Careless In The Community

Announcement - Rules Of Engagement

2011-12-03T05:23:00.001Z

I'm still happy to meet and talk to anyone about any aspect of mental health, but it has to be in a public place and not a mental health facility (as has been my 'policy' for 18 months now). However, due to caring responsibilities (and also to fit-in with my usual flaneuring activities), 'cafe conferences' and 'street therapy' now have a more or less fixed timetable - Monday, Totnes; Wednesday, Newton Abbot; Friday, Torquay; Saturday, Exeter. Tuesday/ Thursday part-day, Teignmouth.

Usual contact arrangements, or just hit on me at one of my regular 'offices'.

'..the best is yet to come...'

2011-04-09T20:28:00.000+01:00

It was my intention when I started this blog a little over a year ago to have said everything I wanted to say about mental health by now. Yet I still have a mountain of half-written material. And I must go on, what’s to come is my best work, and builds on the foundations of everything posted so far. I guess I still have about a year to go (assuming my other responsibilities stay the same) before I can leave here, cross to my other blog Hunter-gatherer - the past in us ( http://hunter-gathers.blogspot.com/ ) and begin on the subject that really drives me - evolutionary anthropology. So, I thought I’d just write a short piece about where all the previous posts are leading to.

What is still to come, is first The Recovery Movement (part three); the final article on the Recovery approach looking at two local attempts to put it into practice. That should be followed by my completing an essay (about 6000 words) on my last experience of being an inpatient in 2005, a period for which I have complete medical, nursing, ambulance and police records. It’s working title is I Know, Because I Was There - health records and personal recall, two versions of a ‘psychotic’ episode. Once completed it can then be reformatted into three or four (not too long) blog posts. Following that is another essay for which I’ve allowed my myself 6000 words, and called Challenging Expertise - my misadventures in mental health education; which charts and reflects upon my experience of being a service user in education, being a service user undertaking training in mental health work, and on how academia (at all levels) trains it’s workforce and researches it’s subject. Hopefully it too will convert to three or four reasonable sized posts. This should be rapidly followed by ‘the thesis that never was’, Ways Of Being With - rethinking expertise in mental health. This was the research project which was rejected by a local university and caused me not to complete my M.Sc in Mental Health. It will run to about 12,000 words (half that already) but, minus the stuff I’ve written about before, it should be dividable into six post-sized chunks. It explores the wealth of tacit knowledge involved with being with people in mental distress, then offers a radically different (compared with current practice that is) way of thinking and behaving when trying to be an effective helper. In fact if offers a lot of ancient heuristics which are being re-emphasised as a result of the findings of neuroscience. Then comes The Sound Of Water - on the possibility of an ecotherapy. This piece is a critical exploration of the idea that there can be an ecopsychology and by extension, ecotherapy. Though many practicing green care claim that it amounts to ecotherapy, very little has been written or researched about it. It will also include an application of the principles of Ways Of Being With. Again another four or so posts. Finally Natural Mental Health, a post which asserts that there is such a thing as normal, or better still natural, mental and physical fitness (you can’t really separate mind and body) and that there is excellence in living, which can and should be emulated. After all, imitation is, what is special about human learning.

Needless to say these six projects (amounting to about twenty more posts) have been progressing in parallel for sometime (they need to, if they’re all to fit together!) The final piece should, at one and the same time, become the first post on the new blog about pre-agricultural ‘forms of life’ - how we have spent 95% of our real history as hunter-gatherers, and how that legacy is still with us.

Universal emotional expression

2010-11-20T08:21:00.004Z

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 (http://community.fox.com/drpaulekman/blog/). Lie to me draws mainly on Ekman’s work on micro facial expressions and their connection with deception - emotional expressions which show for about 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 (http://www.youtube.com/watch?v=IA8nYZg4VnI)

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 (http://www.paulekman.com/).

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.

The Recovery Movement (part two)

2010-11-18T07:13:00.002Z

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 2008/9 ( http://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 Illness ( http://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.

Mental health services - the future

2010-11-11T15:52:00.002Z

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.

Walking meditation

2010-11-04T12:23:00.001Z

My preferred form of meditation is to walk.

The basic elements occur naturally, one following-on from another. By focussing 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.

So what is wrong with me?

2010-11-02T12:37:00.001Z

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.

Homelessness and mental health

2010-11-01T13:19:00.001Z

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.

Mental health in Groups

2010-09-12T07:48:00.001+01:00

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

An imagined spiritual journey

2010-08-05T08:08:00.001+01:00

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 Marazion 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 Marazion 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

The answer...

2010-07-27T15:50:00.004+01:00

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?

http://www.susanblackmore.co.uk/

The humour in madness

2010-07-17T16:58:00.001+01:00

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 café 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

Sex and mental health

2010-07-16T19:20:00.001+01:00

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.

Eye movements and mental distress

2010-07-04T06:49:00.002+01:00

Don’t you just love it when someone’s eye movements tell you what’s going on in the rest of the room and what they feel and think about it?

An outrageous claim? Yes, but only if you claim too much.

We take cues from everywhere, so quickly and usually unconsciously that the world around us seems seamless and our thoughts and feelings seem to come from within ourselves. But of course our mental map is not the territory itself, and whilst we can consciously cope with 40 pieces of information per second, our unconscious can handle 11 million. Our motivation to act and most of our learning comes from others. Facial expressions and tone of voice give us the vast majority of our information about others emotions. Language, spoken and accompanied by hand and other gestures, or written down, gives us all the cognitive stuff. Posture, our distance from others, and the degree of touch - tell us our relationship to another in any one moment. But all this information has to be structured in some way in order for us to navigate in the world, and there the eyes have it.

The eyes constantly make small scanning movements, the brain seamlessly puts the composite picture together so we have the complete illusion rather than the more prosaic view seen down a pair of binoculars. But those kind of eye movements can for most practical purposes be ignored, what concerns us here are two types of eye movements which we make in response to the actions of others - both involuntary and initially unconscious but which we habitually tell ourselves, after the fact, were a deliberate choice that ‘I’ made.

Trust your unconscious, it knows more and better than ‘you’ do. Whatever you are thinking and feeling in any given moment is being cued by something in the environment around you. (Remember, sensory deprivation is the fastest way to create madness!)

So, first your eyes will notice (recognise) something in the environment of others and track it before you are conscious of it. You feel a sudden emotion and may even have time to wonder why, before realising who has walked into the room ‘unnoticed’ by you a few seconds earlier. You may think about something from the past, little realising you are watching it happening to others in the present moment. (Afterwards many people will consciously attribute magical or other-worldly explanations to these real, commonplace, and mundane activities of the unconscious parts of the brain).

When observing others eye movements we can see what they notice, consciously and unconsciously, but those movements are overlaid with a second set which indicate their response to what they have noticed.

And it’s at this point that I must be especially careful about what I write, since people have got into all sorts of trouble by overstating the meaning of such phenomena which have been observed over many thousands of years. The problem is that many have wanted to explain the ‘what’ and ‘why’, rather than stick to questions of ‘how’. For the meaning of these second kind of eye movements, often called ‘eye accessing cues’ are almost entirely context specific, dependant on the how well you actually know the person you’re looking at, and of course how well you know yourself - since you are, by virtue of your very presence, cueing them!

The claim is that once you’ve controlled for eye movements in response to activity in the environment, then other movements will indicate how an individual is responding cognitively and emotional to the action around them - how they are thinking and feeling about you!

Now, what follows is my version, and compared with many others, a mild and tentative version, but it’s what my experience tells me is reasonable to claim. First is the observation that there is a marked tendency for people’s eyes to move in one direction (left or right) when trying to access memories, and in the opposite when constructing a thought - imagining some future action. The second observation has been that eye movements tend to stay either level or rise in an upward direction when thinking (particularly visualising), whilst tending to drop below the horizontal when feeling emotions (as bodily sensations, but also as felt in the sounds of the human voice).

When you combine the two elements you get a tendency to visualise thoughts about the future looking up in one direction and about the past in the other. A tendency to imagine future feelings through constructed internal dialogue when looking down in one direction, and remember emotions through the sounds of others speech when looking down in the opposite direction - both with, or without bodily sensations.

If you are in a normal state, that is not mentally distressed, these processes may be so seamless, unconscious, complete and taken-for-granted that you would wish to question their existence. But then you probably exist very efficiently in the world and are genuinely bewildered by the apparent psychological troubles of others. However if you have experienced periods of intense stress and consequent distress, or been witness to them over an extended period of time, and perhaps empathised with those around you a little too much, then you may have noticed the gap, or window that can open-up. Brief moments in which the very construction of social interaction can be seen and felt. The ‘digitised’ bites of which they are made up. A bit like those classic illusions used when being taught about visual perception, or when tiredness late at night causes you to loose the ability to synchronise the pictures and sounds coming from your TV.

But that’s as far as I go, others have and do claim a lot more - as a simple search of the web will reveal. Needless to say that with a lot of testing and matching with both the content of speech and the universal emotions all sorts of possibilities open-up.

Oh! I almost forget - if you are genuinely left-handed (one of the 10 to 13%) then all the above may be reversed, and happen in the opposite direction to the majority! Incidentally, did you know that it you have a diagnosis of Bipolar you are 3 times more likely to be left-handed than the general population…

A Desired Outcome

2010-07-01T20:19:00.001+01:00

What will you feel, see, hear, smell and taste when you have achieved it?

You can bet your life a mental health worker won’t frame the question in such a way, although an NLP practitioner might - that is, what would be the sensory or experiential evidence? Rather your average worker would want some rational, cognitive (rather than emotional), probably written, description of a desired outcome to a well defined problem, which can then be made a measurable target - whether it be on a care plan, a WRAP or as a homework assignment for CBT.

But the real issue however, when trying to help someone in mental distress by asking them to set goals, aims or outcomes, is what I call the ‘future orientation’ problem. The worker is desperate to give hope (the promise of better times to come) and is often relentlessly positive. They ‘see’ the client’s negativity and respond by setting expectations which are too high for the client - today. The client then thinks I cannot possibly achieve that, I could barely get through the door to the appointment. Expectations or future tasks, like the skills and demands of any job, have to be set at just above the person’s current level of functioning. Something that is doable tomorrow!

At 17 (in 1976) I saw the world like Reggie Perrin, but wanted to live the life of Last Of The Summer Wine. In his great speech to the British Fruit Association at Bilberry Hall, Reggie declares:

‘I know that I don’t know and believe in not believing. …Would the sun shine less brightly if there was no purpose in life? Would the nightingale sing less sweetly? Would we love each other less deeply? Man’s the only species neurotic enough to need a purpose in life.’ (David Nobbs 1975 The Fall and Rise of Reginald Perrin)

Likewise, in the early years of Last Of The Summer Wine one could find dialogue such as:

COMPO: I don’t believe in infinity.
CLEGG: That’s what I like to hear - rugged independence.
FOGGY: How can you not believe in infinity?
COMPO: It’s easy.
FOGGY: But you don’t know what it means!
CLEGG: You know. Le infinity.
COMPO: Hoh! No way, mon-sewer.
FOGGY: No prompting. Let’s see what he makes of it. Well, come on Einstein. Let’s hear your definition of infinity.
COMPO: (pause) It means the sky’s got no lid on it.
…[ ]…
FOGGY: You think there is a lid on it?
COMPO: King Street Fisheries have got two mirrors facing each other and when tha walks in, tha can see thyself reflected hundreds of times.
CLEGG: You vain little devil! No wonder there’s always a queue. It’s Valentino here stuck in front of the mirror.
COMPO: Tha can see thyself hundreds of times. Tha goes on and on and on.
FOGGY: We’ve noticed!
COMPO: Getting smaller. Disappearing into the distance until it seems tha goes on forever. Now some clever twog might think he’s in infinity when he looks in that mirror, right? When, all the time, he’s in some tatty little chip shop.

(Roy Clarke 1977 ‘Green Fingers’ [Episode 27] Last of the Summer Wine)

What became the world’s longest running sitcom, began as a tale of men made redundant in late middle age trying to recapture childhood play, and in the process reconstruct the reality of their lives. Time-rich and with a glint in the eye, they set about making relative, the taken-for-granted reality of the other members of their community. The dialogue above might just be about an argument or an attempt to persuade, but it can also be seen as knowledge being constructed and negotiated. Growing-up, I was told I must have a career for it was that which gave meaning and purpose. I just wanted to go Walkabout, to wander aimlessly in the hope of meeting interesting people and of learning something new everyday. I wanted to be a perpetual student, in the best sense of word, as any good academic will always remember they must remain a student. But of course, I ended-up spending the majority of the next 30 years as a client of mental health services!

Stated more mundanely, the problem is that if a mental health worker asks a client outright about their aims and goals they are likely to receive the reply; ‘I don’t have any’, or ‘I don’t know’. For every client I’ve ever met has been preoccupied with the near future - they don’t believe they have a long-term future - and equally have never been able to live ‘in the moment’. It is the potential disasters of the next week and their inability to get out of bed tomorrow which concern them. And with good reason. Mental health has been slow to understand the underlying rationale of positive psychologies. The point being that a normal person sees life a little too positively, with a level of optimism high enough to ride the waves of unpredictable events, but always believing in a brighter future and their ability to influence the outcome. The depressed person (all clients are a little depressed, whatever their diagnosis, due to their isolated situation) is actually more realistic, stares life in the face - is distressed because they see only too clearly. A situation in which the client may see their objective circumstances and limited opportunities more readily than the worker. It is with such basic insights that some experimental psychologists have embarked on ‘happiness’ research - and been blithely ignored by mental health services.

However, a virtue of the ‘define your desired outcome’ approach is that it may allow the brain to better identify anything which might bring you closer to it - opportunities only exist after they’ve first been recognised as opportunities!

Also if you know the who, what, when, how and why - then you can start to rehearse for it. Equally you should be able to identify someone who already has what you want and begin to imitate them. It is certainly easier to move towards something you want, than away from what you don‘t want (where your attention will inevitably stay on the undesired).

So how does one get around the paralysing belief of not knowing what you want? Easy. Outcomes are invented and if you don’t already have one, you make one up. (The real objective after all is the pay-off that comes from purposeful activity itself). Desired outcomes are just plans and fantasies about the future - conceits, albeit occasionally useful ones. They become useful (potentially real) if you can already see a series of actions you would need to take to bring them closer, rather than needing others to act for you. Is there something you can do tomorrow which will bring the desired outcome closer?

But it all starts to unpack when you consider achievability - or indeed ask yourself, how would I know when I had achieved my outcome? (Hence the question at the beginning of this post). The future is unknowable, you are not in control of the environment of others - now is actually all there is. The effective helper is one who acts today to make it easier for the client to getup tomorrow. The idea of ‘outcomes’ is only useful beyond today if it is flexible enough for a particular outcome to be changed in the light of unpredictable events (which occur often) but in the face of which other people’s response will, from habit, be to try to reproduce today, the world as it was yesterday.

Much better to follow an evolutionary social model of human behaviour as argued for elsewhere on this blog and understand that as social animals our motivation can only come from others. Seek movement and change, be always in the moment, let go of both the past and the future. Travel in the hope of never arriving, allow the brain and body to take you where it pleases. And never for a moment believe that the ‘I’ or ‘me’ of the so-called ‘self ’ is fixed forever. Outcomes? Like the past, the future is just an evolving story we tell yourselves about a person on a journey.

'Them And Us' In Mental Health

2010-06-27T07:33:00.001+01:00

When I was a user of services I was often criticised by workers for having an out-of-date and undesirable ‘them and us’ view of the world of mental health. It bugged the hell out of me, because for years I had been trying to act from the opposite perspective (I still am) - but then something would happen that sent me back to thinking ‘they’ occupied some other world. In my everyday life I try to let-go of preconceptions, but then someone says or does something, which shows they still perceive, believe in, or approve of some basic divide.

Now of course, it must be to some extent what I choose to notice, and we all have a tendency to notice differences rather than similarities. However it is unfortunate that most of the time it is workers who are inclined to assert there is no more (or should not be any more) ‘them and us’. I’m also as aware as anyone that amongst workers there is a range of ‘lived experience’ - I myself, between my first and second admissions, was briefly a student mental nurse.

The answer to why a ‘them and us’ situation (and it is a social situation, not an attitude) persists, and perhaps must persist, despite the increasing dialogue between workers, users and carers is really very simple. But first, a look at the proposition:

‘As part of the human condition, we are all engaged in the same daily struggles to maintain our wellness. There are no “them” and “us” - just us. Commonality between us all is emphasised rather than differentiation. Some of us may need more robust wellness strategies than others, but the process is similar for us all. Our daily routines, our relationships and our levels of resilience become very important in maintaining our wellness.’ (Devon LIT Workforce Development Group Recovery - Concepts and application Version 2. 10.4.08)

(This is the missing item referred to in my January post - The Recovery Movement [part one] )

A few years ago I came to the conclusion that as part of my own self-management I had to treat every encounter, every relationship as personal. For the irony is, that the mental health system has traditionally been structured around providing impersonal, bureaucratic care for clients whose very problems manifest themselves in an inability to maintain intimate relationships! My only solution, to guarantee that I act for the right reasons, and feel the right emotions - is to only turn-up to do something today, because someone I care about has asked me to be there, or because I am likely to meet someone I’m attached to.

The fundamental building blocks of ‘them and us’ are the Mental Health Act and client confidentiality. By virtue of being a user it is so easy for workers to maintain the notion that you’re the one with the problem. You feel constrained in the way you are with them - I must look calm, not agitated, the things I say must sound reasonable. Because you know the person you’re talking to only has to make one phone call, express their ‘concern’, and a whole chain of events may lead to the use of the Act. It’s a sense of vulnerability that persists despite it being over five years since my last admission. I know my self-management skills are excellent, that there is no need for me to ever be an in-patient again, but nonetheless, the feeling remains that the obligation is on me to conform to their perceptions of reality. In a sense, my fear still allows ‘them’ to define what ‘appropriate’ behaviour is!

Client confidentiality is presented as protection for the client, but it’s convenient for them too. Remember, in the vast majority of encounters it is we who disclose not them, and our notes usually record what they choose to record. They decide what can be kept confidential and what they are ‘obliged’ to share with other workers and agencies. Equally, you inform them about concerns regarding yourself, and occasionally other clients, and they choose whether to act. And there need be no comeback for them. Because you are seen as the one with the problem the quality of your knowledge and judgement is rarely acknowledged, let alone acted upon.

There is however a third factor which helps to maintain them and us, it is the way that Involvement (public participation and feedback) is organised. Involvement procedures have become as bureaucratic as the rest of the mental health industry. The rules and regulations, intended to be objective, calculable and de-personalised in order to treat everyone the same, with fairness and equality, mean the individual can rapidly be lost - more remoteness is the last thing someone needs who has become ‘ill’ as a result of a lack of communication skills in interpersonal relationships!

No one service user’s view becomes any more valid than that of another on any particular issue. Although we have differing skills, this counts for nothing - we are all ‘experts by experience’. So when at a meeting each of us gets an equal opportunity to state our views and we say different things, the consensus seeking Chair (having allowed us to ‘let of steam’) need take forward to others - what? One mechanism of bureaucratic control is to be told that whatever your view is, though legitimate, is yours alone - a cause for individual complaint or change in treatment, but not a reason for workers to question their working practices.

