Chris Newton - a tribute

A good friend has died, and how I feel about it is nobody’s business but my own. But the fact that he was a client of mental health services, on and off, for over forty years, yet managed to transform his life during his last twenty years is something that should be both acknowledged and celebrated. As his physical health declined, his mental state and that of many around him improved for the better. If asked for an explanation he would have named Jesus. For me, a non-believer but I hope an observant outsider, it was the church as a community which provided much of the answer.

We were unlikely friends, as different as chalk and cheese; he was from a working-class background with little formal education and had become a renowned biker; I’m middle class, over-educated and a believer in walking as the only proper means of movement! What we shared was a history of confinement. He often left the door of his flat open, so did I. He claimed it was to be welcoming to visitors - I once used that explanation too. But really it was a fear of not being able to get out of the door. What forged a connection between us however was a willingness to learn new things, and that requires an increasing openness towards others. It is the lack of such a capacity or willingness amongst those in mental distress, and perhaps their helpers too, which may account for the low success rate of mental health services.

Chris was in his early-fifties when we met in 2006 and never expected to reach sixty, he’d spent a total of twenty-five years either in prison or other secure environments - once sentenced to twelve years for aggravated assault, serving eight, five of which had been in Dartmoor. Son of Sergeant Robert ‘Tiger’ Newton, late of the Indian Army and sometime policeman, who installed discipline with his fists, Chris found himself on psychiatric drugs whilst still a child, diagnosed schizophrenic as a young man, and until he became a Christian, drank heavily and used street drugs. Workers were still telling him he would never live independently in the community up to a year before he achieved precisely that.

We first met at a regular social activity organised by the Community Care Trust (now absorbed into the charity Step One) when he moved to Teignmouth in south Devon. He hardly spoke at first and would often sit in a corner with his back to the rest of the group. Then one day he surprised me. Leafing through some photos he’d just picked-up from the printers, he mumbled something about a church event he had been to, saying: ‘If you don’t give, you’ll get nothing back’. I remember the first time he invited me to his flat. After ten minutes or so of intense talk he apologised and said he’d have to stop. I assumed it was because of the emotional nature of what we were talking about, but I was quite wrong, it was because he was not used to talking, full stop. The muscles that make speech needed a rest! Soon however he was talking to anyone, throughout the day.

Within a year or so of living independently in the community, our conversations on the street would be regularly interrupted by locals, with no connection to the world of mental health, who would enquire after his wellbeing. At first his life centred around the Baptist church, later he found greater acceptance with the Church of England. (On a practical level, Chris was often preoccupied at this time by how much he should cover-up, or not, the tattoos from his biker days as ‘Chopper’ Newton!) To me, his spirituality seemed to be all about letting go of that ‘preoccupation with self’ that comes with chronic mental distress. Once you have got yourself together you can start being of use to others. The writer Karen Armstrong argues that the spiritual is making others, or other things, the central focus of your life, allowing transcendent experiences which go beyond our usually limited perception of others, guided by what seems a ‘golden rule’ of all faiths - doing to others as you would have them do to you. Inevitably there came a point when Chris felt, perhaps for the first time in his life, the frustrations of giving more than he was getting back. After all, his God was a spirit within people, not an otherworldly presence looking down, and clearly not everyone felt that.

Early Good Friday morning 2009 saw us sitting in a bus shelter sharing our frustration at how, as we changed, others didn’t seem to want to follow, in particular two of our peers who lived just a stone’s throw away. One was clearly disabled by the system of care he had received over thirty years, the impact of which was noticed in the odd moments when his previous personality broke through. The other person just seemed to be on a ‘single track’, blocking-out anything that challenged or contradicted a set pattern of behaviour. Why wouldn’t they change? What had we done differently? It didn’t seem to be about a lack of capacity to act differently, rather that unwillingness to learn new things. An unwillingness to test or experiment, to risk and be prepared to look a fool from time to time. For example, Chris explained he had recently been through a bit of a crises, but hadn’t thought about drink at all, but a little later when all was well and he was socialising in a pub, he’d rapidly became agitated and had to leave.

