day personal control of one individual or family. (The late Wilbert Gore, he of Gore-Tex fame, allegedly built factories with only 150 parking spaces - when people started parking on the grass he knew it was time to add a new small plant elsewhere rather than expand on the same site). Whilst for ‘bandits’, or other family-controlled outlawed groups, then holding the group together may become their principal preoccupation!

The key recent insight has come from Robin Dunbar (Dunbar 1992, 1996) in his study of grooming behaviour in primate groups. Having observed the stable group sizes of other primates - the number that any one individual can effectively groom - he made the intuitive leap that the natural size of social groups is directly proportional to brain size (more specifically the neocortex, the cognitive processing bit!) What followed was a complicated statistical exercise, including making allowance for brain size relative to body size, which hypothesised an upper limit for a human group holding together of around 150 (mean group size 147.8). (Indeed amongst the 21 modern hunter-gatherer groups Dunbar considered, the average size was 148.4).

One shouldn’t underestimate the implications of ‘Dunbar‘s number’. We are social animals and whilst we can recognise thousands of faces, our brains have a limited memory and processing capacity - there are only so many people we can truly ‘know’; both in the sense of cognitively knowing enough to understand and therefore have a relationship with, but more fundamentally, the capacity to feel for, care about and be emotionally attached to. The ‘bands’ in which our distant ancestors lived were of course comprised of their closest genetic relatives. There was no distinction between those with whom they lived and worked (shared a culture with) and those with whom they had a strong genetic attachment or attraction to. In our world we are very unlikely ever to meet those closest 150 relatives for whom our brains are forever searching.

However, it remains the case that our loyalties are limited; to be cautious or even hostile to outsiders or strangers is normal, so is discrimination and exclusion. As you get to know too many people it is common to ‘become a stranger to’ someone you once knew well. Equally, we should be wary of those who claim to be entirely ‘open’ people and a friend to all the world. There are some things we cannot succeed at, we are severely weakened if we are not either fully participating in our own groups or are over ambitious (compromising our chances of survival) and try to embrace beyond the capacity of our own brains for emotional attachment. The benefits of training, education and the ‘collective brain’ offered by computer technology cannot override the social brain. We do better when we recognise fundamentally different or opposing interests and negotiate with other groups with different interests and loyalties, rather than pretend we can embrace the whole of humanity. We should suspect delusion in those who espouse selflessness and claim self-sacrificing devotion to too many. We may well have a primal drive to belong, but only to our own group.

(Note - I’m only implying ‘group selection’ in cultural and not biological evolution, none of the above contradicts neo-Darwinism which I take as a given in everything written on this blog).

Dunbar R (1992) ‘Neocortex size as a constraint on group size in primates’ in Journal of Human Evolution vol. 20 pp. 469-493

Dunbar R (1996) Grooming, Gossip and the Evolution of Language Faber & Faber: London

Thursday 5 August 2010

An imagined spiritual journey


The first scene always begins when I walk into a railway booking office and ask: ‘Please could you tell me the price of a single ticket from Penzance to Berwick-upon-Tweed?’

The journey begins when I am nineteen years old and ends, well, whenever it ends. The staging for the journey is England in the late 1920’s.

The journey is the walk from the actual start to Penzance station; by railway to Birmingham Snow Hill, from Birmingham New Street to Leeds, Leeds to York, from York to Berwick-upon-Tweed, and the walk to my final resting place.

Readers familiar with the early English church will know the actual start and finish points, plus the ‘stations’ on the journey, but may be surprised that the route appears to be being taken in the ‘wrong’ direction - but then, I am a left-handed person in a right-handed world!

In reality the route passes within fifty feet of my present home, within a quarter of a mile of my second childhood home, within two miles of one of my adult homes, within ten miles of my birthplace, within two miles of my father’s birthplace, within a few hundred yards of my paternal grandfather’s workplace, and within four miles of my first childhood home. Physically knowing the route from the late twentieth century, and having a knowledge of railway history, allows the staging to appear real in my mind.

Throughout the journey I carry a copy of Q’s anthology (soft leather cover, printed on India paper with gold edging). It is open at John Clare’s ‘I Am!’

It’s a journey through a constantly changing landscape; speed (the measure of time) also changes, but I for the most part, remain stationary.
The journey begins with the going down of the sun on one day, but ends with the dawn of another.


(At the time of writing I appear to be starting the journey for the fourth time. I am forty-eight years old.)

Nick Hewling 12.8.07

Tuesday 27 July 2010

The answer... (updated 2023!)