The workforce however is divided into professions with what are thought to be unique sets of knowledge and skills (the specialised division of labour) which they must maintain, or lose their value in the job market. There are good reasons therefore for them not to work collaboratively, and management may also concur, not wanting their workforce to identify a collective interest with each other. The Involvement worker stands between client and service provider or commissioner, describing themselves as facilitators or trainers (training staff how to Involve, and clients how to become involved) but may in reality act as ‘gatekeepers’. They will encourage the client to see beyond their own problems and learn the manners of consultation and compromise. But often what occurs is a process of incorporation, whereby the powerful group facing opposition seeks to incorporate the members of opposing groups into their own organisation as a way of nullifying that opposition. Such individuals often rapidly take on the values of the group to which they were formally opposed, and indeed can then be used as a channel for ‘selling’ the dominant group’s set of values back to opposition groups as a whole. As Involvement develops, as users and carers sit on various NHS committees, it is unclear whether they sit there in their own right or as in some sense ‘representatives’ of their own groups or networks. A few years ago my local mental health trust formalised its payment policy for Involvement. (Workers are always keen that the ‘contribution’ of clients and carers be recognised; in their turn some will refuse to attend unless they are paid). The Trust recognised three levels of payment, each with its own mini ‘job description’ on the expectations and obligations of the role, from simply turning-up, to doing work for and being responsible to a particular committee whilst at the same time being a ‘representative’ of, and feeding back to, any user or carer group the individual might belong to!

Involvement activity also has something of the character of ‘consumer rights’ or political ‘special interest’ groups. In a them and us situation you are not only the victim of the powerful in terms of rights and resources, you also allow them to define the terms of the debate and the ‘world view’ you have of yourself. For example, complaining that the experts aren’t expert, but instead of taking back power, simply demanding better experts! And in forming networks and lobby groups there is also the danger that ‘complaining and campaigning’ becomes an end in itself - a different kind of dependency where you remain tied to those who seem to oppress you rather than seeking a genuine alternative. Worse still, in trying to be an effective opposition, the way your own group is organised may come to look much like those you seek to challenge. There is the phrase ‘grievance gravy train’ (first used in New Zealand) to describe the activities of individuals and special interest groups who used employment, welfare and equal rights legislation; not just for the resolution of individual disputes, but for the building of careers, organisations and political influence for their own sake. (New Zealand also provided the term ‘Pro-sumer’ - meaning a professional consumer of health and social welfare services).

The reason such processes as bureaucratic control, incorporation and special interests occur and serve to further underpin ‘them and us’ is that health authorities are not actually prepared to negotiate with those they seek to help. Nowhere in law is anything conceded apart from the right to be consulted. Through Involvement activities you can turn yourself into a professional patient, rewarded for conforming (accepting training in how to ‘present’ your experiences, or how to become a quasi worker by formalising peer support!) At worst Involvement becomes an add-on to traditional practice, a way of making work and expanding influence. Alas during my four years involved in Involvement I cannot think of a single issue raised by users or carers in a forum which then led to a change in the way workers practiced during their day-to-day encounters with clients. But then groups being what they are, once you express such pessimism it rapidly comes to be seen as disloyalty!

Those who pursue a Recovery approach sometimes claim to have gone beyond the need for formalised Involvement because relationships are negotiated at every level between client and worker in an open and transparent way. But it remains the case with Recovery, as with any other client-centred approach, that the worker will always claim your views are valid, but only to you. They will never accept that your views could be representative. They will waste thousands of pounds on surveys designed by themselves in order to gather opinion, little realising that a few hours spent reading user’s blogs will furnish the entire range of opinion from across the globe. Equally, they will never concede that you could have superior knowledge on the causes and best treatment of mental distress - by definition the mental patient cannot have a greater insight than them, despite the common mantra that you ‘know yourself best’.

Despite all the above the relationship between user and professional may become very close. Often the same workers who have tried to support you over many years are those with whom you end-up trying to negotiate. You like and are attached to them, but they do not reciprocate the hard work you have put into trying to affect real reform. You listen to a hypocritical remark, or occasionally a blatant untruth which they have convinced themselves must be the case, and you know for certain sure, that now ‘it’s not me, it’s the others’ and that it is time to leave.

Stephen Fry And I - self-stigmatisation?

2010-06-21T05:27:00.003+01:00

Acquiring the DVD of Stephen Fry's two part documentary The Secret Life of a Manic Depressive has caused me to reflect on how differently I now feel about mental health services, Stephen, and myself - 5 years on from when the programmes were made.

Stephen and I go back a long way. I've often relied upon him for a bit of 'vicarious living', although of course we have never met. We seem similar in many ways (apart from the sexuality that is - I consider myself 95% straight).

Everyone enjoys some vicarious living, and since the rise of Hollywood in the 1930's, probably more so in our time than in previous eras. But the more socially isolated one is - the more one lives in fantasy with little 'reality checking', and the more one depends upon it for the sense of intimacy and belonging one would normally get face to face. Stated another way, those with a diagnosis or label of mental illness depend on fantasy more than others.

So having imaged for many years that Stephen and I had a temperamental connection, the revelations in the two documentaries came as no surprise. But my attitude on first viewing was very different to the one I have now. Then I was happy to describe myself as Bipolar, the label had explanatory value for me. Indeed the only reason to accept a diagnosis should be if it has some practical use value to you; if it explains something about you to yourself, making it easier to live with yourself; if it gives you access to useful help, or helpers; if it helps you to act differently, or to let you get things you want but don’t already have.

Also at that time I believed mental health services still had some useful expertise I could acquire (even though by that stage I'd been a service user - off and on - for 18 years) Equally, alongside 'Bipolar' explaining something to me about myself, when I found some supposed characteristic of the Bipolar person I'd not previously known about, I still gave serious thought to the possibility that I must have missed something more about myself. I was well on the way to becoming the next Kay Redfield Jameson.

Why do we hang-on to beliefs, routines, habits which appear illogical and sometimes positively self-destructive? Because they appear safer than the alternative. All change (good or bad) is at first experienced as stressful (occasionally terrifying). Others will be reassuring and tell you of the benefits of change, but this of course counts for nothing! Any change requires acting before we really feel competent to do so.

Having learnt something of the above much has changed in my life over the last five years. I have no 'symptoms' so cannot legitimately use the label, my identity is based upon my actual activities and the social contacts I make, my explanations of myself come from evolutionary biology and neuroscience (natural variation in the limbic system and as a consequence a lot of dodgy learning) and not from psychiatry or clinical psychology. But as I get better and happier, the more angry I become about the pathetic record of mental health services, past and present. However, I still take one prescription drug - having been on one mood stabilizer or another for 17 years, it gives me a certain minimal status and some entitlements in the face of unemploy-ability!

And Stephen? Well, I still follow his antics and enjoy his writing - he persists in making me laugh. I can see that his giving-up smoking and taking more physical exercise are hugely beneficial. But it now seems crazy for him to use an intense work schedule as therapy - a way of staying one step ahead of depression rather than stopping and confronting it. It is not until we give ourselves permission to relax that you can feel and let go of pain. He remains a man uncomfortable in his own body - especially in those moments of verbal linguistic magic. And that takes us to the core fear of the supposed Bipolar person - that recovery, change, or just stopping to relax and let go, means an end to creativity. IT'S A MYTH. Indeed, the ability to let go brings greater spontaneous creation. Stephen declares he must shut himself away in order to write, even to the extent of keeping the curtains drawn to shut out the rising sun. Tish and pish I say my fluffy friend, raise your eyes to the horizon, the answers come from being at home in the outside world.

For more on labelling ourselves, see my February post Goffman and Becker; stigma and labelling.

Stephen's website is at; http://www.stephenfry.com/
The DVD is available at Amazon; http://www.amazon.co.uk/Stephen-Frys-Secret-Manic-Depressive/dp/B002XT38GO/ref=sr_1_2?ie=UTF8&s=dvd&qid=1277016760&sr=1-2

Walking Through Life - how mental distress is caught and taught

2010-06-13T22:20:00.005+01:00

As a child you watched how parents or siblings walked and then you began to copy them. So it was with everything else you learnt, as peers and other adults entered your environment. Experience and learning are inseparable. The more you practice existing skills, the more you try to reproduce today, the world as it was yesterday. All learning consists of first imitating (copying or modelling) how others behave, then repeated practice (trial and error) - both mentally and physically - until you gain a skill. All behaviours are habits. And the only way to overcome an unwanted habit is to copy a better one from someone else. We are social animals with a social brain.

At some point you learnt to walk down the street and avoid eye contact with someone (the invitation to normal social interaction), if that became a habit, not just towards those you disliked for a reason, but a practice applied to the whole social world of others you acquired a mental 'illness'. The classic way of avoiding eye contact is to look down and away (a gesture normally reserved for the occasional experience of shame), but if you stare at the pavement for a lifetime - rather than naturally allowing the eyes to return to the horizon giving an automatic upright posture - then you become a physical cripple because of your social isolation.

Another form of isolation is when we look through people, being physically present but mentally somewhere else. But that leaves the person terribly exposed, you can't do two things at once - fantasise and be in the present moment. Very quickly others notice that your speech simply doesn't fit the situation. The so-called 'psychotic' person follows an erratic path and easily becomes disorientated because they are disorganised. Eventually, they too will look down and away.

Sometimes people come to believe that hanging-on to familiar, habitual, well understood, fears will keep them safe, not just from occasional real physical danger, but from other anxieties in everyday living. The desire to be in control too much - causes more isolation from others. But when you make eye contact with others, when you operate your body in the same way as someone else, you begin to have the same kinds of thoughts (though the content may be different). The desire to belong, which is in all of us, is rewarded.

(See previous posts on meditation, and physical therapy for the 'up' side of the story. The acquisition of new social skills and better habits will be discussed in future posts).

A national mental asylum?

2010-04-18T20:17:00.003+01:00

Once in a while I find myself thinking that the experience of being transported at night by ambulance or police van, strapped or caged at a right angle to the direction of travel, becoming progressively disorientated as the streaking neon lights wipe short term memory, is not dissimilar to always being escorted whilst moving along the remorselessly straight corridors of the old Victorian asylums - and not necessarily because you were a threat to self or others - but because without help you would rapidly become lost.

For almost a decade now people have been saying that almost all confined young offenders have some form of mental disorder and/ or substance misuse problem. Amongst adults who are confined the official rate of ‘serious’ mental disorder is barely higher than amongst the general population - but that’s just a joke, nobody believes it. Much better to accept that a majority of the entire prison population now has a drug and/ or mental health problem - that prisons combined with special hospitals, regional secure units and other secure psychiatric wards - add-up to a new asylum system to replace the old. Given modern transportation and communications the corridors are now dual carriageways and motorways. Mental health law is as strong (and flexible) as it ever was. The impersonal bureaucratic rules and regulations remain. The NHS now runs prison medical services, so we can look forward to more and cleverer drugs!

During my career as a mental patient I spent time in two Victorian-style asylums, albeit towards the end their existence, I also had occasion to visit three others. Recently I was directed to a site with some photos of the first hospital in which I was a patient - Severalls in Colchester - I was amazed it hadn’t been redeveloped. www.environmentalgraffiti.com/featured/most-incredible-abandoned-mental-asylums/19808 The site is about 300-acres and held up to 2000 patients. Opened in 1913, it was based on the ‘echelon plan’, individual buildings but linked by interconnecting corridors to avoid the weather! Over the years the buildings have suffered vandalism and fire attacks but as the pictures here show you can still get a flavour of the environment. When I was there the staff were very proud of the murals, part of which are still visible. I was also told that one of the corridors was the longest of any asylum in the country - is that true?

Last Year's April Fool

2010-04-01T07:16:00.002+01:00

Twelve months is a long time in online history. Last year I distributed the following April Fool to academic acquaintances, linking it to the one that appeared in The Guardian - a year on it all seems to have come true!

ACADEMICS MASS HYSTERIA SHOCK

Dear All

How sad that social scientists across the country have reacted in such a panic stricken way today to the news of the end of The Guardian (see below). Whilst it is true that for decades they have relied upon it as their sole source of ideas, surely they have registered some of the changes in knowledge acquisition over the last two decades.

The realisation that the majority of journal articles are never read.

The fact that students don't take books out of libraries, but just photocopy the introduction and conclusion.

That software could write a fake article on post-modernism and that it would be published.

That the reason the entry for your subject in Wikipedia is being edited every other day is that not just your rivals, but your research students and even your research subjects contest your authority.

The fact that the more enterprising of your colleagues have gone over the heads of the academic audience to the public at large on video at TED, Web2Expo, Meaning of Life TV, Blogging Heads, Edge.org...

Now with the advent of twittering there is no need to find research participants or record them. They've done it for you - you can see the world as it is today. With the development last year of a search engine to go with it, you can do global research on any issue tomorrow!

Flexibility in the face of change I am told is the key to mental wellbeing.

Best wishes

Nick

Twitter switch for Guardian, after 188 years of ink

Newspaper to be available only on messaging service

Experts say any story can be told in 140 characters

Rio Palof
The Guardian 1.4.09

Consolidating its position at the cutting edge of new media technology, the Guardian today announces that it will become the first newspaper in the world to be published exclusively via Twitter, the sensationally popular social networking service that has transformed online communication.

The move, described as "epochal" by media commentators, will see all Guardian content tailored to fit the format of Twitter's brief text messages, known as "tweets", which are limited to 140 characters each. Boosted by the involvement of celebrity "twitterers", such as Madonna, Britney Spears and Stephen Fry, Twitter's profile has surged in recent months, attracting more than 5m users who send, read and reply to tweets via the web or their mobile phones.

As a Twitter-only publication, the Guardian will be able to harness the unprecedented newsgathering power of the service, demonstrated recently when a passenger on a plane that crashed outside Denver was able to send real-time updates on the story as it developed, as did those witnessing an emergency landing on New York's Hudson River. It has also radically democratised news publishing, enabling anyone with an internet connection to tell the world when they are feeling sad, or thinking about having a cup of tea.

"[Celebrated Guardian editor] CP Scott would have warmly endorsed this - his well-known observation 'Comment is free but facts are sacred' is only 36 characters long," a spokesman said in a tweet that was itself only 135 characters long.

A mammoth project is also under way to rewrite the whole of the newspaper's archive, stretching back to 1821, in the form of tweets. Major stories already completed include "1832 Reform Act gives voting rights to one in five adult males yay!!!"; "OMG Hitler invades Poland, allies declare war see tinyurl.com/b5x6e for more"; and "JFK assassin8d @ Dallas, def. heard second gunshot from grassy knoll WTF?"

Sceptics have expressed concerns that 140 characters may be insufficient to capture the full breadth of meaningful human activity, but social media experts say the spread of Twitter encourages brevity, and that it ought to be possible to convey the gist of any message in a tweet.

For example, Martin Luther King's legendary 1963 speech on the steps of the Lincoln memorial appears in the Guardian's Twitterised archive as "I have a dream that my four little children will one day live in a nation where they will not be judged by the colour of their skin but by", eliminating the waffle and bluster of the original.

At a time of unprecedented challenge for all print media, many publications have rushed to embrace social networking technologies. Most now offer Twitter feeds of major breaking news headlines, while the Daily Mail recently pioneered an iPhone application providing users with a one-click facility for reporting suspicious behaviour by migrants or gays. "In the new media environment, readers want short and punchy coverage, while the interactive possibilities of Twitter promise to transform th," the online media guru Jeff Jarvis said in a tweet yesterday, before reaching his 140-character limit, which includes spaces. According to subsequent reports, he is thinking about going to the theatre tonight, but it is raining :(.

A unique collaboration between The Guardian and Twitter will also see the launch of Gutter, an experimental service designed to filter noteworthy liberal opinion from the cacophony of Twitter updates. Gutter members will be able to use the service to comment on liberal blogs around the web via a new tool, specially developed with the blogging platform WordPress, entitled GutterPress.

Currently, 17.8% of all Twitter traffic in the United Kingdom consists of status updates from Stephen Fry, whose reliably jolly tone, whether trapped in a lift or eating a scrumptious tart, has won him thousands of fans. A further 11% is made up of his 363,000 followers replying "@stephenfry LOL!", "@stephenfry EXACTLY the same thing happened to me", and "@stephenfry Meanwhile, I am making myself an omelette! Delicious!"

According to unconfirmed rumours, Jim Buckmaster, the chief executive of Craigslist, will next month announce plans for a new system of telepathy-based social networking that is expected to render Twitter obsolete within weeks.

Acceptance is the hardest 'skill' to learn

2010-03-27T09:21:00.003Z

It’s a skill because it doesn’t come naturally.

I once asked a friend of mine who is a senior mental health worker, and almost universally liked by everyone: ‘Isn’t the idea of “unconditional positive regard” totally unrealistic - it implies you can like anyone who walks through the door?’ He then claimed that he did like almost every client. I think he was fooling himself, and what he meant with the benefit of hindsight, was that he came to like almost every client - that the more he understood someone the more he liked them.

Carl Rogers started it when he asserted the possibility of unconditional positive regard towards others, built on the idea of accepting oneself:

‘I find I am more effective when I can listen acceptantly to myself, and can be myself.’ (Roger 1967:17)

‘…the curious paradox is that when I accept myself as I am, then I change.’

‘If I can accept the fact that I am annoyed at or bored with this client or this student, then I am also much more likely to be able to accept his feelings in response.’ (p.18)

‘I have found it highly rewarding when I can accept another person.’ (p.20)

The post-war humanist perspective in psychology lost touch with the biology of the human animal - as indeed did the cognitive revolution that followed it. Anxiety should rise when meeting strangers or outsiders, they are a potential threat, you should be cautiously testing each other. We do have very strong first impressions; it is called intuition, and relies on fast emotional responses - it is what keeps us alive. The only question on first meeting someone is: ‘Do I feel safe with this person?’ So the effective helper knows that they must appear safe and non-threatening, but what if you don‘t feel that? We can all be aggressive and violent, if we need to be. It’s not a matter of accepting people as they are, it’s about creating useful encounters where mutual learning can take place and that depends on establishing a relationship of trust. Sometimes it can happen very fast if there is a mutual liking, if there isn’t then it will never happen.

When asked, people self-report that what makes the best first impression is a sense of ‘warmth’ and ‘competence’ in the other person ( www.scientificamerican.com/article.cfm?id=mixed-impressions ), but I think what they really mean is someone who is non-threatening and can deliver something they need. Because first impressions are emotional responses they have very little to do with what is actually said, more with how it is said and the rest of our non-verbal behaviour. We trust those emotions displayed through facial expression much more than the accepting words.

The client is present because they know there is something wrong with them, whether they state it or not, something that stops them functioning in the social world as they would wish. That is why they are seeking help, they’re not looking for acceptance but action, on the assumption that they are meeting with someone with skills and expertise.

But what of Rogers’ underlying point that accepting oneself and others as we are now, is in some sense a precondition of change? Wrong. The preconditions are self-awareness and a willingness to learn new things! And the speed at which it can be done depends on the rapport between the people involved.

One barrier to rapport (effective communication) is the myth that the helper can be accepting as part of their professional role, setting aside their personal feelings. This is obviously ridiculous because feelings always leak-out through facial expression and tone of voice. This first becomes apparent when a prospective helper is still a student and at some point becomes aware of a conflict between their developing intellectual understanding and their emotional response in a given situation. The trick is integrating the two. If I believe in the knowledge I have acquired then I must live that way, the mistake is thinking that one is work and the other a private concern. The answer comes in two parts, firstly in terms of organisation there has to be proper team working - teams purposefully constructed of different kinds of people with different skills, hence giving the client choice!

Secondly, any kind of therapy is the learning of new social and psychological skills and the helper is the model. Acceptance is the skill of tolerating what we cannot change. Now if either or both, client and worker have it in their heads that the client is suffering an illness for which there is no cure… Even the Recovery approach leaves the medical model in place, telling the client to expect occasional relapse. So often both client and worker set each other up to fail. But if your model is one of adaptation in a particular social environment you have two choices, neither of which require acceptance of anything. Either you change yourself (learn new skills) to fit the environment you find yourself in, or you move on and live in a new environment.

It is a belief in people‘s lack of capacity to change which makes acceptance, so unnatural as it is, such a hard skill to learn - requiring decades of practice by the helper!