Whilst he found that being supportive of other people with mental health problems was a strain, he felt he was much more effective working with the religious charity Prospects (and later the breakaway group Count Everyone In) which supported people with learning disabilities. Indeed, he had me join a sponsored walk and attend, for the first time in many years, a religious service which he helped put together specifically for people with various disabilities, the first of its kind to be held at Exeter cathedral. He also worked for a while with MENCAP, going into Doctor’s surgery’s and educating them on how to communicate more effectively with people with learning disabilities. Chris described himself as schizophrenic (for which he accepted a moderate level of medication) but regarded it as largely a thing of the past, more pressing were his learning difficulties, for now he knew beyond a shadow of a doubt he could learn a lot more. Nonetheless, he knew that it was his relatively minor ‘learning difficulties’ that allowed him to connect with, and be useful to, those with major learning difficulties. Furthermore, for the boundaries are always blurred, to help some others with ‘learning disabilities’.

Early on in our friendship he determined that he should finally learn to read and write in order to better study the Bible. More surprisingly still, he chose the ancient method of copying out those passages he had come to know from hearing them spoken. About a year into the enterprise (self-taught, but with the occasional help of a number of us who just happened to be around at the time) he became conscious of the quality of language in different versions of the bible. I found myself in the somewhat surreal situation of sitting with him in our favourite café trying to explain 16th century history and the appearance of English translations - he’d already worked-out for himself that it was the language of the King James that he wanted. This went hand in hand with his learning the basics of Makaton, to better aid communication with those with learning difficulties/ disabilities and his inclination to learn to draw. Now, by the time I met him he only had sight in his left eye, with the limits in depth perception that brings!

We undertook a number of trips together, two of which come to mind as important. First, in 2008 we visited Broadhempston Community Woodland. Transport was provided by a local mental health worker and as we skirted the edge of Channing’s Wood (an ‘open’ prison) Chris commented: ‘That’s one I was never in!’ From the start he enjoyed the undeveloped new woodland planted just twenty-five years previously. As we set off to climb Beacon Hill it soon became clear that he knew more about the trees than we did. For between spells of confinement he had clocked-up a total of twelve years as a casual agricultural labourer, migrating with the seasons on his bike from Cornwall to Scotland. The woodland was being developed as resource for people with all kinds of disabilities and disadvantages, but Chris was quick to point out that the rules and regulations that come with any money intended to help the disabled, often leads to the spoiling of the very experience on offer.

The other trip that sticks in my mind was to Paignton in 2009, for it seemed to mark some kind of transition. It was when we were sat having a meal in a relaxed ordinary way that I realised how unique it was for either of us to be comfortable enough to sit in a crowded café for forty minutes. There really is a thing called normality and those who have it often take it for granted so much, they come to deny its very existence.

Also, in 2009 Chris came top of the list for an allotment after a year of waiting. The location was between a housing project and an industrial estate, but its situation was different. Lifting one’s gaze from the ground, you could see to the southern part of the estuary, look to the west and you could see all the way up the valley to the moor, and an ever-changing horizon. He cultivated with a success that bemused his neighbours and quite without the orderliness that preoccupied them. It was on the few occasions when I helped-out, that, even more than being with him, one could see, spread out in front of one, almost like a map, his chaotic mind. Patches of temporary order emerging from place to place within a disorganised whole. Yet the whole was hugely productive, and produced flower and vegetable displays at a number of events. Most notably his displays for the annual flower festival of St. Michael’s church in July 2009 and 2010, displays which were conspicuous because they lacked the formality of style of all the others. They were personal and intimate, one depicted a flowing river, another; photographs of those people with learning disabilities who had helped on the allotment.

