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hypotheses, plans, ideas about how the world is, and what the people within it think and feel, our map becomes rapidly out of date. If we act with an out of date model of the world - we will look mad to others, and they will treat us as mad.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 An unmodified and out of date model of the world is one where our thoughts and feelings are anchored in the past, hence our predictions of the future may be hopelessly wrong.



Wednesday 16 October 2013

Model STR Worker Quits

A few years back a couple of researchers came to Devon to investigate how the Recovery approach to mental health was being developed. Their guide was the man then responsible for Recovery training and he directed them to interview a friend of mine. They came away from the encounter very excited, one even declared that the subject was a ‘model’ STR (support, time and recovery) worker. The trainer was delighted but not in the least surprised, my friend’s employer however was somewhat taken aback, she had a different view of what an ideal worker was – or possibly, as one wag claimed, she had just never noticed the skills he had.

The incident has stuck in my mind as amusing, though in an ironic way. For one, the researchers were not very good, their subsequent report would have barely passed as part of an undergraduate dissertation; two, the trainer knew that the skills the model worker had acquired had very little to do with his input, but had been largely self-taught from the bottom up. The boss thought the Recovery approach had to be taught, and that someone could not have worked it out independently for themselves. I, as a client of mental health services, and having known this person for almost twenty years now, know that what he does owes very little to training, in Recovery or anything else.
Now he is leaving his post and I won’t be seeing him again as a client. Everyone feels very emotional about this - he’s almost universally liked by both clients and workers. A familiar character known to all, respected for being good at what he does and popular also with outsiders such as workers from other agencies and students on placement.
We’ve always got on too, but we really only have one thing in common - we both failed our ‘eleven plus’ examination at school and therefore drew the short straw in what was then a much more selective school system. He came from a working class background and left school at sixteen with minimal qualifications, whilst I had a middle class upbringing and eventually got a university education. These days we would both have undoubtedly been diagnosed as dyslexic. It was his eldest child who became the first in his family to go to university. But that bit of shared background has given me the legitimacy to challenge him from time to time on his reading and writing skills and the psychological barriers that schools often erect. (There was nothing Recovery-like about the way I manipulated him into learning to write emails!) But then I’ve always known ‘he’s everything I’m not, and I’m everything he’s not’, in those situations, so long as you keep talking, you can make it a win-win situation, where ‘the whole is greater than the sum of the parts’. 

As a young man he joined the Merchant Marine and during the Falklands War found himself stuck in mid-Atlantic aboard a tanker deployed to refuel the naval task force. There he acquired the ability to maintain his physical and mental balance on deck in the face of the heaviest swells that could be tolerated whilst transferring fuel via a pipeline suspended on a line to another ship. That’s a skill I’m convinced is not unrelated to being able to ‘hold the centre’ when in a confined space full of constantly moving people in varying degrees of mental agitation and distress. When he started supervising group activities with mental health clients in day-centre settings he had no mental health training and no experience.
He married a local girl who’d been to the same school as he, has continued to live, work and raise a family in the town in which he was born and brought up. As a mental health worker he walks the same streets as his clients, and it doesn’t bother him if he runs into them on any day of the week. Such a situation is actually very rare, most mental health workers don’t live in the same place as they work and don’t know their client’s territory.

We first met back in 1994 when my new CPN dutifully took me on a tour of local social activities for those with mental health problems, my friend was running a group in a rundown school building twice a week, he was offering conversation over the newspapers, a cooked lunch and a video to watch in the afternoons. The first thing I noticed about him, apart from his distinct accent, was how upbeat he was. We didn’t meet regularly for some years, but it soon became apparent from occasional encounters that he was relentlessly positive. At the time I was prone to a lot of depression and found the habit extremely annoying, to my mind it was mindless optimism. In the years to come, on almost every occasion we met, he would suggest activities I might wish to become involved in, nine times out of ten I turned him down. He’s never lost that positive attitude, but these days his expectations are more sensitive to his audience.
Another annoying habit was calling everyone mate or matey! However it soon became apparent that this was because he had difficulty remembering people’s names - I must confess that in recent years I’ve found myself adopting those very words! More endearing is his addiction to anything free, he had a run of luck a few years ago when he seemed to be winning a radio phone-in competition almost every week. He’s been quite clever at supplementing a modest income with various extras for the family. Thankfully he’s quite strict with himself when it comes to gambling, but more than once, when I’ve been early for an appointment, I’ve been able to find him in the betting shop.