(See also my post, The ‘therapeutic relationship’ explained - Jan 2010)

Rogers, C (1967) On Becoming a Person: A Therapist’s View of Psychotherapy (Constable: London)

John Clare - from the Northampton Asylum

2010-02-21T06:59:00.001Z

They, have never thought to lay a pathway from the hospital entrance to where the pavement ends on the edge of our town. If you do not have a car, and generally we don’t, and given the irregular bus service - then you must for a short distance walk along the main road. The hospital has changed its purpose over the years, today if you are a patient there it usually means you are coming to the end of a prison sentence, but receiving treatment because you have a mental disorder. If you are driving along the road and are frightened by a menacing male figure; well, remember he looks ragged because he has so little to his name, is walking because he has no money, is scared by the amount of traffic (that is you) and shocked by the outside world which he hasn’t felt, unaccompanied and for himself, for - how long?

When I have business at the hospital I always walk. Those who seek to ‘involve’ me always offer a lift, I refuse saying it’s just up the road. In fact it is a half hour walk at a leisurely pace - and it has to be that way. Those workers who organise us, talk of ‘journeys’ to a recovery, or care ‘pathways’ - I prefer something more grounded in the reality of the material world and with a real history. On that journey I inevitably think of the times in my ‘career’ as a mental patient when I have just had to be outside, have used walking as an attempt to clear my mind. I often think of the poet John Clare’s fifty mile walk home, over the best part of two days and a night, having escaped from his first confinement, and who, were he alive today, might well have had the same diagnosis as myself (Bipolar Affective Disorder) - and of course have found a large part of his pathway occupied by the A1! The real journey to the hospital has only one ‘staging post’ and that is the wooden bus shelter, which survives - just. There I pause, to make that adjustment you must make when passing from your own world to that of workers and clients interacting with each other. I roll a cigarette, look for any additions to the graffiti (a kind of testimony) and think about the problem every client has - the inability to explain oneself to others.

John Clare (1793-1864) was a small farmer who briefly found fame in the 19th century, becoming known as ‘the peasant poet’ but was then socially excluded when he began to experience mental health problems. He spent the last 20 years of his life confined in the Northampton County Asylum but was able from time to time to continue writing poems, one of which was ‘I Am’;

‘I am! Yet what I am who cares, or knows?
My friends forsake me like a memory lost.
I am the self-consumer of my woes;
They rise and vanish, an obvious host,
Shadows of life, whose very soul is lost.
And yet I am - I live - though I am toss’d

Into the nothingness of scorn and noise,
Into the living sea of waking dream,
Where there is neither sense of life, nor joys,
But the huge shipwreck of my own esteem
And all that’s dear. Even those I loved the best
Are strange - nay, they are stranger than the rest.

I long for scenes where man has never trod -
For scenes where woman never smiled or wept -
There to abide with my Creator, God,
And sleep as I in childhood sweetly slept,
Full of high thoughts, unborn. So let me lie, -
The grass below; above, the vaulted sky.’

Forty years after his death however, he did achieve a kind of inclusion, validation and immortality through the efforts of a legendary teacher Arthur Quiller-Couch who included the poem in the first edition of the Oxford Book of English Verse. Quiller-Couch (known to all as Q) taught at Cambridge University and in the early 1930’s was personal tutor to one Alistair Cooke who then went on, through his radio broadcasts (Letter From America 1946-2003) to give several generations in the UK their first taste of America. He pioneered ‘writing for talking’ in which the broadcaster speaks personally and directly to what he imagines is just one person!

In the late 1930’s a young women from Philadelphia made her way to New York in the hope of becoming a playwright. It would be thirty years before she found success, but she educated herself at various public libraries and discovered there Q’s writing on modern language and literature. Indeed one of her books is entitled Q’s legacy, alas not as widely read as her second book which simply contained her correspondence with a secondhand book dealer in London’s Charing Cross Road. Helene Hanff wrote short, direct and extremely powerful letters to Frank Doel, which would not look out of place today on any social networking site.

From 1975 until his death a couple of years ago, John Mortimer created in fiction a great comic hero. Horace Rumpole, defending barrister, who rejects status and money, in order to uphold the rights of ordinary citizens. He’s ridiculed by the people around him, but always comes out fighting using humour as a weapon. Famously he often quotes from his bedtime reading - Q’s anthology. He has a soft leather bound copy, printed on India paper with gold leaf around the edges, alas my copy has only a cardboard cover - but it’s still just the right size to slip into a pocket when out and about searching for some grass to lie on beneath that vaulted sky.

(And of course, all the above is what is meant by the vertical transmission of memes!)

Bate, J (2003) John Clare: A Biography Picador: London
Quiller-Couch, A. T ed. (1906) The Oxford Book Of English Verse 1250-1900 Clarendon Press: Oxford

Minimum Qualifications (for helpers and supporters)

2010-02-14T07:35:00.002Z

If I feel I need help.

If I can ask for help.

If I can lift the phone.

If I can open my door to you, or get through your door, or meet you in a public place.

Then

Can I feel safe with you?

Can I talk to you?

Are there words to describe my feelings and thoughts?

Can you see how I feel?

Can I trust you (does what you say, match the way you act)?

Can you show some understanding?

Can you do something today, that will allow me to act tomorrow (hope)?

Are we both in the present moment?

Introducing Ecotherapy (...the Brandeau connection)

2010-02-04T06:44:00.016Z

Ecopsychology starts from the premise that the more natural an environment we are able to live in, the better our physical and mental health ought to be. It has an inescapable logic to it - the problem of course is that almost all of the environment that is habitable, is now man-made! There has been very little academic research on the idea of an ecotherapy, rather those who believe in it have simply got on with it in an intuitive and practically way. I’d like to introduce what will be one of the ongoing themes of the blog with an autobiographical extract describing my experience of it. Those providing it didn’t call it 'therapy' and neither did I. But it occurred during what turned out to be the happiest period of my adult life - that is until very recently.

…What followed was six months of unemployment. I managed to get four interviews; one of which was for a clerical post at one of the local mental hospitals, none led to a job offer. I wrote at the time: ‘It took me several days before I could bring myself to sign-on the dole, it seemed to me to be a gesture of defeat. I felt guilty and ashamed at being out of work; perhaps the legacy of a middle class upbringing… I felt all I had to do was keep filling in application forms and a job would turn-up… The handful of interviews I did have all seemed to go well, l felt they liked me, then came the letter of rejection… After a time you find yourself writing less and less applications and you lower your expectations of employment; you take positive steps to avoid further rejection and alienation from employed society… After several months I could see in the faces of friends that they did not believe I could not get a job’. After Christmas 1982 I packed-up my flat, accepted the offer from the university of my choice for the following October, and left for Paris to stay with my sister. After a few weeks sleeping on her floor, I wrote out an advertising card to place on the notice board of the British Council, it began; ‘I’ll do anything!’ Amazingly I got a response - it turned out to be the greatest stroke of luck I’d ever had.

The deal didn’t sound great, but it paid of in spades - literally. The man at the end of the phone offered me work at a small Chateau vineyard/farm in South-west France. It was bed and board only, but if I stayed more than a month there was some pocket money thrown-in. I accepted after his wife sent me a description of the small community they were running. The farm had nine hectares of vines, some grassland and woods; enough for thirty or so sheep, a kitchen garden, two pigs, half a dozen ducks, about eight chickens and four geese - plus two cats and a collie sheep dog. The human occupants were the couple who owned it and anyone prepared to work for bed and board - but they had a lot of ‘connections’. Students came from Denmark, Holland and the UK, but most of all from Southern California where the couple had previously lived, and worked at various universities. The only other habitation that could be observed from the farm was a neighbour’s barn, the nearest telephone was a fifteen minute walk away, there was no television or radio (just a music centre in the main kitchen/living room) no flushing lavatories, a cold shower, and one hot bath per week. There was a wood fire and wood fuelled range in the main room. There was one Renault Four van, one decrepit 2CV which drifted across the road when cornering, two vineyard tractors (one pre-war), which given the steep slopes would be regularly ‘tipped’ by over confident drivers. The sheep dog only recognised three calls but had the right instincts and was loved by all. In the spring and summer we got up at six, worked till breakfast at seven, worked till twelve or one, took a leisurely lunch, siesta’d till four, then worked till nine, had dinner and went to bed. Sunday was a day-off. Cooking was Mediterranean and sometimes Mexican - meat a luxury, vegetables the staples. But of course there was as much wine as you wanted.

Their philosophy was to be as ‘self-sufficient’ as possible, and wherever practicable to use traditional methods of farming and viticulture. And it worked. The owners had been young enough in the late 1960’s to recognise some of the virtues of the ‘counterculture’ but had tempered it with economic realism. They had a historical perspective on peasant culture, its strengths and weaknesses. However, some of the ‘natives’ in the surrounding countryside were convinced it was a ‘free-love’ colony! On my first visit I stayed four months. It was my first experience of living in a remote rural area - of being outside all day, of doing manual labour, of communal living. The number of workers varied from two or three, to seven or eight. I’ve never felt so hungry or eaten better. My brain was fed by people better educated than myself. I came to feel physically fit and free of mental distress. I was to return another four times during university vacations.

Some farm jobs are highly skilled and interesting to learn, but once learnt become monotonous to do because of their repetitive nature. Others require flexibility and a high level of concentration. Some jobs require little skill and are just drudgery. Spring pruning of vines using traditional methods is a skilled job. First you have to bend horizontal and tie the two remaining branches of last year’s growth to the wire frame using twigs of willow, carried in bundle around your waste. Two knots are required for each branch and the surplus willow cut with a knife. If the job is done on time, you won’t come back to the same vine for maybe another six weeks. Then the new growth from the tied branches can be pruned, a judgement must be made about which two new branches will grow the strongest so as to become next year’s horizontals - but they also have to be the most likely to bare grapes. They are then woven vertically between the higher wires of the frame. Then the rest of the new growth has to be either removed or woven vertically depending on the likelihood of them bearing grapes. (Sometimes, if the schedule is lost, you have to do some pruning before tying). Then you move on to the next vine. There may be forty or fifty vines in a row, a row may be as narrow as six feet. Nine hectares is a lot of vines for half a dozen people to complete in the six weeks or so before they become overgrown. You’ve just got to be quick, you need a certain rhythm and choreography. (Traditional methods did of course vary according to the variety of vine, the type of wire frame etc. - even within the Bordeaux region where I was).

Happiness in work is more strongly associated with the use of a person’s skills than with the material reward received. In psychology there is a concept known as ‘flow’; it comes to those who can lose themselves in their work, it comes to children playing games, it comes (if you’re lucky) when making love. It is the sense of happiness that comes from the loss of self-consciousness. To be happy in your work, you need a job which uses all your skills and then asks for just a little bit more.

Some jobs however are communal and require a lot of team work, like the killing and butchering of an animal. During my Business Studies course we visited an abattoir. (The slaughterhouses of Chicago were the inspiration for Henry Ford’s moving assembly line - though they of course disassembled). We watched each part of the process broken down into the detailed division of labour, each man is given a few simple tasks that he could repeat at speed. Pigs were corralled six at a time, then electrodes applied simultaneously to the temples of the first animal. The stunned animal was then hoisted by a leg and it’s throat cut, the blood draining away as it moved slowly along the gantry to where it would be immersed in the machine containing boiling water and which would scrap of the hair. The remaining pigs became increasingly more agitated and vocal as their turn approached. The circumstances surrounding the killing of an animal on a small farm are very different. (A description of the killing of a pig in a traditional way on a French peasant’s farm is given by John Berger in Pig Earth). It is those who have bred, feed and nurtured the animal who will kill it, butcher it and eventually eat it. They have valued the animal and in turn know it will sustain them. The killing of a pig or sheep my involve everyone for a whole day - killing, slaughtering, butchering, and preserving. As much of the animal as possible will be used, such as the blood and brains. I remember the killing of a pregnant ewe who had broken a leg. People worked together quietly, smoothly; without the noise and violence of the factory. Those involved gave reverence and respect both to the animal and themselves. The carcass and unborn lamb were buried on the farm.

Meat is for feasting and flavouring. There is a festival or feast day somewhere in the world, for every day of the year. Obviously the fourth and fourteenth of July were an excuse for a party - but so was Swiss Dependence Day! We’d have a fire outside, partially melt a whole Swiss cheese and grill sausages, practice yodelling and drink Swiss beer. At some point during my first visit I acquired my nickname ‘Danger’ or ‘Nick Danger’; as in some fearless comic strip hero - it was meant to be ironic since I never volunteered for any of the dodgier jobs, like repairing the tiles on the roof of the barn, or taking a tractor on the steepest slopes. Alas the name stuck since my then girlfriend found it hilarious and used it all the time!

One evening I got into conversation with a guy (whose name and background I have totally forgotten) about left-handedness and how I’d always suffered academically as a result - like not being able to spell! He suggested we do an exercise their and then. He got me to read aloud a paragraph from a magazine. I was a bit slow and haltering. He then told me to read it backwards, this time I was faster and more rhythmic - amazing! He then got me to march-on-the-spot, telling me to swing my left arm with the right leg and vice versa. After a second or two he stopped me, pointing out that I’d done the opposite, raising the left arm with the left leg and vice versa. Once I’d done it the ‘right’ way for about thirty times he stopped me and swiftly ran the knuckle of one finger up the full length of my spine. He then gave me a different paragraph to read aloud - this time it was much easier, faster and more fluent. It forced me to think about brain and body, hand/eye co-ordination, and the psychological distress that might follow from the lack of it; of being left handed in a right-handed world, and of course asymmetry itself.

When I had done my Business Studies course the subject that interested me most was Industrial Relations. But there was no first degree course in the subject, so it had to be done as a specialisation within another subject, I chose Sociology. But I’d never studied any Sociology before! During evenings on the farm I sat by the fire and read an introduction to the subject. It seemed to be about every imaginable relationships between people; from simple conversations to the political and economic structures of whole nations. It also ranged from management and worker relations in factories and offices (supposedly my subject) to developing societies (the Third World and peasant societies of the past) seemingly connected to the kind of community I found myself in. Finally there were the studies of institutions like prisons, the military and mental hospitals - what was I letting myself in for?

When I came to leave the farm and stepped of the train in Paris I experienced what has been described as ‘culture shock’! The noise, the speed at which people moved and things happened, the artificial light. What an alien world, surely it was the environment that drove people crazy…

Chateau Brandeau is now owned and run as an organic vineyard by the son and daughter-in-law of the couple who owned it in my time - see links.

It's Groundhog Day - again!

2010-02-02T05:55:00.006Z

Groundhog Day (1993) director Harold Ramis, based on a story by Danny Rubin, staring Bill Murray and Andie MacDowell. Murray plays Phil Connors an egocentric Pittsburgh TV weatherman who, during a hated assignment covering the annual Groundhog Day event in Punxsutawney on the 2nd February, finds himself repeating the same day over and over again…

Over the last ten years or so I’ve got into the habit of re-watching this movie on the 2nd February, it reminds me of what my life has felt like in times past, and could become again, if I get too preoccupied with myself.

It’s one of those movies which leads audiences to endlessly speculate on it’s meaning. Perhaps the dominant view is that it’s about an individual over concerned with ‘self’, leading to unpleasant situations that continually repeat, until he can transcend them and let go - putting other people rather than himself at the centre of his universe. A tale of self-improvement that looks outward, rather than being focused on one’s own need to be ‘in control’. It’s also a hilarious comedy!

Ryan Gilbey writing in The Observer 1.2.04:

‘While Groundhog Day is undeniably charming, it shares a certain stubbornness of purpose with its star. From the moment Rubin typed the first line of his first draft, he resolved to withhold all explanations about how Connors came to be stuck in a time-loop. Co-written and directed by Harry Ramis, the finished film exploits the witty device of a narrative that achieves momentum without moving forward. Rubin refused to surrender the enigma at the movie's core; the absence of narrative exposition remains the most audacious element of Groundhog Day, not to mention one of the most daring ellipses in Hollywood cinema.’

…As well as making its impact on cinema and language, Groundhog Day has exerted a strong influence on religious thinking. Rubin and Ramis continue to receive letters congratulating them on a positive representation of Buddhism. Presumably they file such correspondence alongside similar messages in which the film is claimed by Jesuit priests, rabbis, and followers of the Chinese spiritual movement Falun Dafa, aka Falun Gong. All the letters are characterised by a singleminded belief that the movie endorses the author's faith. 'At first, I would get mail saying, "You must be a Christian, because the movie so beautifully expresses Christian belief,"'Ramis said recently. 'Then rabbis started calling, saying they were preaching the film as their next sermon.'

Roger Ebert writing in the Chicago Sun 30.1.05:

‘Tomorrow and tomorrow and tomorrow, in his case, doesn't creep in at its petty pace from day to day, but gets stuck like a broken record. After the third or fourth day, the enormity of his predicament is forced upon him. He is free to change what he says and does from one Feb. 2 to the next, but it will always be Feb. 2 for everyone else in the world, and he will always start from the same place. They will repeat themselves unless he changes the script, but tomorrow they will have forgotten their new lines and be back to the first draft of Feb. 2.

...One night in a bowling alley, sitting at the bar, he says almost to himself: “What would you do if you were stuck in one place, and everything that you did was the same, and nothing mattered?” The sad sack next to him at the bar overhears him and answers: “That about sums it up for me.” Slowly, inexpertly, Phil begins to learn from his trial runs through Feb. 2'.

Goffman and Becker; stigma and labelling

2010-02-01T06:17:00.013Z

I'm sometimes asked by people from the world of mental health about the work of Erving Goffman. Regrettably I’ve never been asked about Howard Becker. Yet together they are the source of many of the taken-for-granted ideas in mental health practice today.

The attention paid over the last fifty years to stigma, discrimination, and the social consequences of a psychiatric label (not to mention the existence of a ‘time to change’ campaign) would have been unlikely had these two men not met as graduate students in 1947 and shared an education in the Department of Sociology at the University of Chicago. Goffman died in 1982, but his reputation has continued to grow. Howard Becker is still very much with us http://home.earthlink.net/~hsbecker/index.html

Like Goffman I hang around cafes and street corners a lot. The social situation of the café and the performances given within that space by the providers and clients of a service formed the heart of his approach. He was, first and last, interested in the contrast between what he could observe of a social interaction and the ‘definition of a situation’ given by the individual participant - in the space between the two lay the performance (Goffman 1971:13-27). The degree to which you allow your world view to be questioned by those around you is the degree to which you are grounded. The more interpretivist your approach however, the more idiosyncratic your form of presentation is likely to be and therefore potentially less understandable. It’s been said you either love or hate Goffman’s writing. He wrote long discursive essays offering novel conceptualisations on every other page, hugely rewarding to read - but it does require effort. Some say his work has proved impossible to ‘operationalise’ - well, all you really need to do is read him in a café, lift your head every few minutes, and watch!

He’s famous for his ‘dramatological’ approach to the analysis of everyday interactions across a whole variety of modern settings. However it’s worth recalling where, for him, it all began. Whilst a postgraduate he managed to escape to Edinburgh in 1949 for a year or so, and hence to Shetland Isle to undertake fieldwork amongst what was then the last complete crofting community - well almost! Their window on the outside world, and the outside world’s window on them, was through the Isle’s only hotel. Goffman became a semi-permanent guest, finding himself watching the occasional tourists every evening, having spent the day amongst the islanders. It was there that the ‘front of house’ performance (one side of the swing door) of the crofting family who ran the hotel began to fascinate. Behind the door they remained crofters, keeping to their peasant (subsistence agricultural) lifestyle, including a diet of root vegetables as staples, with meat restricted to ‘feasting and flavouring’. Coming through the door they were transformed in dress, speech and manners; carrying generous servings of meat, a variety of vegetables and desserts - accommodating the expectations of their wealthy middle class, often English, guests. See the footnotes in The Presentation Of Self In Everyday Life published first in 1959 (Goffman 1971).