What follows is an outrageous exercise in selecting half-quotes, which I’ve strung together into two paragraphs, all taken from the final chapter of Sue Blakemore’s The Meme Machine (see January post What are memes? Sue Blackmore explains) However they all appear in the order in which they were written, and I believe provide an accurate summary of the conclusion of the book. Indeed they are the passages and phrases that I have highlighted myself (in yellow!) on my own photocopy of the chapter which I carry in my satchel at all times.

‘..Only when we see a human being as a product of both natural and memetic selection can we bring all aspects of our lives together within one theoretical framework. ..Memes fight it out to get passed on into another brain or book or object, and in the process cultural and mental design comes about. ..There is no need to call on the creative ‘power of consciousness’, ..Free will, like the ‘self’ who has it, is an illusion. ..explanation adds nothing. It is just a story ..after the fact. ..all human actions, whether conscious or not, come from complex interactions between memes, genes and all their products, in complicated environments. ..by consciousness I mean subjectivity - what it’s like being me now. ..not a force, or a causal agent, that can make things happen. ..the most mindless and least conscious of our actions can be imitated just as easily as our most conscious ones. Cultural and social variation is guided by the replicators and their environment, ..new ideas came out of the combinations of the old. ..a combined product of the genes and memes playing out their competition in ..life. ..The creative achievements of human culture are the products of memetic evolution, ..selves can often do more harm than good, for creative acts often come about in a state of selflessness, or loss of self-consciousness, when the self seems to be out of the way. ..knowledge is a kind of adaptation. So is foresight. ..comes about by selection, only in this case it is selection between memes.’

‘..the ‘me’ that could do the selecting is itself a memetic construct ..The choices made will all be a product of my genetic and memetic history in a given environment, not of some separate self that can ‘have’ a life purpose and overrule the memes that make it up. ..there is no room for anyone or anything to jump into the evolutionary process and stop it, direct it, or do anything to it. ..and no one watching. ..how can ‘I’ live as though I do not exist, and who would be choosing to do so? ..concentrate on the present moment - all the time - letting go of any thoughts that come up. ..kind of ‘meme weeding’ ..in any moment there is no observable self. ..Ideas will come up but these are all past- and future-orientated; so let them go, come back to the present. Just notice what is happening. ..pay attention to everything equally. ..attention is always being manipulated by things outside yourself rather than controlled by you. ..and created you. ..there is no distinction between myself and the things happening. It is only when ‘I’ want something, respond to something, believe something, decide to do something, that ‘I’ suddenly appear. ..‘I’ in the middle - me in charge, me responsible, me suffering. ..Learning to pay attention to everything equally stops self-related memes from grabbing the attention ..waking from the meme dream. ..accept that the selection of genes and memes will determine the action ..just get out of the way and allow decisions to make themselves. ..it is odd to observe that actions happen whether or not ‘I’ will them. A great sense of freedom to let so many decisions alone. You do not have to try to do anything or agonise about any decision. ..letting the false self get out of the way, and the decisions make themselves ..the whole process seems to do itself. ..hope and desire are based on the idea of an inner self who must be kept happy ..meet them all with a refusal to get involved ..life really is possible without hope. ..people become more decisive rather than less. ..the selfplex ..it is there for the propagation of the memes that make it up. Its demolition allows more spontaneous and appropriate action. Clever thinking brains, installed with plenty of memes, are quite capable of making sound decisions without a selfplex messing them up. ..you stop inflicting your own desires on the world around you and on the people you meet. ..giving up the illusion of a self in control. ..guilt, shame, embarrassment, self-doubt, and fear of failure ebb away and I become, contrary to expectation, a better neighbour. ..When there is no selfplex, there is no concern about the future of my inner self - whether people like me or whether I did the right thing or not ..free to notice other people more. ..easy to see what another person needs, or how to act in a given situation, ..stopping all the harm we normally do, ..there is no one to rebel.’

..the question of course was; how does cultural and social evolution work?

2023 - time moves on and I no longer carry a physical copy but a digital one on my mobile device, now even more simplified and arguably even more of a distortion of Sue's original!


Saturday 17 July 2010

The humour in madness

As users of mental health services we end up ‘performing’ to a kind of script. Such is the way services are organised, we find ourselves telling our story over and over again to a variety of workers as part of our treatment. A small minority of us have also told aspects of our ‘personal journey’ during training sessions for workers. But including the humour of your situation, doesn’t often go down well. Or maybe it’s just me and the way I tell it, since it does tend to be quite black!