A hallmark of those early years was the ‘Misery Tour’, formally organised days-out using a hired coach which would pick up clients from day centres, half-way houses and residential care homes. You might end up anywhere from Lyme Regis to Plymouth, possibly via Dartmoor. For clients however the scenery was never the priority, nor was the opportunity to meet new people. On alighting from the coach there were only ever three concerns - food, alcohol and or tobacco. For the supervising workers, watching the ‘crocodile’ wind off along the pavement, it was the terror of losing people that was uppermost in their minds. Nonetheless, although social activities have changed a lot since then, the instinct was right, for the value lay in their social nature, a protection against the emotional isolation at the heart of mental distress.
We met one-to-one, once a week, for about five years. We would talk in a cafĂ© or pub, or while out walking, in any one of four or five local towns. From meeting at the agreed rendezvous to saying goodbye, would be about an hour and a half. But like more formal counselling or psychotherapy the encounter had a pattern to it from the initial tentative exchanges, leading to more focused and intense concentration on an issue, followed by winding down to a ‘closure’ with which both parties were comfortable. The real work might happen over a period of only twenty minutes, but the challenge was getting there.

Very quickly our encounters stopped being dominated by me talking about myself and became a conversation. His style was to be anecdotal, the points he wanted to make came in the form of what I think of as ‘pub stories’ with a moral delivered with a laugh and a smile. In contrast, I like to form explanations of human behaviour and ask questions that challenge. The common ground between was that we both based what we said on observation and our own examples. His positive outlook however comes with a kind of fatalism, though he would ‘spin it’ as acceptance! Things are just the way they are, people are just like that, but there is good in everyone! He is ‘non-directive’ by instinct. Equally, he would never use a phrase like ‘unconditional positive regard’, but he claims to have it. I tackled him once, saying it was totally unrealistic, implying as it does that you can like anyone who walks through the door! He countered that he did like almost every client, that there was virtually no one he couldn’t work with. I think he is fooling himself, and what he means, with the benefit of hindsight, is that he can come to like almost every client, that the more he can understand someone, the more he can like them.
We have argued a lot, though in a good natured way. We often talked about other clients and other workers - on the understanding that the conversation remained just between ourselves. That’s how we came to learn so much from each other. Strictly speaking, he broke the rules in numerous other ways too. It is tempting to think that we developed some kind of ‘special relationship’. Was he ‘inappropriate’ with other clients, or just me? But then there really are limits to worker/ client relationships, and those who seek to eliminate the ‘them and us’ attitudes in mental health would do well to remember them. (At one point he was concerned about my mental state and by contacting my then CPN, set in train a series of events which led to me being picked up by the police on a 136, and later detained in hospital - one day I’ll try and find it in my heart to forgive him! A detailed account of that period of my life is the subject of several future blog posts.) But I know many of his other clients too. If I asked him about our relationship in contrast to others, I know what he would say: ‘Everyone is unique mate.’ And of course I’d be saying to myself: ‘Is that it? Is that the sum total of your accumulated wisdom?’  

What I do know is that I give value for money in a way other clients don’t. I have a lot of knowledge and expertise that others have not had the opportunity to acquire. Challenging others however, requires hard brain work and intellectual confidence. Which is not to say of course, that at other times I can be as non-responsive as the next client.
It was during this period that the organisation for which he worked adopted a Recovery approach, and also began to address the forms of dependency that many clients seemed to have carried with them from the old institutions into their lives in the community. Day-centre type work took on a different character as workers sensitised themselves to the ways in which they may have reinforcing a client’s fixed and unhelpful routines. They learnt to let go a little, and not conspire in closing down any opportunities clients had for breaking-out of habitual thinking, behaviour, and emotional responses. It is one of my friend’s great virtues that if someone can point out something he’s missed he’ll be eager to learn rather than be defensive. Having undertaken some basic Recovery training himself, eighteen months later he was urging me to do the same. It wasn’t long before we were attending the same seminars. He also started using me quite shamelessly as a cooperative client willing to talk at length to mental health and social work students. Equally, for three years I sat as the user representative on a committee which, on behalf of the NHS commissioners, monitored the work he and his colleagues did.