In 1955 Goffman worked for about eighteen months in a psychiatric hospital, the 7000 bed St. Elizabeth’s Hospital in Washington DC.
His job was what might be called today a ‘personal trainer‘, or someone offering physical therapy. His real purpose however was to research the nature of ‘total’ institutions, where people live, work and play in the same - often confined - location. However only a handful of the managers knew his real reason for being there. It was this experience which led to the four long essays which were first published together under the title Asylums in 1961 (Goffman 1968a). Many of the social processes he identified were what we routinely call today ‘institutionalisation’. He believed in the importance of keeping detailed field notes and of immersing yourself in the situation, but in the way he wrote you wouldn’t necessarily know in what capacity he had been present! Howard Becker recently took another look at one of those essays (Becker 2007: 223-237) entitled ‘On the Characteristics of Total Institutions’ (reproduced in Goffman 1968a:14-115) which is about the structure and organisation of mental health care. ‘No reader of Goffman’s essay on total institutions can be unaware of the considerable disparity between the social reality he talks about and the way he talks about it.’ (Becker 2007:228)

‘ “trimming” and “programming” to describe how “the new arrival allows himself to be shaped and coded into an object that can be fed into the administrative machinery of the establishment, to be worked on smoothly by routine operations” (p.229)

…“secondary adjustments,” to refer to “practices that do not directly challenge staff but allow inmates to obtain forbidden satisfactions or to obtain permitted ones by forbidden means”

…a variety of “personal adjustments,” such as “situational withdrawal”, which (he notes) psychiatrists might call “regression” ’ (p.230)

‘Goffman used his linguistic inventiveness to name things in ways that evaded conventional moral judgements and therefore made scientific work possible. (p.236)

When I look again at Asylums I can’t help but see an equivalence between those huge institutions and our equally large, confining and impersonal rule-governed bureaucratic mental health organisations. Mental health law is as strong as ever. Illness maybe thought of as episodic for most clients, but there is still the social phenomenon of a ‘revolving door’; and being shoved from ‘pillar to post’ becomes a reality when your behaviour is thought undesirable, persistent or enduring. One can see diagnosis itself as part of the identity ‘stripping’ process, the restrictions of the Mental Health Act as leading to a denial of ‘personal space’; if you are sent under section ‘out of area’, away from your community, surrounded by strangers, under the authority of staff whose language you don’t comprehend - isn’t that ‘asylum’?

Also in 1961 the book Encounters first appeared containing two essays on social interaction in general. In one he writes about ‘role distance’ (Goffman 1961:85-152), the extent to which an individual is able to distance themselves from the rules and expectations of a social situation. The problem is often seen in ‘tongue in cheek’ like behaviour - but when applied to those who are confined, physically or psychologically, it can be seen as the degree to which an individual can escape a role prescribed by others and establish an independent identity. The problem arises when someone has come to have some attachment to there situation at the same as being disaffected or resistant to it. ‘A full twist must be made in the iron law of etiquette: the act through which one can afford to try to fit into the situation is an act that can be styled to show that one is somewhat out of place. One enters the situation to the degree that one can demonstrate that one does not belong.’ (p109) Yet it can’t be called role distance if a person has completely refused a role;

‘…for the special facts about self that can be conveyed by holding a role off a little are precisely the ones that cannot be conveyed by throwing the role over.’ (p.108)

‘Should the subordinate exercise role distance, this is likely to be seen as a sign of his refusal to keep his place (thereby moving towards greater intimacy with the superordinate, which the latter is likely to disapprove), or as rejection of authority, or as evidence of low morale. On the other hand, the manifestation of role distance on the part of the superordinate is likely to express a willingness to relax the status quo, and this the subordinate is likely to approve because of its potential profitability for him.’ (Goffman 1961:129)

Then in 1963 came Stigma. First Goffman seeks to turn our reasoning around from individuals with attributes which are stigmatising, to seeing situations - constructed relationships in which stigma is made and reproduced. This led to his famous assertion: ‘The central feature of the stigmatised individuals situation in life can now be stated. It is a question of what is often, if vaguely, called “acceptance”.’ (Goffman 1968b)

Also in 1963 Howard Becker’s Outsiders: Studies In The Sociology Of Deviance was first published. The word ‘deviant’, before it became corrupted, simply meant any individuals or groups who acted in ways other than the currently accepted norms of society. Becker’s study included prostitutes, drug addicts, criminals, jazz musicians, gypsies, hobos and winos - to name but a few!

Through the studies reported in the book Becker became the principal developer of labelling theory, but he was quite clear that his studies were about society’s response to perceived difference, rather than what might actually constitute ‘otherness’ itself (Becker 1991). Society labels the individual or group, they are then treated differently as a consequence of the label. ‘When I was working on the theory of deviance, I wanted to argue that when others labeled someone as a deviant, that identification often became the most important thing about the person so labeled…’ (Becker 1985:142). Becker is also a jazz musician, and was aware of the drug culture from a young age, he studied and wrote about in the post-war period but the political climate of 1950’s America was such that it didn’t get published for many years - he received his PhD in 1951 for a study of schoolteachers.

When I worked as a volunteer in a mental health centre in 1989, the clients knew my background of mental health problems, when it became clear I had secured a place on a psychiatric nursing course one client (during a conversation where I wasn’t present) apparently reacted in amazement - exclaiming ‘they’ would not allow it. He concluded I must have covered-up my background and lied at the interview!

The view I take now on the stigma and labelling of mental health problems was formed at that time when I was briefly a student nurse, and informed by both Goffman and Becker. However I expressed it someway differently. For to be completely stigmatised, you must be prepared to accept the label. It is also possible to not only define yourself by a stigma, but also come to depend upon it for your own identity. It can grant a special status with certain rewards. To be labelled may exclude you from one community, but allow incorporation into another. There seemed to be, and I see no reason to change what I wrote back then now, four general types of relationship.

1/ I see myself as OK and so does society; this is a relationship of normals, of acceptance and incorporation in like-minded communities.

2/ I see myself as not OK and so does society; this is also a relationship of acceptance and incorporation, someone who accepts the ‘sick role’ and is in long term care.

3/ I see myself as OK but society does not; this is a relationship of rejection and exclusion (on both sides). Someone who does not consider themselves ‘ill’ in anyway whilst those around them do.

4/ I see myself as not OK but society sees me as OK; this is also a relationship of rejection and exclusion; anyone who is ‘screaming’ but not heard.

At various times, before and since, I have embraced all of these roles.

In the last twenty-five years Howard Becker has turned his attention to how academics think, write and undertake research on social behaviour. He has produced three widely acclaimed books, Writing for Social Scientists (Becker 1986), Tricks of the Trade (Becker 1998) and Telling About Society (Becker 2007) - which sadly the world of mental health and health research in generally seem unaware of.

Since the subject of much of my writing is fear, I’ll end with a couple of quotes from Becker on the events that led him to write about social researchers. In the late 1970’s he offered a series of writing seminars for graduate students, with the explicit intention of bringing greater clarity to sociological writing, but what he uncovered was an alarming array of writing ‘habits’ - amongst his students, and the other more senior faculty members who seemed to gravitate to his seminars (Becker 1986:1-25).

‘From one point of view, my fellow participants were describing neurotic symptoms. Viewed sociologically, however, those symptoms were magical rituals. According to Malinowski, people perform such rituals to influence the result of some process over which they think they have no rational means of control.’ (p.3)

‘They feared, to summarize the long discussion that followed, two things. They were afraid that they would never organise their thoughts, that writing would be a big, confusing chaos that would drive them mad. They spoke feelingly about a second fear, that what they wrote would be “wrong” and that (unspecified) people would laugh at them’ (p.4)

References

Becker, H. S (1986) Writing for Social Scientists University of Chicago: Chicago
Becker, H. S (1991) Outsiders: Studies In The Sociology Of Deviance The Free Press: New York
Becker, H. S (1998) Tricks of the Trade University of Chicago: Chicago
Becker, H. S (2007) Telling About Society University of Chicago: Chicago
Goffman, E (1961) Encounters; two studies in the sociology of interaction Bobbs-Merrill: New York
Goffman, E (1968a) Asylums: Essays on the Social Situation of Metal Patients and Other Inmates Pelican: London
Goffman, E (1968b) Stigma: Notes on the Management of Spoiled Identity Pelican: London
Goffman, E (1971) The Presentation Of Self In Everyday Life Pelican: LondonGoffman taught me how to think, Becker how to write - though I suspect that if either were reading this they’d shout: ‘They’re the same thing dummy!

Bipolar - bi-lateral? (Kipling said it...

2010-01-31T07:43:00.004Z

Although I rejected psychiatric diagnostic labels some years ago, I did once unearth a study claiming a statistical association that may just point the way to something. (Alas I didn’t record the reference at the time, or I’d give it to you now). The claim was that if you have received a diagnosis of Bipolar Affective Disorder, you are three times more likely to be left-handed than the general population! There’s a poem of Kipling’s which has been a favourite of mine for thirty years.

The Two-Sided Man

Much I owe to the hands that grew -
More to the Lives that fed -
But most to Allah Who gave me two
Separate sides to my head

Much I reflect on the Good and the True
In the Faiths beneath the sun,
But most upon Allah Who gave me two
Sides to my head, not one.

Wesley’s following, Calvin’s flock,
White or yellow or bronze,
Shaman, Ju-ju or Angekok,
Minister, Mukamuk, Bonze -

Here is a health, my brothers, to you,
However your prayers are said,
And praised be Allah Who gave me two
Separate sides to my head!

I would go without shirt or shoe,
Friend, tobacco or bread,
Sooner than lose for a minute the two
Separate sides of my head!

Kipling, R (1993) Selected Poems (Penguin: London)

For all things asymmetrical go to http://www.righthandlefthand.com/ and McManus, C (2003) Right Hand, Left Hand: The of Asymmetry in Brains, Bodies, Atoms and Cultures Phoenix: London

It's the company you keep!

2010-01-30T06:20:00.007Z

I've been directing people to the short article below since it first appeared on the Edge.org site almost two years ago. On the surface it's just a small investigation of a few hundred of the early student users of facebook - but give it some thought and a second read and the implications are enormous. Much of my writing on this blog insists that the real world, along with the virtual one, is like the article describes. Mental distress is made and unmade everyday through our interaction with others. When it persists for long periods we become progressively more isolated. Mapping social networks suggest how such a process works.

Social Networks and Happiness http://www.edge.org/3rd_culture/christakis_fowler08/christakis_fowler08_index.html

The 'therapeutic relationship' explained

2010-01-29T07:48:00.011Z

...or rather, how it comes about that often the relationships between mental health workers and their clients aren’t beneficial to either party.

We become clients of mental health services because we find it impossible to maintain happy social relationships - we may never have experienced them, or experienced trauma when they breakdown, or had difficulties in making new ones.

We then enter a system of care which doesn’t offer us ordinary relationships, or training in how to conduct and maintain them, but instead involves a form of social interaction based on the worker playing out two roles; that of bureaucrat on the one hand, and counsellor on the other.

Firstly, there is always the aspect of a ‘paid friendship’, so you can never be sure of the genuineness of the worker, their feelings about you are always hidden to a greater or lesser extent. They are not choosing to be with us. What are we to conclude when we see a mismatch between what they say and what they display non-verbally? They are of course observing the same in us, but usually concluding it’s an aspect of our character, rather than a reflection of their behaviour!

If the relationship should turn out to be a good one it is quickly terminated by the worker; if it is less successful it may persist for decades.

We usually meet them at a time and place of their choosing, often in a specially designated building isolated from normal social life. This is presented as an aspect of confidentiality and freedom to disclose. However, whilst the location often feels familiar and safe to the worker, for us it may be quite the opposite.

Given the isolating nature of mental distress, and the fact that the worker has many other clients, they are almost always (for good or bad) more important in our lives than we are in their's.

They assess us, and even if they accept our conception of our problems, even if we are able to assert our rights and entitlements, they remain the gatekeepers to care. We are promised confidentiality, but also told that when they deem it necessary they will consult others.

We are told the encounter is our space, ours to control or direct. Yet because they do not self-disclose - we are expected to talk about the most intimate, and therefore most difficult to articulate, aspects of our lives to someone who always remains a stranger.

Since the assumption is that we are the ones who bring our problems to the encounter, what is actually happening in the room is either ignored or grossly misinterpreted because of an unconsidered factor - what years of meeting everyday with a variety of people in mental distress has done to the health and perceptions of the worker! (Remember, they get their supervision from even more experienced workers).

Normal, healthy encounters are as follows. We meet as strangers, often have strong first impressions of like or dislike, intuitions of threat or safety (which we ought to follow, leaving immediately if necessary). It is only after some time that we reveal confidences, when some trust has been established based on both parties willingness to mirror and match the other with minor disclosures about themselves. Equality and reciprocity are built-in to normal social encounters. We are attracted by points of similarity between ourselves and the other person. Friendship may or may not follow. If it does, then it becomes appropriate to give advice or instruct. You earn the right to say - ‘don’t do that, I know what happened last time, even if you have forgotten’. When on the receiving end, you may not like what is being said, but by now you have undeniable evidence that the person cares about your wellbeing. And of course, all this time you have been meeting at a time and place negotiated between yourselves.

So how can these abnormal encounters with workers actually improve practical opportunities for more and better social interaction in the real world? You walk away from a meeting with a mental health professional and within a few hours, like all encounters, you remember little of what was said rather the atmosphere that was created. We leave with a feeling of whether it was a good or bad experience. But we should go further and ask ourselves, have I learnt something practical today which will make it easier to get up tomorrow?

Motivation and acting 'as if'

2010-01-28T06:18:00.004Z

'Evolutionary theorists argue that social intelligence was the primordial talent of the human brain, reflected in our outsize cortex, and that what we now think of as “intelligence” piggybacked on neural systems used for getting along in a complex group' (Goleman 2007:334).

Given the social model I’ve been pursuing on this blog, then in what sense can an individual act purposefully and ‘make something happen’? Fulfil a fantasy about an imagined future - a ‘desired outcome’? Change and adaptation provokes anxiety for anyone who has become isolated. But to find a different way of being in the world requires getting back into some form of social involvement, navigating and negotiating a way back into public spaces in order to gain acceptance from others, some mutuality and sense of social belonging despite the overt and covert negative messages that come from society at large. And in what has become an unknown environment you have no choice but to jump in at the deep end, and act ‘as if’ you already have a competence you don’t yet feel. Once in a new environment however, motivated by others who have become important to you, you can begin to acquire new skills in living, by taking risks and acting as if you were already the person others desire you to be.

People like mysteries and not the idea that psychological abilities can be learnt as a set of skills. But the mastery of a skill brings joy, flow or happiness. That loss of self-consciousness first experienced in childhood play. Improvisation is innovation in one’s own behaviour. The traditional ‘four stages of competence’ learning model on the psychological states associated with the acquisition of skill (the origins of which are unknown) can be adapted for self-awareness in general. Unconscious incompetence (I don’t know, what I don’t know), conscious incompetence (I know I don’t know, but can’t do), conscious competence (I know, I can do, but others can see I’ve not mastered the skill) and unconscious competence (I and others take my competence for granted).

I learnt how to be crazy from imitating the psychologically troubled and becoming progressively isolated from the mental healthy - and I learnt to be sane through others ‘taking me by the hand’ and placing me in new social environments where I was forced to act in novel ways, and realise the way to mental wellbeing is to imitate the mental healthy.

Goleman, D (2007) Social Intelligence: The New Science of Human Relationships Arrow: London

Religion and Mental Health

2010-01-27T08:58:00.010Z

Traditionally mental health services have been pretty bad at addressing the spiritual or religious needs of their clients. The problem can be very simply stated - a majority of workers don’t have strong religious convictions, whilst most of their clients do.

Until recently the strategy of most workers was avoidance, but that often came across as disrespect because so many clients describe their problems, and see the world at large, in religious terms. Establishing any kind of rapport requires some suspension of disbelief.

The ridiculous situations that can arise are well illustrated by a recent example from general nursing where a nurse from Somerset was suspended for praying for a patient!
www.guardian.co.uk/commentisfree/belief/2009/feb/06/petrie-nurse-prayer-suspended (I should state at this point - given the content of the rest of this site - that although I consider the psychologist Sue Blackmore, evolutionary biologist Richard Dawkins and philosopher Dan Dennett as intellectual mentors - I do not follow them in considering religious beliefs to be ‘dangerous memes').

Those of us without religious beliefs should also acknowledge the obvious truth, that local churches often provide a level of support and sense of belonging (social inclusion) which mental health services have never come close to! A great friend and peer of mine is learning to read and write by studying the Bible, he’s almost sixty and has undergone in the last four years the most rapid and fundamental turnaround in his mental health I’ve ever seen in any client.

In the last three years or so various leaflets and documents have been produced for mental health workers, clients and their supporters about mental health and religious beliefs. From the Royal College of Psychiatrists the leaflet Spirituality and Mental Health http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/spiritualityandmentalhealth.aspx From the Mental Health Foundation Making Space For Spirituality - how to support service users http://www.mentalhealth.org.uk/publications/?entryid5=51515&q=684278%c2%acmaking+space%c2%ac plus their full report http://www.mentalhealth.org.uk/publications/?entryid5=51514&q=0%c2%acspirituality%c2%ac For more involved discussion on the psychosis versus the spiritual crises/ emergency/ emergence debate http://www.rcpsych.ac.uk/pdf/Psychotic%20Episode%20or%20Spiritual%20Emergency%20Nicki%20Crowley%20EDITED.pdf Finally a video of theologian Karen Armstrong on the possibilities of transcendence through practical acts http://meaningoflife.tv/video.php?speaker=armstrong&topic=selftransc - do unto others, as you would have them do unto you.

Online meditation and Wisdom2.0

2010-01-26T07:37:00.005Z

Think of the Web as an add-on to your brain. When you combine it’s increasing connectivity with the memetic selection of searching you have a partial reflection of how the mind works. What was once a very weak analogy between the brain and computers, is becoming stronger.

Whether your influence over the domain in which selection takes place is greater than you have in your social environment is unclear - it appears that way, but it could be an illusion. However the dangers of too greater specialisation, leading to extreme dependence on a particular environment are very real. The more precisely you search and the more limited your connections, the more you exclude and put blinkers on yourself. Another form of emotional and cognitive isolation.

Equally the stressors in the virtual world often mirror those in the physical one. The idea of applying meditation techniques to the way we use computers and the internet has been taken up by Soren Gordhamer in his book Wisdom2.0

http://www.amazon.co.uk/Wisdom-2-0-Creative-Constantly-Connected/dp/0061651516/ref=sr_1_1?ie=UTF8&s=books&qid=1264459010&sr=1-1 Later this year there will be a Wisdom2.0 conference http://www.wisdom2conference.com/

Soren writes columns for The Huffington Post

http://www.huffingtonpost.com/soren-gordhamer and Mashable.com http://mashable.com/author/soren-gordhamer/

At http://www.youtube.com/watch?v=9QBcEFUNCOk&feature=PlayList&p=3B93FF3D190E0C51&index=6 there is a short video.

My first time as a 'peer supporter'

2010-01-25T06:40:00.004Z

...Earlier in the year I had moved into a flat of my own. It was located in a multi-ethnic, working class area of the city. I set about the process of applying for nurse training. I discovered that if I could get accepted there were two hospitals within reasonable distance which had an intake the following May. I thought about doing some voluntary work in the meantime. It turned out that there was a day-centre for the mentally ill within ten minutes walk, I offered my services.

You can’t imagine a grimmer place to live, the centre was in the middle of a concrete shopping centre surrounded by high-rise residential tower blocks, but located underneath the concrete ‘piazza’ style shopping area. The entrance to the day centre itself was through what should have been the fire exit. (The main entrance was the ‘front office’ of the charity which ran it). The centre had just over thirty regular attendees, about half of whom lived in residential units supervised by the charity. It was a ‘social maintenance’ centre for ‘chronically mentally ill clients’ who had become ‘socially impaired’. My first challenge was to get to grips with the language.

In the vernacular of the centre, people were not ‘mentally ill’ they had ‘mental health problems’. They were not patients but either ‘clients’ or ‘service users’. In practice the users were ex-psychiatric patients who had spent long periods in hospital, been to various degrees institutionalised, and were now trying to live something like a stable existence ‘in the community’. There were three staff; a psychology graduate, a social worker and an art therapist. They were anxious to provide a safe and stable environment, but worried about recreating the kind of dependence that clients had developed in hospital.