So whilst there is often humour in mental distress, you don’t often get the chance to share it. Take for example suicide, finding others who are happy to discuss such thoughts and actions is rare, having the opportunity to add the humour too, is rarer still. Occasionally wonderful things will happen, like the time I was in a cafĂ© with a small group of fellow clients, plus a couple of workers, and the guy next to me started to peel of his shirt to show me the consequences of failing to hang himself. We laughed together for a moment whilst the others sat in stony silence. But what we were laughing about was not so much the absurdity of an incident that had happen six months before, but that he had found himself laughing about it within half an hour of it happening.

When suicide is the subject there seem to be two sources of potential amusement; the absurdities and contradictions of the situation itself, and the ideas and language that mental health professionals bring to it. And the two may seem to bare very little relation to each other - providing an ironic twist.

Like the identification of suicide ‘hot spots’ which are then fenced-off with the occasional telephone provided, leading to the action simply moving elsewhere. How studies of ‘suicide by train’ highlight platform behaviour whereupon the potential suicide just moves further on down the line. The very rigidity of the professional’s model of ‘suicide prevention’ (while we have a ‘duty of care’ we never leave the client alone), which leads us to lie about getting better. And how for the last fifty years they have rolled-out prevention training (to which the experienced client is almost never invited), which often includes how to spot the deceiving client! But such ‘arms races’ arise out of the contradictions of the situation.

The simple fact is that the clients intend to kill themselves, but fail due to incompetence. They then learn from experience, as do those who seek to prevent them. And that game (for it does appear to have rules) can go on for decades, leading to bizarre and absurd behaviour by clients, carers and workers - played out in domestic and clinical settings. Ridiculous because eventually everyone has to be left alone, and even the most confined and watched person can still exert choice. Thankfully when peer supports peer, there is the opportunity to create a space to talk about the real issue - is life worth living? The chance to create distance from the pressures of daily life, time to create more choice, more freedom to act, be in a new situation in which the world looks different (you do an activity with your peer today, which shows the world to be a less fearful place) - where the supporter takes the responsibility and where only very occasionally will their role be to clean up afterwards.

Humour can be an acceptable way of educating and getting information into the public arena - if you’re a ‘jumper’, height is important. Choosing a multi-story car park may well mean ‘a one-way ticket to Stoke Mandeville!’ If it’s to be a hanging, then consider the ‘drop’. No drop and it’s up to half an hour of slow strangulation; with a drop, the length required varies with build and body weight - and will what you’ve attached the rope to, take the strain?

A year or so ago the stand-up comedian Mackenzie Taylor (http://news.bbc.co.uk/local/berkshire/hi/people_and_places/arts_and_culture/newsid_8701000/8701610.stm) developed a routine, based around his history of mental distress, and one particular suicide attempt, entitled No Straightjacket Required which he performed at the Edinburgh Fringe. I was lucky enough to see a preview in which he made some telling observations on; the therapist who never laughs, the distressed mind being like Jazz with eight things happening at once, how political correctness led the BBC to deem ‘brainstorming’ offensive, how the NHS made him a ‘client’ but never ‘wined and dined’ him, how you may have to wait for the second train since the first may be coming to a halt, on why he seemed so happy beforehand (because he had a plan which would bring all his troubles to an end), why the right combination of pills and booze might be thwarted by what you’d eaten before…

‘What's funny about a man who tried to kill himself because his unstable mental condition had pushed him to indescribable lows? Well, the answer is a surprising amount. Mackenzie Taylor tells the audience all about his attempted suicide at the end of last year's Brighton Festival, never shying away from the often incredibly harrowing details of what brought him to try and end it all. It is this completely honest, open discussion of mental health which really makes this an interesting show, not straight forward stand-up, yet not quite help-group. A show that challenges our approach to laughing at mental health, and the darkness that lurks within all of us. Go see it, or he might try it again!’ - Three Weeks

Friday 16 July 2010

Sex and mental health

The character and diversity of sexual relationships found amongst people in the mental health industry are much the same as in the wider world. This should surprise no one. Just as people often meet their future partners in the workplace, some relationships of enduring emotional and or sexual attachment have always existed - and will always exist - between clients, staff and carers.

However, even more than the neglect of client’s spiritual needs, mental health workers make no attempt to routinely address the problems their clients have in the conduct of sexual relationships. If you have had a useful and productive talk with a mental health worker about sexual concerns, then you are the exception. Most workers have a set of priorities for clients that place addressing sexual needs at the end of a very long list. Yet if the objective is to promote positive change; well, what does most to boost your self-confidence? What is one of the key motivations in life?