One survival from the old days was the attempt by my friend, once or twice a year, weather permitting, to get as many clients and workers as possible to undertake a big country walk, with the promise of a pub lunch before the return leg. It was on such occasions that, out of their normal environment, you see most clearly the contrast between those in mental distress and others in the community. The way mental ill-health disables physical health, and vice versa. You also notice the contrast between workers and clients more clearly. The natural answer is to imitate the healthy, that’s if you can bring yourself to discriminate between the two, something almost all have had trained out of them. Try telling anyone that the easiest way up a hill is to follow the arse of the fittest female!  A few years ago it was decided to impose a gender divide in community social activities, women’s and men’s networks. The recognition that many clients problems were intimately tied to past traumatic experiences with the opposite sex, led to a cop-out. One ‘well fit’ female worker, for whom I have the greatest respect, refers to men’s network activities as, ‘The Jolly Boy’s Outing’. Now, I can think of various names for female only activities, but then I’m ‘pushin’ it’ already!
He was never much of a one for keeping notes. (When I stopped being a regular client, I was able to acquire the file the organisation had kept on me for ten years or so.) However, when it mattered;

‘20.1.04 NICK TALKED ABOUT MEDITATION TODAY AND DIFFERENT LEVELLS of CONSESNESS, STATES of MIND AND THE CONCEPT of BRIEF THERAPY THE IMPORTANCE of THE HEAR & NOW. A VERY POSITIVE CONVERSATION ENSUED, NICK EXPRESSED HE WAS FEELING GOOD.’
‘3.2.04 TODAY WE TALKED ABOUT SUBJECT’S FROM LITERATURE TO DEATH AND MORTALITY AGREED TO MEET SLIGHTLY EARLIER NEXT WEEK’

‘8.6.04 NICK SAID HE WAS FEELING LOW TODAY AS PAINTING HIS FLAT AND THE HOT WEATHER WAS GETTING HIM DOWN. TALKED ABOUT STRATAGIE’S TO AliviATE THIS. Nick SAID HE WOULD Like THE TRAIN JOURNEY TO TOT NES. AND IS GOING TO FinLAKE ON THE 24th
Perhaps the best way to sum-up the difference between me, the client of services and my friend the worker, is to recall an incident that occurred not so long ago. We were out for a walk with another client who is famous for being quite uninhibited in saying out loud every thought that comes into his head. Sometimes he seems aware of what he does, and able to choose whether to control it, sometimes not. Unless you have been in and out of psychosis many times, much of what he says is incomprehensible. But all of it is spoken using the most explicit language! ‘Hey, keep it down mate! You know I’ve known you ____ all these years and I still don’t understand a lot of what you say’. I couldn’t help interrupting their conversation by asserting: ‘That’s the difference between us, I do understand what he is saying, but don’t want to; whilst you don’t understand, but want to!’

Despite having received care from workers using the Recovery approach and undertaken some training in it myself; I am not a fan, as readers of other posts on this blog will be aware. I would not wish to work in the same way as my friend does, even if I had the skills. Nonetheless, I am in a ‘unique’ position to confirm, what others could only hope was true, that he has indeed been an effective helper of hundreds of people in mental distress.
Finally, here are some photos I took a while ago, they are of course in no way related to the above post…







Sunday 13 October 2013

Normal service will be resumed shortly

photo by Nick Hewling
(Taken in A&E November 2011 shortly before 'Security', or whoever he was, broke my camera.)

Just a short post to reassure you that the writing promised some time ago will appear on this blog in the not too distant future. Alas, my creative efforts have been severely disrupted by two periods as a psychiatric patient. The photos below are from May 2012 and were taken whilst staying on a ward which may be familiar to some readers!

photo by Nick Hewling

photo by Nick Hewling
photo by Nick Hewling
photo by Nick Hewling
photo by Nick Hewling