Early on, I think the manager must have asked me to write down what I saw as my role as volunteer, for I found the following rough draft in my file:

‘1/ Objectives; a) help users/clients to help themselves, cope with
day to day problems, greater independence in the community. b) participate as a member of staff in promoting user-led service.
2/ How?; being there for clients, befriending, listening, providing information and practical assistance.
3/ Problems; clients reluctance to take responsibility, lack of motivation, confidence, dependence.
4/ Tasking problems; being with them and participating in their attempts to undertake new tasks.’
The document is not dated but must have been from the end of 1989. I was a volunteer there for six months. It feels strange reading it now, for since then, over the last twenty years several people have provided exactly the same service for me!

Strictly speaking it was not a ‘drop-in’ centre, but it felt like one. There were the constant changing faces of clients and their friends. Undoubtedly the atmosphere was dominated by the oldest client, he must have been approaching seventy, had been in hospital for many years, been diagnosed with paranoid schizophrenia, but now refused all medication, and was very thin. He was such a presence because he never stopped moving, mostly pacing up and down, sitting only for a minute or two at a time and even then swinging his legs rhythmically. Often, though the centre didn’t open to clients till ten in the morning, he would be pacing outside by nine when the staff arrived. Every day he walked six miles to and from his room in a ‘bed and breakfast’ that took DHSS clients. He appeared to ‘hear voices’ constantly and would mumble, or occasionally shout back at them. He looked mad, (sorry, ‘damaged’) and knew others thought he was. When he had to move, one of the staff helped out and said his entire possessions only filled two black bin bags. The centre was a kind of sanctuary for him, he was the first to arrive and the last to leave. He was at one and the same time a pathetic example of neglect, and a monument to endurance and the determination to survive.

The guy I came to know best lived down the street from me and had also been labelled a paranoid schizophrenic, but was very different. About thirty-five, very outward going and sociable. He took medication but was often drowsy in the mornings and a little overweight. I asked him many months later when I was a nursing student, (and had an essay to write on: ‘Is mental health a valid concept?’) ‘What does mental health mean to you?’ He replied; ‘…being in control…having my own thoughts, no alien thoughts’. His mental condition had become obvious to himself and others when he was in prison, but he had been lucky enough to serve the last six months of his sentence in a regional secure unit, a small scale unit for offenders with mental health problems. It was while we were sitting drinking coffee in my flat one day that I witnessed for the first time someone rapidly becoming psychotic, and then just as rapidly normal again. I must have inadvertently ‘cued’ him, for half way through a sentence he interrupted me and began speaking much faster in the voice of an evangelical preacher about his own sins and those of others. The contrast with his normal voice was striking, not just the speed, but volume, passion and incoherence. I thought for a moment, realised what had set him off, then choosing my moment said something about the topic we’d been discussing much earlier. Just as easily he came back to normal speech quite unselfconsciously. I’m afraid my curiosity and enquiring mind got the better of me. I deliberately cued him again, then brought him back as quickly as I could. That satisfied me, anymore would have seemed unethical…

…One of the activities open to clients was to attend the ‘health shop’ run by the local health authority and take part in the ‘stress clinic’. This was a course run by a young man who was later to become well known for developing ‘laughter therapy’ in Britain, based on the Indian practice of a group of people going to piece of open ground in the early morning or evening and deliberately making themselves laugh together for a while. One of the exercises in the stress clinic was to write one’s own ‘obituary’ and part of my attempt survives; it’s a bit embarrassing really, but perhaps it illustrates how I was thinking at the time:

‘Nick Hewling died this week at his farm in Provence aged seventy-four, where he spent the last twenty years of his life cultivating his vineyard and promoting his own wine. He moved to France after a distinguished career in the National Health Service, first as a psychiatric nurse and lecturer, then as a psychotherapist. However he will probably be best remembered for his best selling books on mental health. Although widely respected as an innovator in psychiatric care, he didn’t enter the profession until his early thirties, previously he had been… Later he was a professor at the University of … He leaves a widow and two children.’

Also I find a copy of a ‘life events’ stress questionnaire, where you mark up and score stressful events from the previous two years. (This was early 1990). Low stress started at one, fifty being the average or medium(?) and one hundred being high stress - I scored one hundred and five! (I think it must have been some sort of ‘adaptation’ of the Holmes-Rahe Life Stress Inventory). The facilitator also tried getting us to use what he called ‘stress meters’ to monitor our levels throughout sessions (as in Galvanic skin response, polygraph etc.), but with us monitoring ourselves - as the needle swung back and forth one quickly became anxious about what was making one anxious!...

Self-management - practical and emotional resources

2010-01-24T06:46:00.004Z

Practical resources I can usually organise for myself. They allow me to go where I want, when I want. They allow me to reach the emotional support and motivation I need - for that can only come from others.

My practical resources all centre around my leather satchel for which I paid almost £130 three years ago - an extravagant purchase you might think for someone on £91.80 per week benefits, but it’s intended to last a lifetime and it does the job required of it. It contains all I need to survive, it goes wherever I go!

So what’s in the bag?

It contains; diary/ address book, A-Z for Exeter, Torbay and Plymouth, several Stagecoach Devon timetables, a First Great Western timetable, A4 writing paper, pencil, red pen, yellow highlighter, post-it pad, red and black whiteboard markers, cloth for cleaning white board, extra tobacco and papers, spare lighter, re-usable cloth shopping bag, extra large plastic bag, sun glasses, reading glasses, benefits letter, CV, photocopy of some meditation techniques, my WRAP (on 2 sides of single sheet A4), bottle of tap water, Mac-in-a-Bag, sun hat, comb, spare key to my flat, Ventolin inhaler, 8 combined Aspirin/ Paracetamol/ Caffeine tablets, 6 low dose sleeping tablets, 2 condoms, 2 sticking plasters, 2 x 20p, a AAA battery, digital voice recorder, student ID and carrier, memory stick (back-up for my own computer, but also allows me to work on anyone else’s; contains hundreds of emails/ contacts, all my own writing, electronic versions of articles, bits of books, policy documents, reports, guides to everything that seems worth knowing about mental wellbeing!)

About my person I carry keys, coins, tobacco, papers and filters, lighter, tissues, wallet containing single debit card, driving licence, folding money, stamps, a couple of passport photos and my mobile. And last of all my go anywhere/ anytime Gold Mega Rider bus pass for Stagecoach Devon.

All the above gets me by bus/ train/ walking to my emotional resources and sources of motivation; and they in turn mark-out the limits of my territory (between Exeter and Plymouth with occasional forages as far as Bristol).

My only goal is the next horizon, my only need to meet someone there I care about - who will teach me something I don’t already know!

Psychological Skill

2010-01-23T06:41:00.008Z

Psychology is best understood as a set of physical skills. Now I suspect that sentence will seem odd to most readers, but a small minority will be thinking, ‘tell me something I don’t know!’

Unfortunately as my writing gets better, along with my confidence in understanding our social world, there seems to be an ever greater risk of losing what modest readership I already have. Perhaps one should just practice psychological skills, rather than try to write about them.

You see the problem is, there is this strange phenomenon of people liking mysteries and not wanting them explained. A lot of modern magicians have experimented with building explanation into their acts, but have sooner or later hit a wall - and it‘s not just a need to maintain trade secrets in order to earn a living. People want to be amazed, in awe of, and frightened (up to a point). In the world of mental health it often appears that someone in distress, does not want, nor responds to, either explicit explanation of their difficulties, or to training in techniques to relieve them. It’s even got to the point in our individualistic society where many will argue that there are no universal ways of understanding or helping - apart from the mysterious ‘love conquers all’! And the more knowledgeable person certainly doesn’t want to end up suffering the emotional isolation of what I call Sherlock Holmes Syndrome - of going to the trouble to explain (about inductive and deductive reasoning, how he built-up his library, apprenticed himself to learn about such things as horses and dogs, the logic of railway operations and timetabling, etc, etc) only for Watson to call it all inborn ‘talent’ and ‘genius‘, the police to call it ‘luck‘, and the public ‘…well when you put it like Mr Holmes, I can see it really is so simple anyone could…’ It was others who set him apart. People fear something is lost in explanation when in fact the reverse is true - it only adds to the wonder of the world.

But there is a more fundamental problem about explanation, learning and skill. For those of us who did not learn our social skills unconsciously and naturally in early childhood, it is a cause of fascination to watch the socially skilled finding themselves quite incapable of describing what they do so self-evidently well! Conversely it is alarming to watch one’s own continuing incompetence at the same time as knowing exactly what one is doing wrong. The old truism that those who find a subject or skill difficult to learn make the best teachers, often holds-up. Now we are into the domain of tacit knowledge, the knowledge and skills we know others have, know to be vital to much social interaction, whether work or leisure, which have proved impossible to write about or codify in other ways?

There is a huge body of knowledge (useful or otherwise, effective or harmful) that one knows is learnt, over long periods of time, possibly quite unconsciously, when alongside the most experienced of practitioners. You know they have ‘it’, that’s why you place yourself alongside them; they know they have ‘it’ but can’t articulate it to you.

Consider the following. The range of human emotions are universal and so is the way they are expressed. Human emotion is communicated through facial expression and tone of voice. (Whilst thoughts are communicated through the content of speech and hand gestures). There is relatively little individual variation. Emotion is felt as your facial muscles react to what you see or hear in the other person. Emotion comes first, thoughts follow.

Some of you will be thinking ‘well that’s bleedin’ obvious’, for others it may be a ‘bolt from the blue’.

I don’t do empathy (the ability to feel what others feel). At least not very well, and not most of the time. I didn’t learn that basic human skill in early life, which most people acquire so un-self-consciously that they don’t even name it. It’s not a ‘learning disability’ - I have the capacity, it simply became blocked. Hence my adult life has been one long painful process of mechanically acquiring the skill. And I’m not fluent in it - others can see the joins, often become fearful of me, and turn away. (Doing one of Paul Ekman’s tests I correctly guessed only 3 out of the 8 universal emotional expressions - and that was with 30 seconds to think about it!)

As for a ‘theory of mind’ (knowing how others think) well, a long time ago when I was a patient on a ward a student nurse demonstrated a few NLP basics, such as the reasoning behind ‘eye accessing cues’ - you see I’m profoundly left-handed, I’ll move anti-clockwise when 90% of the population are moving clockwise.

Twenty wasted years in the psychiatric system. Being diagnosed with depression, schizoid affective disorder and manic depression - actual taught me nothing. They only described, rather inaccurately, how my limbic system reacted to such dodgy data!

Psychiatry, clinical psychology and mental health nursing don’t know they are stuck at the end of a cul de sac - ramming each other out of road rage, whilst the rest of the world passes on the main road. Paul Ekman’s Facial Action Coding System has been available since 1978 but I know of no mental health worker who has ever learnt it. And of course any part of NLP has been thought ‘beyond the pale’ for the last twenty years.

There is much that is not mysterious. Simple laws can lead to massive complexity. Complexity does not mean something is necessarily complicated to understand. Darwin taught us that 150 years ago - he also guessed right about facial expressions!

The 'demanding' patient?

2010-01-22T07:00:00.003Z

For the service user there is only one thing worse than the sinking feeling you get when you realise that others are saying they hear what you say, but are looking upon you as ‘mad’; and that’s the moment when you express suicidal thoughts and the worker stops listening, at the same time as insisting on not leaving your side - until you stop sharing those thoughts!

In my twenty year ‘career’ as a psychiatric patient it has been impossible to separate my changing or persisting notion of ‘self’ or personality, and the problems I may have, from the real social experience of being part of the mental health care ‘system’. And some of my peers will go so far as to state that it was the experience of hospitalisation itself that caused what others subsequently labelled a mental illness.

All I ‘know’ as a client (diagnosed as Bipolar) is that over the years I have met other clients, who after getting to know them a little will mention that at some point they have been given the label of a Personality Disorder; that it almost always came after having been given other diagnostic labels; that in terms of discrimination and stigmatisation it is the ‘shitty-ist’ label you can give someone; and that throughout my life I have satisfied many of the criteria for various types of personality disorder, though no one has given me that label - yet! My experience of mental health care, has meant that when I ‘see’ what others call aspects of a personality disorder, it is almost always in the context of some form of confinement; of people forced to live and work together who would, given a free choice, choose not to be there - workers, clients and carers. But the explanations offered by others for those behaviours, displayed in the present moment by people who have often experienced mental health care for many years, centre around traumatising childhoods - a failure to emotionally attach, dodgy learning, and the fixing of an identity at a young age with little change thought possible, until in middle-age they appear better able to cope.

Being on a ward for twenty-four hours a day, means the influence of clients on each other is much greater than that of staff. You learn to communicate very rapidly because you have no choice. What remains incomprehensible speech and bizarre behaviour to staff, becomes more and more understandable amongst peers. What looks like nonsensical behaviour to the outsider who spends most of their time away from the ward begins to make sense to those within it. Equally amongst new workers, what might be called a ‘myth of inarticulacy’ grows up. There is no sense to the client’s world, when viewed by those who are confident that they are ‘normal’ and living in the ‘real world’, therefore the obligation remains with the client to fit-in by making themselves understandable - staff come to have a an ethnocentric outlook. And the only way out for the client is to start ‘performing’ for the staff, you learn what it takes to get what you want, you do your best to manipulate the situation you find yourself in - until in middle-age you get so good at it, it looks like improvement and a change in personality. The only problem is, by then you’re a mental health ‘junkie’ and have to resort to such methods as writing your way out of it!

She said she had been watching me since I’d come down from the secure ward three days before. Between supplying me with cigarettes, she told me how I’d changed and was getting better - no nurse was ever quiet that observant! She described me to myself and gave insight. That was sixteen years ago. We met on and off in all sorts of mental health type locations over the years. When she was agitated (she would have said anxious) she’d seek me out repeatedly - maybe half a dozen times an hour. And perhaps ten times in as many years, we had in essence the same conversation about depression, suicidal thoughts and actions. By the end she had been in ‘the system’ forty years, me a mere twenty - she was the consultant, I just the junior doctor! Others, sometimes found our talk ‘inappropriate’, how naive - we were the ones in the moment, in reality and staring life in the face.

She described herself as Bipolar, but had a reputation for being terribly demanding and dependant. To me what she was doing was forever testing everyone. All those decades of receiving care but never any long term relief, had left her profoundly distrustful of workers and sometimes other clients. Thirty-five years of lithium hadn’t done much - now her kidney’s were packing-up. There had been repeated suicide attempts from which she’d achieved only greater competence. But then so too had those around her, leading to a kind of ‘arms race’: ‘My husband’s put a lock on the medicine cabinet’. A cascade of questions:

‘You know what it’s like don’t you Nick’
‘Yes!’
‘You’ve been there haven’t you Nick’
‘Yes!’

Always testing, always eyeball to eyeball, but acutely observant too when I was trying to explain something to others about the way it was - me knowing I’d better get it right or she’d lose her trust in me. What all the experience and mistrust had meant was that she valued honesty above all else. Physically she looked terribly slow, mentally she was quick, subtly rewording again and again what might seem like the same question but wasn’t, she tried to trip you up, because she had learnt others could not to be trusted. The answer was to concentrate on the question, and respond straightaway with the honest answer, however inappropriate or absurd it might sound! Only then did she get consistency, reliability. You had to be focused on her, not caring if you looked crazy to those around you. Workers, trying always to be supportive and consistent in their care therefore came over as the opposite, because they weren’t actually listening to the precise question. She didn’t care what the response was as long as it was honest.

It had become our routine that I was the one who always finally walked away. The last time we met we were together with others for several hours; me frustrated, wanting the workers out the way. But our personal relationship had a good ending. Knowing I was leaving she stood up, came over and brought it all down to four words;

‘Will I be alright?’
‘I don’t know’

I turned and left. She didn’t mean will I get better, she meant will I get to where I want to go. As usual when trying to tell workers that something else should be done I get back ‘client confidentiality’ and ‘inappropriateness’ and told my view is just my own and no more valid than anyone else’s. A couple of days later she died. Almost a week later I am told she has killed herself, whilst workers around me have known for days. It was ever thus.

Depressive, manic, rapid cycling, avoidant, dependant, borderline, obsessive? Sure, all of them at various times, persistently and enduringly over forty odd years; learnt, played-out and inseparable from the relationships made with those who make up the mental health system.

… but this is getting to be too much of a reconstruction, with the benefit of hindsight - and as we know every act of remembering involves a degree of reinterpretation.

Clients may not be being ‘demanding’ but ‘testing’ - behaviour firmly grounded in their previous experience of workers rather than imagined consistencies in a ‘personality’ glimpsed by others. Equally a major problem may be workers, believing they are giving consistency of care, but not being quick enough to follow changing emotional states, ending up giving rapidly changing inconsistent responses!

Christmas On The Ward

2010-01-20T20:33:00.004Z

...I finished my essay on: ‘Is mental health a valid concept?‘ and returned to work. I’d only been in hospital for about ten days. Work was okay for a couple of weeks, and I was free of those experiences that had seemed to place me on the edge between reality and psychosis for a few hours at a time. We had a visit to the local prison which fascinated me; the kitchens, the hospital wing, being shut in a cell for a few minutes - my overriding memory was of the warders whose lives were dominated by their keys. We were introduced to different ‘nursing models’ and different wards where they were supposedly used. I attended an out-patient clinic, my talks with the consultant seemed to be all about medication, when and how I should reduce it. Then one night the snow came.

I was enthralled by it, I believed it was building higher and higher on the roof into a kind of tower. I decided to rearrange the flat. Move everything from the bedroom into the living room and vice versa. I took a couple of objects at a time from one room to the other, picking up some new ones for the return journey. Soon the scene became totally disorganised - like the inside of my head. I remember a walk at night, following street lights, trying to make sense of their patterns. Once I saw Bill (who two years earlier had been my therapist and was now one of my nurse tutors) standing in the shadows, he didn’t do anything but it was good to know he was looking out for me. I can’t remember the events that led to my return to hospital, but I know I was taken there again by ambulance and for awhile refused to get out. I was disorientated in time and space, physically uncoordinated, disassociated from my surroundings and recent events. It was then that I was sectioned for the first time (compulsorily detained under the mental health act - either because I posed a danger to myself or others). I was taken to ‘intensive therapy’ (a locked ward).

I found this first period of confinement claustrophobic, the ward was too hot, the windows fixed so as to only open a few inches, there was one living area and a corridor with five single rooms on each side. We ate with plastic cutlery, our belts were taken away. If you wanted a cigarette you had to ask for one at the nursing station and they would give you a light. In the first few days I learnt just how interactive live TV could be. You had to watch from a certain angle, and synchronise eye movements, but then the people on the screen could send you personal messages.

I was only there for a week or so. After a few days my mood began to fall and I was relatively normal for a while. In a more rational state you begin to remember basics truths - like the easiest and fastest way out of a prison is the reverse of the way you came in. Whilst physical means of escape present themselves at times - the real trick is to get those who wanted you in, to want you out. It was a long walk through the remaining snow to the new acute ward. The section was lifted about a week later, now I settled down to trying to get on with another set of strangers, staff and clients. I started to feel depressed. The ward had been recently renovated, the contrast with the rest of the hospital was striking. The staff seemed proud of it, anxious to keep it neat and tidy. Despite being aware on some level that it was longer-term changes in mood, coming from within me, that were in some way fundamental; I was prone to deny it, and think in terms of ‘fate’, or of sometimes being ‘surprised by joy’ and of course - of being in ‘control’ of my responses to life events.