Much of what follows is obvious, but needs to be spelt-out, for one should never underestimate the capacity of mental health services to take the commonplace and complicate it with the dead-hand of specialist trainers, rules of ‘best practice’, and endless committees obstructing by arguing about appropriateness. I made the assumption many decades ago that when it came to the treatment of mental distress, I would come across those people with the best communication skills - how innocent of me!

(I’m reminded of the old story of the sociologist who wants to study prostitution spending years raising a grant of tens of thousands of pounds, hiring assistants to find and survey a random sample - when all he needed to do was take a train to the city of his choice, go to the first taxi on the rank, and tell the cabbie to drive him around for an hour. He might not even have had to ‘frame a question’ at all!)

The central problem for most clients is that they do not see successful personal and sexual relationships around them in their everyday lives - they have nothing to learn from, to model or imitate. Even the conversational conventions between men and women, whether partners or not, are often unobserved because clients spend so little time in ordinary social spaces. Equally within organised activities provided by mental health services, it is very rare to find a couple working together.

A person in mental distress is pre-occupied with self, and needs to let go of that a little before the reciprocity required in normal relationships can be ‘seen’. Equally they often don’t understand how relationships have to be made and negotiated, how giving your partner what they want, will get you what you want. Users of services often believe that ‘romance’ happens by chance and then proceeds in some automatic or natural way. They don’t know how much there is to learn and to practice in order to acquire social and physical skill.

Even more than the rest of humanity they have lived vicariously, but without trying to imitate and test, so retain the expectations of Hollywood and the media’s imagined world of celebrity - the dramatic contrasts between idealised romantic love, and varieties of extreme dysfunction. So, whilst it is true to say all clients have experienced the real world as traumatic in some way, often in close relationships, they may at one and the same time have an expectation of ‘more of the same’ coupled with - inevitably - unrealistic expectations of how different and successful the situation of others is. Like everyone else they grew-up believing what they witnessed in childhood was the norm and however well educated now, may still expect the same, sometimes playing-out a self-fulfilling prophecy. But in addition have a profoundly distorted fantasy as to what happiness, fulfilment, contentment or excitement are, or can be.

Most clients who are in the system for many years experience long periods of celibacy punctuated by a series of short, mutually unsatisfactory relationships most of which occur with other clients. As we know, what attracts people are perceived points of similarity, for those who’s social world is so restricted, it is often clients with similar problems who find each other - they share the same strengths, but also the same weaknesses. In such situations little that is new can be learnt - other than how to move in ever decreasing circles.

To achieve any kind of ‘recovery’ requires teaching in the possibilities of intimacy. And opportunities are forever being lost due to the fear and timidity of workers or their managers. A classic example is the so called ‘predatory male’ patient on a hospital ward. Imagine the following scenario. Staff notice a male patient taking a particular interest in a female member of staff; if she is noticeably younger than him and relatively inexperienced, alarm bells will ring. The woman concerned will report that she has noticed his attention because it does not lead to an ordinary two-way interaction, he is overtly interested but stand-offish, not demanding nor conversational, he just always seems to be around, which makes her uneasy. The behaviour is interpreted by staff as inappropriate and as possibly indicative of some covert sexual intent. The action taken is to separate the two people. The male patient then participates less in the activity of the ward, becomes less cooperative or positively hostile. This is seen as confirmation that the staff’s interpretation of the situation was correct and the right decision made.

Wrong. The male patient may well be less cooperative, he’s been rejected again. The staff reaction may well create more extreme behaviour in the future. The male patient looks menacing and predatory because of his incompetence, he’s never had the chance to learn the skills of normal social interaction, how to approach and begin to build an intimate relationship. A major opportunity is lost because the female member of staff is the person he feels most attracted by or attached to - he is motivated by her. In other words, she is the person in the most powerful position to affect change in him! She, whatever her job or status, should be the one to work with him. If the woman is confident enough in her sexuality, then she can enter into a contract with him, which stated crudely would say; you can’t have me, but we can spend a certain number of hours together. We can hang-around so you can get comfortable being around women, and I’ll teach you what a woman like me, wants and expects in a relationship - I’ll show you how to approach a woman like me.

Real outcomes have to be made, and in specific social situations; aggression, violence and abuse arise - like fun, happiness and contentment - as a result of the interaction between people. No one person is ever the sole cause of anything. Just as the way someone is treated in the first few hours of contact with mental health services may set the pattern for years to come, anyone who is trapped or confined by others will, sooner or later lash-out. But equally someone who is confident but non-threatening, can begin the process of change in others.