But my mood continued to drop and my surroundings appeared grimmer and grimmer. The most depressing place I’ve ever seen in my years in the world of ‘mental health’, was the patient Snack Bar. It was in the basement, poorly ventilated, with low artificial lighting. The one place in the hospital patients could get tobacco. Through the gray mist, ghostly figures sat a stools, communicating only with themselves. A nightclub for the half-dead. To be outside was too cold, roaming around inside did nothing to lift the mood. I did manage once to get access to a full size billiard table for an hour or so, but it required getting someone to unlock several doors in order to get there. I slowed down, time slowed down. The consultant stopped the tranquillizers, and started me on an anti-depressant. (No one explained the basic facts; that they take about two weeks to start to work [anything else is environment or placebo] reaching their maximum impact after six . If you haven’t improved by then - you may be amongst the 20% for whom they have no effect). I was not aware of the pills helping me, but I kept taking them. When I started to express suicidal thoughts I was sectioned again. Soon I was facing the prospect of spending Christmas on the ward.

The high point of the day was the arrival of Mary. She was one of the night staff and was the one person I seemed to be able to relax with and have a normal conversation. It was easier to settle down at night and get some sleep when she was there. The future looked awful, I’d never be able to hold down a job or maintain a relationship. I was defeated. As usual the TV was on all day, with nothing but news of the build-up to the Gulf War. The future was unbearable to think about - I could only look to the past. About a year before I had bought an audiotape of Laurie Lee reading some of his poetry. I thought of one entitled Boy In Ice:
　
O river, green and still,
By frost and memory stayed,
Your dumb and stiffened glass divides
A shadow and a shade.
In air, the shadow’s face
My winter gaze lets fall
To see beneath the stream’s bright bars
That other shade in thrall.
A boy, time-fixed in ice,
His cheeks with summer dyed,
His mouth, a rose-devouring rose,
His bird-throat petrified.
O fabulous and lost,
More distant to me now
Than rock-drawn mammoth, painted stag
Or tigers in the snow.
You stare into my face
Dead as ten thousand years,
Your sparrow tongue sealed in my mouth
Your world about my ears.
And till our shadows meet,
Till time burns through the ice,
Thus frozen shall we ever stay
Locked in this paradise.
　
Just before Christmas my father made the long journey to see me, baring gifts from my mother. He was supportive, as he always is. His apparent simple ability to endure never ceases to impress me. Something I am still trying to emulate. His being there reminded me for a while that there was a life outside the hospital. Christmas would have been tolerable if the staff had not decided to give us a party on the ward. Music, a DJ and disco lights for what seemed hours on end. Now I slowed down even more, spending as much time lying down as possible, I hadn’t the energy to kill myself anymore. I thought again of Laurie Lee and Twelfth Night:
　
No night could be darker than this night,
no cold so cold
as the blood snaps like a wire,
and the heart’s sap stills,
and the year seems defeated.
O never again, it seems, can green things run,
or sky birds fly,
or the grass exhale its humming breath
powered with pimpernels,
from this dark lung of winter.
Yet here are lessons for the final mile
of pilgrim Kings;
the mile still left when all have reached
their tether’s end: that mile
where the child lies hid.
　
(Mary came alone to my single room, knelt by the bed, put her head close to mine, and spoke for a few minutes. She took my hand, then stroked my arm; but it was with a lover’s touch, and it was enough - she gave me undeniable evidence that I was alive, and likeable).
　
For see, beneath the hand, the earth already
warms and glows;
for men with shepherd’s eyes there are
signs in the dark, the turning stars,
the lamb’s returning time.
Out of this utter death he’s born again,
his birth our saviour;
from terror’s equinox he climbs and grows,
drawing his finger’s light across our blood -
the sun of heaven, and the son of god.
　
Slowly my mood began to recover a little, I was taken off the section, but the increased suicide risk was not recognised by others. (At the lowest point of depression you do not have the energy or organisational ability to kill yourself, the greatest likelihood of an attempt comes before, and after). Three times I went to the bridge over the motorway ready to throw myself off. My stolen car was found by the police, but then my flat was burgled. One night I didn’t return to the hospital, the police arrived, put me in a cell for an hour or so whilst the duty psychiatrist was found, after which I was returned to the hospital. At one point I spent many days in bed in my flat, but was visited by a couple of the nurses from the hospital who persuaded me to return to the ward. My diary shows an appointment with the consultant, presumably as an out-patient as late as mid-April. There was talk of returning to work, joining a new intake who had started in September, it would mean doing just one essay to catch up. Then one day I was looking at the reading, it was all about ‘nursing models’, and what should have been a simple task for a graduate to take apart and critically analyse - just seemed totally nonsensical. What I was reading just didn’t register, I had no concentration, it was utterly baffling. It was then that I threw in the towel. (I’ve not worked since). I would resign, leave the flat, stay with my parents on the coast. I was almost thirty-two, had been trying my best since I was eighteen, and had lost…
　
(That was the third period in my life when I’d been in and out of madness, and there have been many more since, some more extreme, others less so - yet you learn nonetheless, up to the point where now it seems I can live in parallel realities, switching between them at will!)

The above events took place at Christmas 1990 in All Saints Hospital, Birmingham. A Victorian asylum next to Winson Green Prison. Neither exist anymore of course - the Home Office acquired the hospital site, and the other Victorian asylum was renamed The Birmingham Prison.

Lee, L (1985) Selected Poems Penguin: London

What is social neuroscience?

2010-01-20T07:34:00.008Z

Neuroscience has expanded hugely in the last fifteen years or so since researchers have been able to buy time on hospital fMRI scanners during off-peak periods. By attaching ever more sophisticated computer technology, it has become possible to collect data that promises to close a major ‘missing link’ - between how the brain and behaviour of one person, influences that of another - how the physical science of the human body links to the psychological and the sociological. How the verbal and non-verbal communication of one person becomes that of another. Equally the results show a trend towards the brain being much more flexible, adaptive and capable of new learning (in all age groups) than was previously thought. Indeed the key question to ask now may well be; how do people manage to stick to habits and routines which narrow the possibilities of their lives when their brains have the capacity to do otherwise?

(Most neuroscientists proceed on the assumption that Darwinian evolution by natural selection applies to the human species - both biologically and culturally; or to phrase it differently; the rules of evolution apply to the maturation of the physical structure of an individual brain, plus all it’s acquired contents - all the learnt stuff!)

So researchers are now talking tentatively about a social neuroscience; how the daily physical experience of the world of others maps into the creation and growth of new connections in the brain leading to the strengthening or weakening of neural pathways (a physical process of chemical encoding) and of course, how it all comes out again before proceeding into someone else’s brain.

Asking ‘why?’ type causal questions, or trying to attribute agency becomes increasingly pointless. Rather we should stick to ‘how?’ When someone makes an assertion, the right response really is; who told you that? Nothing written on my blog is original, it’s just a series of links - OK! (And how come all these brain scientists are into eastern philosophies and meditation?)

Start with two very short TED talks; first Chris deCharms

http://www.ted.com/talks/christopher_decharms_scans_the_brain_in_real_time.html then proceed to the mighty ‘Rama’ http://www.ted.com/talks/vs_ramachandran_the_neurons_that_shaped_civilization.html For a good written introduction go to Daniel Goleman’s Social Intelligence http://www.amazon.co.uk/Social-Intelligence-Science-Human-Relationships/dp/0099464926/ref=sr_1_1?ie=UTF8&s=books&qid=1263909589&sr=1-1 (he finally got the right title for a book!)

The Recovery Movement (part 1)

2010-01-19T07:40:00.006Z

The current fashion for the Recovery approach in mental health, means it is inevitable that it will feature in many of these blogs. I am, in part, a product of it myself, having been a client of one of the services which uses it, however I am also one of its critics. I don’t believe that the turnaround in my own mental health over the last four years or so can be attributed to the ideas and practices that Recovery-focused practitioners use.

Most people approach Recovery from an individual perspective - a worthwhile personal experience leads them to recommend it to others. I, on the other hand, have always seen it as a social movement within the world of mental health (hence the capital R).

The easiest way to introduce the subject is to signpost to short documents from individuals and organisations using the approach from here in Devon and the rest of the UK - I’ll leave the large number of connections to it in the US, NZ and Australia until part two (A brief history of Recovery).

In essence the Recovery movement has sort 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 ethical, moral and political values has emerged which are intended to inform the personal conduct of workers in their interactions with clients. To date, the movement has not generated any new theory of human behaviour or understanding of mental distress, nor has it advocated specific therapeutic interventions, and as such has not challenged the legitimacy of any of the occupational groups within the world of mental health.

A good starting point is the list of Recovery - concepts and applications devised by a group of commissioners, providers, service users and carers from Devon in 2008 and collated by Laurie Davidson http://www.scmh.org.uk/pdfs/recovery_concepts.pdf (There were originally eleven, not ten items - but that will be the subject of a future post!) The concepts were then used to inform the writing of Making Recovery A Reality published by the Sainsbury Centre For Mental Health http://www.scmh.org.uk/pdfs/Making_recovery_a_reality_policy_paper.pdf They were also reworked into a simpler form for the pamphlet Putting Recovery at the heart of all we do issued to all employees of Devon Partner NHS Trust http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/info/Putting_Recovery_at_the_heart_of_all_we_do.pdf In 2009 the SCMH issued Position Paper - Implementing Recovery: A new framework for organisational change http://www.scmh.org.uk/pdfs/implementing_recovery_paper.pdf laying out specific proposals from which standards and outcomes could be set. Finally, the Recovery movement, client-centred as it is, offers the user‘s own ‘story’ as the principal form of evidence for Recovery. A recent example Beyond the Storms: Reflections on Personal Recovery in Devon http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf edited by Laurie Davidson and Linden Lynn.

The Man With No Name (uncut)

2010-01-18T07:33:00.007Z

(Note: When this piece first appeared in a local newsletter some eighteen months ago I slightly censored the original text, the cuts have now been restored and the content updated. Some readers wondered if the other person referred to is a real person - I can assure you he is. I’m prompted to post it today having listened to the remarkable Breakdown86 at wolfman’s podcast http://www.podomatic.com/profile/wolfmanmischa CAUTION! Some readers may find the content disturbing to listen to, it’s difficult for me to judge since it follows a very familiar pathway - remember your ‘pause’ and ‘stop’ buttons).

I first met him on a psychiatric ward, I knew his name then but have forgotten it since. We lived in almost the same street for many years but rarely spoke, though we saw each other all the time. The last time I saw him, a few weeks ago, he passed briefly through the café before jumping the train. We have known each other now for nearly sixteen years, and it seems that there is a bond of shared experience that will never go away. Let me try to explain.

At times he seems like my mirror image. He’s certainly a benchmark by which to measure myself. On one occasion when we met (passed on the street) I was in a neighbouring town, and waiting for the bus home. I was sitting on the wall, staring in the direction the bus would come, looking south-west; the setting sun illuminating me, my body relaxed and my eyes rested naturally on the horizon. I saw him coming from the same direction, the perfect opportunity to ‘read’ him and therefore myself - the simplest of encounters with the minimum of ‘noise’. I knew his gaze had to past across the uprights of the bus shelter and that would clean his memory at the right moment. I remained motionless and allowed the gaze of my eyes to remain fixed. At the right moment I glanced away for a split second in recognition, then back to look directly and uncompromisingly into his eyes - demanding a response. It was then that something remarkable happened. For the first time in all those years he looked undeniably normal, and his expression, in response to mine, was one of sorrow and sympathy. With my seemingly fixed stare I looked distressed to him - he had misread me, in a way only a ordinary person, who cares but doesn’t understand, can do. He had lost, for a while, his capacity to be mad.

He’s a walker, night and day, and so am I. But he needs to be outside more often - he covers more miles. Those who are disturbed don’t wander, they walk with purpose, rhythm and speed. To the onlooker they may appear to be staring blankly ahead whilst taking an erratic course - they look crazy. But this is only because urban landscapes are artificially regular and regimented. The real walker, who moves swiftly but smoothly, is actually following the most efficient path through the real contoured landscape beneath his feet. The path of least effort up a slope is always curved. The apparently fixed staring eyes have in fact come to rest naturally on the horizon - seeing through the fixed artificial urban skyline. But they do blink from time to time, like a camera shutter recording fixed points for navigation. The so called ‘psychotic’ hopes to achieve a kind of walking meditation; whereby the hallucinations, which may be of sound, smell, taste, touch or vision, and the unwanted delusional thoughts that emerge to explain them, may be relieved. If he can stay ‘in the moment’, in the here and now, create nothing but constant change around him, know that all thoughts and feelings can only be about the past or future and let them go - then survival is possible. Finally he may be able to allow his unconscious mind to make all the decisions and find a few hours of peace whilst in constant movement.

By the time he comes to rest, his ‘balance’ (physical coordination) and ability to ‘navigate’ (be orientated in three dimensions of space and one of time) will be restored and his mental awareness as acute as his hunter-gatherer ancestors. Alas, opportunities to be alone and abroad at night are ever more restricted by modern society. When forced into the crowd then disaster may strike unless you are particularly confident and relaxed. You may even be able to ‘part the waves’ by walking briskly in a dead straight line through a crowded pedestrian precinct staring relentlessly ahead, not deviating nor giving way even for a moment. The first time, I did it by accident; I was pre-occupied with my own thoughts and didn’t realise until I was in it and saw its effect. It’s both frightening and amazing if you have the confidence to keep going. The crowd parts in front of you, you are like an arrow travelling through air, it gives a wonderful sensation of power. But you mustn’t take your eyes of the real horizon and make eye contact otherwise you will become rapidly disorientated and liable to fall. I must have gone a hundred yards without touching anyone. Afterwards you need to be able to switch realities; and must make eye contact to be balanced, and able to navigate in the landscape of others!

When we met on the hospital ward it was a crazy place, the staff occupied one mental universe, whilst we the patients had our own individual realities - well almost! There is a realm where two, at most three, psychotics can understand each other and therefore act together. We each define a situation differently and ascribe different meanings to it, reflected in the mutually incomprehensible content of our words - but how much real communication depends on language? He’s a bit of an artist and one day I helped him cover the walls of the music room with graffiti. The unit was attached to a general hospital, any part of which could be explored - if you had the confidence to act as though you had a right to be there. At night the grounds could be a playground too.

The fastest way out of a prison is usually the reverse of the way you came in - through the front door! You are never more than three keys away from freedom in the psychiatric system; one out of seclusion, another out of a secure ward on to an acute ward which is open at some point in the day, and the third which unlocks the transport taking you to and from units or the outside world. Physical methods are extremely slow, the psychological much faster - you have to get those who want you in, to want you out. Using what have become the 'black arts' of psychiatry and psychology, against those from whom you learnt them, can be fun; non-verbal behaviour, hypnotherapy and NLP - plus a little old-fashioned distraction and sleight of hand. Two of you can cause chaos, three of you can get one of you - out of anywhere. And it is a game. If you can understand the source of your distress in the system of care; see its rules, routines and the habits of the workers who reproduce it - then there is much to amuse. But it is addictive and I still can’t walk away from it all.

(Oops! I may have just self-diagnosed myself with an ‘anti-social personality disorder')

An evolutionary approach to mental health

2010-01-16T19:40:00.006Z

What follows is a temporary, but necessary diversion into ‘grand theory’. Necessary, because any approach to mental health that isn’t compatible with a theory of human behaviour in general doesn’t stand a chance. (Those stuck in the insular world of psychiatry and clinical psychology please note). I’ve included references this time, just to give pause to those tempted to come down on me ‘like a ton of bricks’!

I have an evolving definition and explanation for what mental distress (disorder or illness, mild or severe) is. It shows itself as a misplaced fear of others. Personal relationships breakdown, followed by an inability to form and maintain new ones. The sufferer becomes progressively more emotionally and cognitively isolated (which may or may not involve physical isolation too).

Madness results from our failure to constantly update and modify the mental map of the world we have in our brain. 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. Though none of us ‘see’ the world as it really is, we all rely on making a more or less 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 of course the only way to maintain an unchanging outlook is to isolate oneself from any evidence that might contradict it. If we fail to observe (insufficient data) or misinterpret (wrong theory) then the map becomes more out of date. If our prediction disagrees with the experiment it is wrong. 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. Mental disorder is emotional and cognitive isolation to varying degrees.

Emotional reactions always come first, from what our five senses are telling us in the present moment, only afterwards do we attach thoughts. If we attach thoughts that come from the past, then we are operating with an out of date model of the world. So often we are not aware of what, in the present moment is ‘cueing’ our emotions and reproducing redundant thoughts. It is natural to be in a meditative state and to focus on the present moment. When the mind drifts away the discipline is to learn to let go, again and again. It is the opposite of taking control. It is about allowing decisions to make themselves, of not worrying about an unknowable future and refusing to get involved in hopes and expectations. The goal should be greater mental awareness of others, at the same time as being more physically relaxed. A full-time activity done with the eyes open. Meditation is not a set of skills that once acquired, can be called on at leisure; for one’s inability to operate in the world, based on the learning made in past relationships, will always return unless such skills are continuously practiced. Unwanted emotions and thoughts from the past will always ‘crash-in’ - meditation is a continuous process of letting go. The myth of self-control leads most to imagine that without it, mayhem and moral collapse will ensue. In practice, the need to manage others falls away and you become a better companion!

The best introduction to meditation I have come across, as a way of operating throughout the day, is to be found in Harrison (1994), and can be read along with his articles on how the core skills have been extracted from their religious context (Harrison 2005-). Sue Blackmore goes further, much further, by placed meditation techniques in the context of human cultural and biological evolution, and how we have evolved the very idea of a ‘self’ (Blackmore 2000:219-246). It’s possible to move towards a resolution of the contradictions of modern life, and the mental distress they give rise to, by developing both an evolutionary perspective and by being aware of the promise of social neuroscience (deCharms 2008, Goleman 2007, Ramachandran 2009). If you view daily life as evolution by natural selection, from minute to minute as well as on a timescale of the last 180,000 years (since we became homo sapiens with our full range of mental capabilities and capacities), see the biological and social as evolving in parallel and feeding back on each other (though at very different rates), then other kinds of questions and explanations suggest themselves (Oppenheimer 2004, Dawkins 1989, Blackmore 2000, Stevens & Price 2000, Nesse & Williams 1996, Nesse 2006).

We have lived out ninety-five per cent of our history as hunter-gathers, moving through and living from the environment. The last eight to ten thousand years, since we have sought to transform the environment (with the invention of agriculture, ideas of ownership and permanent settlement), has been an exceptional, perverse, untypical and abnormal period. Our point of reference for mental wellbeing should be the pre-agricultural world, where we evolved to be nomadic, as part of groups (‘bands’) of no more than about one hundred and thirty people, consisting of relatively close genetic relatives. You cannot ‘know’, as in feel an emotional attachment for, more than about that number of people.

Empathy (the ability to feel what others feel) and a ‘theory of mind’ (knowing how others think) derive from humans almost unique ability to imitate using the ‘mirror neurons’ of the brain, and give the capability to identify with, and be accepted by your group! (Blackmore 2000, Ramachandran 2000, 2003:97-131, 2006, 2007, 2009) If these abilities are blocked by life experience, then you become isolated from the people you are genetically most attached and attracted to. The last eight to ten thousand years has seen the construction of a world containing mental illness. And the culmination is the development of mental health workers, with the normal human capacities, who then try to empathise and share the ‘theory of mind’ of the unhealthy! This leads to the maintenance or reproduction of mental distress. Therapists should be leaders, mentors and role models to whom a client can apprentice themselves, and should not try to connect or catch the habits of the ill. As clients we must imitate the mentally healthy. Three out of four people don’t have a mental health problem during their life times.

And it’s not ‘faulty’ genes either, it is because we did our early learning with very close genetic relatives to whom we are automatically attached. Problems arise as a result of conflicts between the quality of our learning and our attachment to the person from whom we learnt. If you were separated from your close genetic relatives, your learning may well have been exceptional, but your life may become a search for those you are instinctively attached to. Equally you may search the world in vain for a ‘soul mate’, because it is so unlikely in modern society that you will ever meet that person, from the edge of your natural ‘group’, with whom you have a relatively close genetic attraction. It never was nature or nurture - but the ways in which your personal learning, your own cultural evolution, conflicted with the demands of your own biology. Your genes will determine to whom you are attached and attracted to, but it is with your learning that mental disorder is created and maintained.

References　
Blackmore, S (2000) The Meme Machine Oxford University: Oxford
Dawkins, R (1989) The Selfish Gene Oxford University: Oxford
deCharms, C (2008) Christopher deCharms looks inside the brain TED conference presentation Feb 2008

Goleman, D (2007) Social Intelligence: The New Science of Human Relationships Arrow: London
Harrison, E (1994) Teach Yourself To Meditate Piatkus: London
Harrison, E (2005-) articles for Nova Magazine available at http://www.perthmeditationcentre.com.au/articles/index.htm [10.1.10]
Nesse, R.M (2006) response to the ‘2005 Edge Question’ in Brockman, J (ed.) What We Believe But Cannot Prove Pocket: London
Nesse, R.M and Williams, G.C (1996) Evolution and Healing: The New Science of Darwinian Healing Phoenix: London
Oppenheimer, S (2004) Out Of Eden: The peopling of the world Robinson: London
Ramachandran, V. S (2000) MIRROR NEURONS and imitation learning as the driving force behind “the great leap forward” in human evolutionhttp://www.edge.org/3rd_culture/ramachandran/ramachandran_p1.html [19.7.08]
Ramachandran, V. S (2003) The Emerging Mind Profile/BBC: London
Ramachandran, V. S (2006) ‘Mirror Neurons And The Brain In The Vat’ response to the 2006 Edge Question at; http://www.edge.org/3rd_culture/ramachandran06/ramachandran06_index.html [3.6.09]
Ramachandran, V. S (2007) Self Awareness: The Last Frontier http://www.edge.org/3rd_culture/rama08/rama08_index.html [6.1.09]
Ramachandran, V. S (2009) The neurons that shape civilisation TED conference presentation.

Stephens, A and Price, J (2000) Evolutionary Psychiatry: A new beginning Routledge: London

Physical therapy for mental health

2010-01-16T11:13:00.006Z

The brain and body are so intimately connected it makes little sense to separate them when conceptualising mental health. The appropriate ‘treatment’ for mental health problems may well be a physical one. When in the presence of someone who is ‘psychotic’, you probably won’t understand their speech content - why not just watch the body?
Tone and rhythm of speech, facial expression, eye and head movement, gestures, body posture and body movement. What would a physiotherapist see? Suppose on encountering someone for the first time you ignore the apparent mental problems; offer just physical relaxation techniques, enforce a regular but limited sleep pattern, strictly control diet and everything else they put in their bodies - and wait. Introduce mindfulness techniques - for better anxiety and stress management, for greater mental awareness as well as physical relaxation. Then what you are left with is someone with communication problems! A blocked ability to empathise, and a limited ‘theory of mind’.

Reintroduce the most powerful communication tool of all - touch! So they can learn, or more often relearn to be intimate with others - healthy others like you. You offer intimacy. You teach them to dance, to play table tennis and pool, for hour after hour - to gain ‘balance’ (physical coordination) and the ability to ‘navigate’ (in space and time) in that social landscape of others. You provide daily massage, so the client cannot deny the world of others. On such a foundation clients can start to learn again. Acute psychiatric units could be reorganised to provide physical not mental care, for the first week to ten days of any admission, only a client's physical signs and symptoms of ill health would be treated.

A cold body is physically and mentally stressed, warmth is relaxation - too hot and you are anxious. The body and mind feedback on each other. Health in body and mind are the same thing. The source of health lies in natural environments - just as nothing in nature can be ugly, only the man-made! We evolved to be outside and on our feet all day, with our eyes resting naturally on the horizon - catching the sun. Depression is entombing yourself all day, with a slumped body posture and nothing but artificial light, consuming more calories that you use up. It’s about having a fixed territory, being stuck in one place and one time, and defending it in both a mental and physical sense. Mental wellbeing is about being happy with movement and change.

It is not a sign of progress that the modern world is able to offer mental health care! It is offered because the need has developed since we started transforming our natural habits and ways of living. Anxiety and the heightened awareness that goes with it, is the normal response to perceived danger - the natural reaction is either fight, flight or to remain motionless (the predator notices first the moving object). In the absence of real danger, anxiety should rapidly fall away. It is normal to fear ‘outsiders’ or ‘strangers’. Anxiety is part way on the continuum from happiness (loss of self-consciousness) to intense fear. Misplaced fear of others in the modern world, or the inability to attribute fear to the right people (or less often other things in the environment) is what makes others appear as permanent strangers, outsiders or simply mad.

Most communication is non-verbal, and cannot be spoken or written down - but can be physically observed and physically responded to. The meaning of any communication is the message received. You can only be conscious of a tiny fraction of what your brain is doing in any one moment - including thoughts and emotions. You can only ‘know’ your character by what you put in your body, and by the kind of people you spend your time with. The best diet for physical and mental health is a pre-agricultural one; the absence of refined sugars, cultivated and ground grains, domesticated animal meat and milk. The inability to navigate with sight, sound, touch, smell and taste, is a fundamental element of what some call psychosis. A lack of balance, not being able to let the eyes rest naturally on the horizon, which is obscured by the built environment, and feel the natural contours below one’s feet, equally obliterated in the modern world, shows in the long term mental as well as physical ‘crippling’ of the body!

Meditation techniques for mental health

2010-01-15T19:14:00.008Z

Meditation is about being more physically relaxed at the same time as gaining greater mental awareness - throughout the day and with your eyes open! It’s about being in the present moment and therefore more grounded in reality. Despite the rather naive acceptance by some psychiatric authorities of mystical claims about ‘altered states of consciousness’; misunderstanding over an apparent connection with trance, dream like states and psychosis; and the timid approval by the NHS of just one aspect of meditation known as Mindfulness (sometimes referred to as ‘kitchen-sink meditation’) - it is, once stripped of its religious elements, the most important tool I have against madness. It’s the best anti-psychotic there is.

Untangling the myth however is not easy, you need to ‘suspend your disbelief’ and consider for a moment that the meditator is more in touch with reality than you are. You may imagine someone on a mountainside, eyes closed in the lotus position, but the real practitioners may be passing you in the street unnoticed - they blend into the social landscape because they are in the here and now, whilst you are preoccupied with your own thoughts. Your conscious thoughts can only be about the past or future, in the present you only have your senses with which to literally ‘feel’ your way around. Realise your emotions come from the data your senses are giving you now - then you’ll have it! It’s a shock, like waking up from a dream, you are back in the real world for the first time since - when? Suddenly self-consciousness, anxiety and fear can be put to their proper use; of spotting the occasional occurrence of real danger. You can get back to the proper use of your time, finding activities that match your skills and can become absorbed in, achieving some degree of ‘flow’, that sense of happiness that comes from the loss of self-consciousness - something we all felt in childhood play.

The first ‘pay off’ from meditation is the awareness of where you feel fear in your body, what in the environment has triggered or cued your brain to remember some past unpleasant association. It may be an unwelcome series of sensations to begin with, but it soon becomes a useful revelation. This is followed by learning to let go of unwanted thoughts and feelings about the past and future. In the process you can stare life in the face - as it is now.

One of the things meditation tackles well is our ‘illusion of self-control’. We like to think we are consciously in control of ourselves all the time. We distrust our basic, spontaneous impulsive actions. We must be constantly choosing all the time as free independent individuals. As a result we have become acutely self-conscious. Yet there is only so much we can keep at the forefront of our minds at any one time. We come to consider it a failure or lapse in our own standards when we inevitably end up following the impulses of biology, and the learning we unconsciously achieved earlier in our lives. Meditation, by placing us back in the present moment and allowing us to feel what cues us, what stimulates our senses, shows us just how unnecessary the time and trouble we spent on worrying about decisions really was. Decisions are all about an unpredictable future over which we can exert little control. However, we can learn to trust our own brains to get on with it, become grounded in the environment of the present, reconnected to the social world of others, and just be.

Objectives

- to concentrate on the present moment all the time; let go of any thoughts that come up (knowing they can only be about the past or future), know too that in any one moment there is no observable ‘self’; to notice what is happening (not a series of events but continuous change), to pay equal attention to all that can be seen and therefore know what habitually cues you to feel or respond in a particular way (your attention, reactions, emotions, and the ‘story’ you tell yourself about who you are) - and so ultimately realise that it is the actions of others that is creating you.

- to understand that the ‘I’ or ‘me’ that appears when you want something is an obstacle to your sense of wellbeing; to allow decisions to make themselves (unconsciously) since the conscious self is not in control and actions happen whether or not you will them - sense the freedom that comes from knowing you don’t have to try to do anything!

- to refuse to get involved in desires and hopes (about an unknowable future), to know that it is quite possible to live without hope (now is all there is), that in the world of the present you can stop inflicting your desires on others, stop the harm we often do and be able to notice others more.

Finding A Focus

At the core of meditation is the ability to focus on something; whether it be within the body, an external object or a mental image. Focus is not concentration as such, but a fixed point of reference, something you always come back to. A fixed point, baseline or benchmark from which you can navigate your mental interpretation of the physical world. Physical relaxation must come first and the easiest way in is to focus on the breath - not control it, just ‘watch’ it. Once relaxed you can begin to focus away from yourself towards the environment you find yourself in. In a natural environment it makes sense to let your gaze rest on the horizon and make that your focus. Whether we like it or not our attention will be constantly distracted by whatever our senses pick up from the environment and the internal thoughts and feelings prompted by those cues. The ‘trick’ is to always come back to the focus, again and again. You acknowledge the thought or perception, and let it go in the act of always returning to the focus. When truly focused, for however shorter time that may be, you think of nothing else. However the choice of focus at any one time does need to be something that holds your interest - something you enjoy exploring. Good focusing is a joy, as you begin to learn to let go you can start to recapture that childhood sensing and feeling, which never required conscious thought and has a fascination all of it’s own.

Balance

There is however a need to create a balance, between physical relaxation (too much of which leads to sleep) and greater mental awareness (which if not matched with the right degree of relaxation, may provoke a degree of anxiety about ‘what’s going on’ and increase self-consciousness). Stress is not an external force, but occurs within the body, our attention is usually directed outwards so we don’t recognise it in our bodies. In the process of physically relaxing we can identify stress and let it go; so our increasing awareness becomes a tool with which to see the world rather than a product of anxiety that may cause us to turn away.

Relaxation

If the first requirement is physical relaxation, and that is dependant on focused breathing, then an unrestricted diaphragm is a precondition of meditation - it is not the choice of posture itself that matters, but how you hold yourself in it. You can meditate whilst sitting, lying down or walking. The breath naturally changes throughout the day and from minute to minute, if you can learn to watch it and not seek to control it, you notice how it automatically adjusts itself. After meditating for a while you realise it was your conscious attempts to control it that caused the problems in the first place. Unrestricted breathing then allows you to ‘listen’ to the body. Normally when we relax our minds have a tendency to wander, to fantasise or free associate, leading to sleep. Meditation usually has the opposite intention, beginning with the kind of self-knowledge that arises from a greater awareness of the body. You can literally feel mental stress as physical pain - as you begin to relax. Much mental distress is a shutting-off of awareness, of stopping feeling. Becoming more aware of the body begins to put you back in ‘touch’! Much of the tension in our bodies is an attempt to suppress unacceptable emotional responses. The technique known as a ‘body scan’ starts with an awareness of the breath, followed by deliberately focusing bit by bit on every area of the body, identifying tension, gently flexing the muscles, at the same time as noticing the thoughts and feelings that arise. And in the act of physically letting go, it’s a shock to realise just how much mental preoccupation seems to float away. Fear, anger, sorrow and desire all disappear when we are truly relaxed.

Meditating for sleep is different, with the eyes closed you may wish to initially focus on the breath, and body scan. But you shouldn’t seek greater awareness nor be tempted to move on and fantasise in a controlled, ‘story making’ way. Rather think of how dreams are when you’re asleep - less coherent, more a free association of thoughts. One technique is to explore a single visual image rather than imaging a movie.

The link between mental and physical relaxation becomes obvious when you see what great physical performers can do, and realise they could never do what they do unless they were relaxed in a holistic sense. But an even greater revelation comes when you see and hear those same people interviewed! If you want exemplary examples of ‘mental health’ look to the great dancers.

Awareness

Many people equate being alert with conscious thinking. But we can only be conscious of a very small amount of the brain’s activity at any one time and much of it we are never aware of. And we don’t need to be. What is useful is to educate ourselves from time to time about those things that habitually cue us to behave in a certain way. Not so much in order to change, but to stop ‘beating ourselves up’ over those things we have consciously decided should not be part of our self, our ‘I’ or ‘me’. Indeed with a lot of practice you can have consciousness, but no consciousness of self - just awareness!

Mindfulness is a basic technique to help you move from motionless meditation at an allotted time, to incorporating it into what should be continuous movement throughout the day. It’s about focusing on, and paying close attention to the detail of what we are doing in any given moment. Being very aware of the sights, sounds, smells, tastes and textures of the moment, becoming awake and tranquil by focusing intently on minute details. (There are obvious parallels here with being absorbed in the physical practice of a skill, but without the prescribed outcome). When eating just eat, when walking just walk. Walking is a good way to face each day a fresh, when you walk you ‘own’ nothing, you’re in constant movement and there is nothing but change around you, it feels natural to be nomadic - or it should do!

Mentally letting go again and again, brings greater awareness in the hear and now. It is the greatest reward of meditation to be suddenly flooded with insight, an intense feeling or a change of mood. To wonder where it came from, stop, look around, and then be amazed a second time to realise what cued that change. Understanding, and acceptance, of how things just are - in the same moment. And then to let go again. To borrow from Wordsworth: ‘Surprised by joy - impatient as the Wind …’. You lose nothing by letting go of good, as well as bad thoughts and feelings, because as you change, the ones that are useful and real will come back time and time again. Equally tranquillity comes not from changing the world, but from allowing the moments of emotional pain to die a natural death. Sometimes we don’t want to let go of our worries and fantasies, the conflicts that preoccupy us, they become part of our identity and maintain the world as it is, giving the illusion of self-control - the feeling that we can predict the future. But if we can be relaxed and aware in the present, all that falls away - we forget what used to preoccupy us.

When out and about the focus may switch from the breath to a visual object, a fixed point for navigation, but equally there is visualisation, an imagined image for still periods, usually with the eyes closed. But then there are transition states too, for example, ‘body asleep, mind awake’ which can have a better quality than sleep alone. You gain the benefit of an asleep body, but the mind, rather than having the chaos and illogical thoughts of dreaming, stays clear and focused.

And there are the times when it doesn’t matter if what we are sensing, tasting, touching with our bodies is pleasant or not! You just don’t feel the need to explain, understand, or solve, but simply watch and feel - then the realisation of the ‘right thing to do’ will occur at the time when it is appropriate to act. If we are open to the world, not preoccupied with ourselves, then our instinctive responses (which we have been taught to mistrust or contain) will fit the facts and we just feel the appropriate response in a given situation.

To Be More ‘Grounded’

Once grounded, we change and move on automatically. A connectedness to the physical world around us should be our moment to moment preoccupation. We cannot see others in our environment as they are, without it. When we are not preoccupied with ourselves, then we can see the needs of others. And it is in this state that we can approach an understanding of what may be the true basis of what is called spirituality or religious experience. Making others, and or, other things, rather than oneself, the central focus of our lives, allowing transcendent experiences - going beyond our usually limited perception of others. But it is equally valid to assert that in the past there must have been a time when we were all very effective at meditation. That in some sense it must be a natural state, for it is hard to imagine our hunter-gatherer ancestors being able to survive without such skills. Think of hunting, of long hours on one’s feet, of the constant gentle movements needed to pick up a trail, to track and stalk, feel movement in the air, the physical coordination, the ability to navigate, feel the sudden stress of real danger, but be able to let go when it passes, the need for so much stillness, and the quick flowing response. And afterwards, to squat for a while under a tree, to be within the only real temple there is - not enclosed by the buttressing of the branches, but open to the vaulting of the sky beyond. Later, the making of fire - the focus of community and collective narrative.

'To see a world in a grain of sand
And a heaven in a wild flower
Hold infinity in the palm of your hand
And eternity in an hour.'
William Blake 1757-1827: ‘Auguries of Innocence’ (c.1803)

That might well serve as a description of the potential of meditation and truly being in the moment. And Blake of course, experienced visual hallucinations from early childhood onwards. Meditation is a discipline that takes time and effort; though the more competent one becomes the more effortless it feels! Nonetheless like any set of skills, if you don’t practice then you lose them. It’s often when you feel at your lousiest, and have to ‘try’ the hardest that the most rewarding meditations follow. It is not unusual to suddenly feel worse as you relax and become more aware - you realise what’s been going on! This is the crucial moment to learn to continue meditating and not turn away - it is when the benefits really begin. At its best meditation gives a series of ongoing, ever deepening natural ‘highs’ based solely on increasing awareness of the fascination of the world around you. But don’t become a ‘bliss junkie’; stuck in a particular form of meditation, confined by time, place and routine or ritual - with a fixed set of beliefs about what is happening to you and your state of mind, seeking a continuous high, but effectively isolated from the rest of the world.

Meditation offers greater enjoyment of the sense world, deeper more varied emotional experiences and a sense of there being enough time. It feels like life with the ‘blinkers’ off, of a mental fog having lifted, in which we no longer fantasise - but then you catch yourself losing the focus again! But that’s as it should be, when navigating your way around a world of continuous change. Scientists and researchers in search of an ‘evidence base’ for meditation may object that whilst you can demonstrate a link with physical relaxation, the idea of greater mental awareness is not amenable to experimentation. Perhaps they are looking in the wrong place. I would wish to argue that it is the heightened awareness that comes with sudden stress or anxiety, and which to some extent has been measured, which through the discipline of meditation, is being harnessed by an individual who nonetheless remains physically relaxed.
　
Catch Tomorrow Now
　
Can you stop?
Let go of thoughts and feelings
Of the past and future
And just be in the present moment.
Now is all there is.
Reattach your emotions to your senses
In the real physical world of the present.
Notice what cues your thoughts now
Acknowledge them and let them go
Good or bad.
Allow yourself to feel the bad when it happens
Then it passes quickly.
Allow yourself to be ‘surprised by joy’
And let go those feelings too.
Knowing they will return unbidden.
Think of yourself as having no fixed self.
Able to construct a self anew every day
Attentive to others, unconcern for an ‘I’ or a ‘me’.
Aware of the others who make you what you are.
You learn most by imitation.
You only remain fixed
When you remake yourself today
As you were yesterday.
You imagine the past must persist into the future
But only because you reproduce it afresh everyday.
Don’t look forward or back, but around.
Seek to be more relaxed and aware.
Absorb what’s around you
And catch tomorrow now!
　
The Rules
　
Can you stop?
Let go of the past and future - again and again
Be in the present moment
Pay equal attention to everything
Notice in the moment what cues your thoughts and emotions
Now is all there is
Let decisions make themselves
Refuse to get involved in hopes and expectations
Physically relax yourself continuously
Always have a focus

Catch Tomorrow Now - part 2

Can you replace your assumptions about others,
With curiosity and fascination?
And can you unlearn as you let go?
Your routines should be made to work for you,
Habits should be unconscious,
Leaving you free to notice other things.
There is no such thing as a mistake, only new learning.
And the meaning of any communication,
Is always the message received.
Every thought comes with an emotion attached
And rationalising is just a way,
Of putting emotions on hold!
Experiences just make you feel good or bad,
Meanings become attached afterwards;
And meanings never started anything!
Motivation for action can only come,
From an emotional attachment to others.
But it’s a misplaced fear of others,
That is the consequence of mental disorder!

Psychiatrists - they don't know, they don't know!

2010-01-14T16:40:00.007Z

Encounters with mental health workers still tend to take place in locations and contexts of their choosing. They see us when we are unwell, with the tacit agreement that we will talk about what distresses us and find difficult to articulate - not about those areas of our lives where we have demonstrable skills and competences. Even at the height of a crises they are alongside us for at most an hour out of every twenty-four. But as a peer, I may have been talking to the client before they meet with a worker, and again later in the day, know more about that person’s daily life than the worker, and sometimes find myself intentionally trying to undo their work. The ‘trap of the consulting room’ can lead the worker to imagine their training, delivered in a controlled environment, allows them to see client’s problems clearly, and their therapeutic responses as having an impact quite out of proportion with reality. Equally there is the assumption that the motivation to act, in a routine or novel way, is intrinsic to the individual. But the uncomfortable fact is that it is the behaviour of the worker when interacting with the client, rather than the prescribed model or approach pursued, which will or will not, lead to a rapport that may allow a positive outcome for the few weeks or months the relationship lasts.

The mental health professional works only with that part of the client’s ‘personal story’ they feel able to share with this relative stranger, who in their turn is even less inclined to ‘self-disclose’, adding to the existing power imbalance. The imagined ‘client centred-ness’ of their approach may well leave the service user ready to act on a specific issue - the previewed mental health problem - only to find its implementation leaves them exposed to a cascade of social consequences, requiring many more changes than either they or the worker have begun to contemplate. The individualism in nearly all approaches to mental health ignores our social nature and emphasises cognitive tools rather than the emotional foundations of human action. But when a form of counselling works, it is because the client has come to know and trust the worker enough to find their advice credible (and it is a process of advocacy about better ways to live) based on the degree to which the worker embodies what they assert. The client then acts as much for the worker as for themselves. The only problem is the worker is about to ‘ditch them’ - not because the relationship was a failure, but because it was a success!

Despite being involved in Involvement (participating in the giving of feedback to services, and the training of staff) for the last four years or so, it was only six months ago that myself and others got an opportunity to meet with a group of psychiatrists - and that session took over two years to set up. As the reader might imagine they were less than forthcoming, but one thing they seemed clear about, they were confident that when they see us, they see us the way we really are!

Back in 2007 I penned the following under the title A Few Of The Things A Psychiatrist Should Know - by a Service User, it seems they all still apply!

1/ that to ‘suspend your disbelief’ brings rewards; time spent with the same client when they are well, in addition to when they are distressed, in hospital and in the community, outside the atmosphere of the consulting room and the ward, is the only way to ‘see’ what ‘illness’ might be.

2/ all clients have difficultly explaining to themselves the strange things that have been happening to them, their thoughts and feelings - let alone finding the language to explain them to others. But, though they may be ‘inarticulate’ about their madness, they may not be about other areas of their lives.

3/ whatever the causes of mental distress/disorder/illness, the principal consequence is a ‘misplaced fear of others’, and a subsequent inability to make new and lasting personal relationships, leading to emotional isolation.

4/ despite the above, and often as the result of long experience, a client’s ‘fear of madness’ is probably less than yours!

5/ the client’s need is not for longer consultations, but to be seen by the same doctor over an extended period of time; by the same person in the hospital as in the community - how else can trust be established and the doctor acquire what he/she needs most - accurate information.

6/ what is needed is communication skills, don’t waste time trying to empathise with or ‘get inside the head’ of the client, just try to build a rapport; whereby they can tell you what they think it is important, and you can get the information you need.

7/ clients are afraid, if they don’t feel safe they will appear in worse shape than they really are, and not tell you anything.

8/ the most common complaint of clients is ‘why is this person asking irrelevant questions?’ Unless you can address their concerns, and demonstrate the relevance of yours, you get nowhere.

9/ the fastest way to improve someone’s mental health is to re-establish a regular sleep pattern, healthy diet, daily exercise plus learning to physically relax.

10/ very subtle changes in medication make a real difference to side effects, degrees of sedation and therefore compliance!

Peer Support - day to day, moment to moment

2010-01-13T07:33:00.007Z

Being on a ward for twenty-four hours a day, means the influence of clients on each other is much greater than that of staff. You learn to communicate very rapidly because you have no choice. What remains incomprehensible speech and bizarre behaviour to staff, becomes more and more understandable amongst peers. What looks like nonsensical behaviour to the outsider who spends most of their time away from the ward makes sense to those within it. Equally amongst new workers, what might be called a ‘myth of inarticulacy’ grows up. There is no sense to the client’s world, when viewed by those who are confident that they are ‘normal’ and living in the ‘real world’, therefore the obligation remains with the client to fit-in by making themselves understandable - staff come to have a an ethnocentric outlook. And the only way out for the client is to start performing for the staff; you learn what it takes to get what you want, and do your best to manipulate the situation you find yourself in.

If you start from the position of never knowing outcomes, and of most encounters happening by chance, then the focus of informal peer support can be positively framed in terms of; what can I do today that might make a difference? The chance element gives flexibility, freedom and autonomy, but does not imply a lack of commitment or responsibility. Most obviously, you don’t have to be nice to whoever walks through the door! Greater honesty and less role-playing are possible, but equally you can be more emotionally and intellectually honest with yourself. You can observe real client confidentiality; not record or pass on information to other staff or mental health services. There can be a free exchange of information; you can give advice when you feel it is appropriate (especially about the competency of mental health staff and the value of different medications). You can walk away at a time you deem appropriate, whether it be after five minutes, five hours, five days or never! You can express feelings of emotional attachment towards other clients and use touch if it feels appropriate.

Many client’s ‘fear of madness’ is less than that of staff; you can discuss topics staff are often uncomfortable with, particularly self-harm, certain psychotic behaviours and suicide. You don’t have to stop anyone doing anything, or start anything you don’t want to. You can ‘work’ anywhere, anytime. You can use any ‘therapeutic’ techniques learnt over the years, in therapy or as a patient on hospital wards, to bring some temporary relief to others in extreme mental distress. And there is a greater ‘spirit’ of equality; you retain credibility with other service users, no one is paying you to be there; time and expertise are freely given, and in times of your own distress gratefully received. But in part the effectiveness of informal peer support is dependent on a willingness to stay within the ‘world view’ of your fellows and therefore sometimes look ‘mad’ to others. So the consequences of being responsible and loyal, can lead to longer periods of confinement and disapproval or censure from mental health professionals.

Peers are often harder on each other than workers are towards their clients. Sharing common experience often means less opportunity to delude oneself. Divergence in experience means that although the process of informal peer support may seem very similar to common forms of counselling when the subject is mild anxiety or depression, methods increasingly differ when it comes to communicating about psychosis, self-harm or suicide. This becomes apparent when attempts are made to formalise peer support. The devising of rules of good practice, the regularising of contact between people who would otherwise not choose to meet, and the assumption that anyone can learn the ‘appropriate’ skills, leads to systems that look very like the kind of therapy they were intended to replace.

For the service user there is only one thing worse than the sinking feeling you get when you realise that others are saying they hear what you say, but are looking upon you as ‘mad’; and that’s the moment when you express suicidal thoughts and the worker stops listening, at the same time as insisting on not leaving your side - until you stop sharing those thoughts!

For all mental health workers and the vast majority of the public there can only be one ‘model’ in response to expressed suicidal thoughts and that is ‘prevention’. And yet eventually everyone must be left alone. If your model is prevention then over a long career you must inevitably accrue a series of failures. But within that approach workers share ‘responsibilities’ and seek to support each other, whilst ideally enlisting other workers to support the carers of a client.

Although negative ‘outcomes’ are sometimes known - all outcomes remain unknowable beyond today! More often information on how clients are doing is simply lacking. And in terms of personal outcomes, a ‘helper’ never knows the actual contribution they have made to a client’s decision to act, whether it be in a way they regard as positive or negative. For a peer (someone who has shared similar experiences to the client) to seek to ‘prevent’ a suicide usually seems nonsensical; not only is it obviously impossible, but you know from past experience that at times it is something you have positively desired. Besides, what preoccupies your peer, is what might be called the issue of ‘is life worth living?’ What my experience of trying to be supportive has taught me; is that you end up trying to help someone come to a decision for themselves, free of the pressures they feel from the other people in their lives. You know a decision to live or die must be made by and for oneself - only then can it be powerful enough to carry you, either out of despair, or over the fear of death and the pain of dying. For the worst outcome is another ‘botched’ attempt, whereupon the cycle of despair simply beings again.

You walk away, preferable leaving them alone, when you judge yourself to have had the optimum impact on their freedom to choose. Clients confide in their peers for a reason, often for the confidentiality and understanding you can give because you are not staff. Much peer support is ‘unseen’ because the client chooses a time and place away from staff, relatives and carers. Clients do ‘intend’ to kill themselves, it is the most real solution there is to intolerable psychological pain. They fail because of incompetence. They then learn from experience, as do those who seek to prevent them. But it requires effort and organisation, energy and clear headedness.

What are memes? Sue Blackmore explains

2010-01-12T12:51:00.013Z

Get a handle on memes, and cultural evolution.

Browse her website; http://www.susanblackmore.co.uk/

Read The Meme Machine; http://www.amazon.co.uk/Meme-Machine-Susan-Blackmore/dp/019286212X/ref=sr_1_1?ie=UTF8&s=books&qid=1263301384&sr=1-1

Sue is Visiting Professor of Psychology the University of Plymouth.

That 'alternative' CV!

2010-01-12T10:59:00.004Z

One of the things which provoked me to 'out' myself some years ago as a long-term user of mental health services was the advice I received from an employment advisor to 'hide' my lack of employment and periods of sickness from my CV. Not only did she suggest omissions, but a little creative use of dates.

Now I know lots of people do massage the facts of their careers, but the idea of hiding an important part of myself incensed me. So in a mood of indignation I produced a CV which charted my 'career' as a mental patient. Once it was completed it had a surprise pay-off - it help me make sense of my life, to myself.

Here's the main body of the 2009 version, it begins conventionally enough;

1970-75 Vincent Thompson High School, Exeter: CSE grade 1’s in English,
Maths, Geography, Art, Design Studies; ‘O’ level English Language grade C.

1975-77 Exeter College, Exeter: ‘A’ level grade C in Photography, ‘O’ level
Geology grade C.

1978-80 Devon Area Health Authority, Exeter: Clerical Officer; banking and
management accounting, salaries and wages.

1980-82 Exeter College, Exeter: ‘A’ level Communication Studies grade C,
Business Studies grade D; BEC National Certificate in Business Studies, with
Distinction.
1982 (six months unemployed)

1983 Chateau Brandeau, Castillon, France: viticulture and animal husbandry.
1983-86 University of Bath: B.Sc (Hons) First Class in Sociology with Industrial
Relations.

1986-87 University of Bath: postgraduate research into Small Businesses.
1987 (first admission to a psychiatric hospital, nine months unemployed)

1988 Stourbridge College of Technology: introduction to teaching in Further
Education.
1988-89 Solihull College of Technology: part-time Lecturer; ‘A’ level Sociology, GCSE Business Studies.
1989 (nine months unemployed)
1989-90 Birmingham MIND: Volunteer; day-centre for long term mentally ill.
1990-91 North Birmingham Health Authority: Student Mental Nurse.
1991 (second and third admissions to psychiatric hospital)

1991-94 (unemployed)
1994 (fourth and fifth admissions to psychiatric hospital; diagnosed with Manic
Depression [Bipolar Affective Disorder])
1995 - (living on Income Support and disability benefits)
2005 (sixth admission to psychiatric hospital)

2006 - undertaking STR (support, time and recovery) Worker training (NHS
Modernisation Agency/Devon Partnership NHS Trust/Community Care Trust
[South Devon] Ltd)
2007 MDF: The Bi-polar Organisation; recovery, self management and life skills
course.

2007 Co-author of Making A Change (booklet on Involvement for NHS South
West PPI Learning and Development Project).
2007 Registered with Peninsula Postgraduate Health Institute on M.Sc
programme in Mental Health.

2007 - member of Contract and Performance Review committee of Community Care Trust [South Devon] Ltd.
2008 - involved in the development of Broadhempston Community Woodland as a social enterprise.
2008 - member of Torbay, South and West Devon, Recovery and Independent Living Functional Implementation Group for Devon Partnership NHS Trust.
2008 - member of the Mental Health Network of the NIACE/LSC Partnership Programme

2008 - continuing M.Sc programme in Mental Health with University of Plymouth.
　
Current Projects and Interests;

Ways Of Being With; using the concept of tacit knowledge to rethink skill and expertise in mental health practice.
The Sound Of Water; an ethnographic study of a new social enterprise, linking notions of transformative learning and green care [care farming] to mental wellbeing.
Mis-cued; studying the relationship of handedness and asymmetry to mental distress, and the statistical over-representation of left-handed people amongst clients of mental health services.
using the emerging discipline of social neuroscience to understand mental distress.
observing the development of the Recovery movement in mental health.

pre-agricultural forms of life and meme/gene co-evolution.
the ‘history of ideas’ and the sociology of scientific knowledge.
the life and work of Richard P. Feynman.

The Story We Tell Ourselves

2010-01-11T07:40:00.002Z

For a long time I disliked the writing of other users of mental health services. Now I’ve concluded I just didn’t have the tools with which to begin an understanding. They seemed to write solely in order to make sense of their lives for themselves, more evidence of a preoccupation with ‘self’. As an avid reader however, of fiction, biography, reportage; and as a critical viewer of film and television - I knew that writing for oneself, was quite different from writing for others. You have to be aware of, and build a bridge towards an audience. And of course the meaning of any communication is what the ‘receiver’ perceives it to be!

We all share that inability to explain ourselves to others, to make coherent those experiences that derailed our lives, that were brought to a head in the first encounter with the hospital consultant and their accomplices, describing the intimate details of our lives to a group of strangers. To begin with, there is no beginning. Although what follows is of course fact, we all turn our past experiences into a narrative. In retrospect and with hindsight, we take the ‘here and how’ as our ending, selecting those elements of the past which can be logically fitted together to explain the present. Equally, each act of remembering involves to some extent a reinterpretation of what actually happened - a game of Chinese Whispers played out with our own internal dialogue. We tell ourselves, ‘I know, because I was there‘! When in fact it is our selective memory which provides those ‘facts‘.

As soon as I began trying to find a ‘way of telling’, knowing what I wrote could only be a reconstruction, I realised that what was most important was the ‘message’, the ideas and concepts that come from your story - and you can’t do that if you are anonymous! Workers suggest anonymity for your own protection, part of client confidentiality. But, ‘I believe’ has no impact if we don’t know who is saying it - and there is no right to reply if you don’t know who you are replying to. At worst, user writing gets used as a free ‘endorsement’ by service providers. And the reader should also always ask, what is the writer’s relationship with the people and places he writes about?

In the current culture of the Recovery approach, workers encourage or assume that ones experience should be framed in terms of an imagined pathway or journey. A progression to a brighter future, rich in positive meanings and full of hope. Alas this can only encourage the shoehorning of past experience to fit an idea of happiness, which is always tomorrow. I’m only interested in today, and I’ll make my meanings from the only real motivation there is - my attachment or attraction to others in the here and now. Which means I get ‘out and about’ with someone I like today, and not plan tomorrows. Others inspire.

So there is no reason in theory why there shouldn’t be a collective portrait of mental wellness. So often the story we tell ourselves is one of an obsession with self. It may be as simple as whether you notice the differences rather than the similarities between people! So much care is organised around ‘individual needs‘, when the answers are communal and collective, about sharing and intimacy. Staff talk of individual ‘pathways‘, I’d rather they lay an actual pathway from the hospital entrance to where the pavement ends on the edge of our town! And how about renovating the bus shelter at the hospital entrance, but without removing the decades of graffiti, which in itself is a kind of collective testimony.

How much of your life seems to have turned upon chance events, or things you did without being aware of having made any choices at all? The idea of our lives leading to somewhere, even without the help of partial recall, is aided by our commonsense notions that we have an essential character, identity or personality which becomes more fixed over time. This is the greatest danger of storytelling about oneself - that it actually narrows possible futures! It is actually good if others challenge rather than validate the story we tell ourselves. Being flexible enough to live with uncertainty is mental health.

The first time I was the recipient of another client’s work was during my second admission in 1990. A client who had been ‘on the roundabout’ for some years in various hospitals, showed me a poem he had written. Unexpectedly I liked it. It described his addiction to various street drugs, and the inevitable consequence of further admissions - it seemed to show great insight. When I handed it back to him he told me to keep it, though he had no copy. What struck me most was the way it looked (it still does). Written with a real ink pen (rare even then), the required rhythm was ‘spelt-out’ by words written in capitals and others underlined. He explained that it had no meaning for him in itself, it was the creating of it that gave a release from unwanted thoughts and feelings, and in giving it away he hoped others might share that.

A while ago I did the MDF self-management course, on the first day the facilitators asked us to consider 'reframing'; and as an example, describe ourselves and our lives without the 'language of illness'. I thought the idea ridiculous! But back at home I concluded I'd better come-up with something, in case I was challenged later. So in about forty minutes I scribbled down a dozen lines; feed it into the computer, tidied it up, printed it off, slipped it into the file and forgot about it. It was a contrived piece of work, an exercise - and it certainly wasn't how I felt about myself at the time.
　
Nick - reframed!
When I left school they said
You must have a job, a career
It gives meaning and purpose to your life.
I just wanted to go Walkabout
To wander aimlessly, in the hope
Of meeting interesting people
And learning something new every day.
So I am forever a student
Of the strange ways of individuals and groups
Of people in offices, shops, factories
Classrooms, lecture halls, hospital wards
Day centres, consulting rooms, therapy centres
On trains, in cars, buses, boats and airplanes.
I seek movement and change
To be always in the moment
Letting go the past, and the future
Travelling, but never hoping to arrive
Allowing the brain and body to take me where it pleases.
It’s an intellectual adventure
Finding-out, how human life evolves
But never for a moment believing
That the ‘I’ or ‘me’ of a so-called ‘Self ’
Is fixed forever
Just an evolving story I tell myself
About a person on a journey.
　
Strangely it was greeted with enthusiasm by those running the group, they asked if they could include it in a newsletter! Sometime later I showed it to someone from another mental health organisation; they called it a poem and asked to put it in their newsletter. Later still it appeared in a third. Much has changed in the eighteen months since. At present I have no symptoms of Bipolar, so objectively I cannot use that 'frame of reference'. And in reality I have become a student again, reading for a Masters degree. I still write similar things, but now the focus is - what is of practical use to others?
　
Catch Tomorrow Now

Can you stop?
Let go of thoughts and feelings
Of the past and future
And just be in the present moment.
Now is all there is.
Re-attach your emotions to your senses
In the real physical world of the present.
Notice what cues your thoughts now
Acknowledge them and let them go
Good or bad.
Allow yourself to feel the bad when it happens
Then it passes quickly.
Allow yourself to be ‘surprised by joy’
And let go those feelings too.
Knowing they will return unbidden.
Think of yourself as having no fixed self.
Able to construct a self anew every day
Attentive to others, unconcern for an ‘I’ or a ‘me’.
Aware of the others who make you what you are.
You learn most by imitation.
You only remain fixed
When you remake yourself today
As you were yesterday.
You imagine the past must persist into the future
But only because you reproduce it afresh everyday.
Don’t look forward or back, but around.
Seek to be more relaxed and aware.
Absorb what’s around you
And catch tomorrow now!
　
When we write for ourselves, in joy or misery, our stories are about ‘coming to terms with’. But when we write for others they are realer - for an actual pathway is only created after many walkers have taken the same trail. Finally,
　
Writing to recover…

To explain to oneself
To make sense to oneself
For oneself.
Then,
What can I share
Can others understand
Can I make them listen
Even think differently
Will my meanings be their meanings
Does it matter
Do I want to help others
Is there an audience…?
Can we transform each other
Can there be a communal portrait
And in a world of madness,
Can anyone call another ‘companero‘…?

(written 2008)

If you can't beat'm, join'm

2010-01-11T06:59:00.001Z

Fed-up with others posting my words on the web (often without my permission) I bow to the inevitable!