But Chris had another life of which I knew little. In time he became a frequent visitor to Bristol where his ‘family’ lived. He had lost contact with his remaining blood relatives many years before, but formed an attachment to two women, one of whom he came to think of as his mother, the other his daughter. I was lucky enough to attend the wedding of the latter and hear her account of Chris’s life since they had met over twenty years earlier.

He also had a life of physical illness. He had suffered from bowel cancer and had a total of six operations over the years, and also underwent various other invasive procedures for related complications. There came a point when he decided enough was enough and began to refuse most of the treatment being offered. He lived for more years than he expected. He’d fixated on sixty as a target age to be reached for several years before he actually achieved it. I myself felt the need to start writing this tribute before his sixtieth – he has died at the age of seventy-two.

For about five years from around 2010 we would talk for an hour or so two or three times a week in a local cafe. As he became more articulate, I demanded more of him. I watched as he became aware of how others, and therefore himself, had grossly underestimated his capacity for intellectual growth. I didn’t find it easy that he framed nearly all his talk in religious terms, over and over I pointed out that I disagreed and that somehow if he wanted to spread a message he had to take-on the reality of non-belief amongst so many of the community. Just as he’d learnt to control the anger that had got him into so many fights in the past, so now he learnt to temper his desire to spread the word to anyone who would listen.

In time his spiritual life deepened further, through the Church of England he connected with the Society of St Francis. In May 2018 he was ‘professed’ into the Franciscan Third Order. Now I don’t know what that means, but I know it meant everything to Chris.

Christopher Robert Newton 1952-2025

Natural mental health

 See my long essay, split into three parts; Natural mental health (part one)

Note to self

Rational thought, followed by deliberate conscious intention, is such a weak tool for bringing about action - let alone change - that I have to carry instructions to myself on a cue card!

I doubt the below will mean anything to you, but then it’s not meant to!

(The more astute may realise some of these half sentences are cribs and at least one lifted in its entirety.)

Whatever happened to, ‘..the best is yet to come…’ (2011, 2019)

Human beings are notoriously bad at predicting. What we are good at, both instinctively and through the acquisition of further skill is anticipating in the short term, ‘the two second advantage’ [1] as some have called it. Many, unaware of how much of life is highly sensitive to initial conditions, boldly go in for futurology. The key to anticipation, having made one move, is how able are you to dump everything you think you know, and make a fresh assessment of the new, current and different situation? Think of all those sports where the ball travels so fast that you must start your move before it has been hit! And when you miss, how fast can you forget?

However, we are always being told by others to set aims, objectives, goals, plan and sign-up to mission statements. When I posted the following in 2011, I was playing that old trick, that rarely works, of hoping that a public declaration of intent would force me to get on with it and comply!

Screenshot

Things don’t turn out as we intend, the best attitude to ‘failure’ or indeed anything which might be regarded as a mistake, is to see it all as part of an inevitable process and an opportunity for new learning. You can even go so far as to regard depression in this way, as always reactive to something; you feel down in response to a loss (of any kind), is your response grounded in a real event where sadness or grief really is the right emotion, or is it that things just didn’t turn out the way you planned them? If the latter is the case, one legitimate response is to conclude that it was simply a lousy plan in the first place.

Events happen, change occurs around us whether we like it or not. I was a psychiatric inpatient for a brief period at the end of 2011, and for a month or so in the spring of 2012, the autumn of 2014 and the summer of 2016. My father died in 2014, he’d been the last of the previous generation, so his estate contained within it not only the possessions of many direct ancestors but their ‘life documents’ too [2]. In 2014 the sea wall outside my window collapsed and in 2016 I moved home. But I should confess, that all of this is by way of a distraction - for there is a sleight of hand in what I’ve written so far!

As stated in the post, all the writing was already half complete, I wouldn’t have had the nerve to assert their contents if they hadn’t been. Now, the first and last have already been posted, leaving just the meat in the sandwich. But, having had the pleasure of finding things out, the kick of discovery (to misquote Feynman) [3] I’m bored and face the tedium of laying out the argument and evidence step by step. (The answer to that kind of task is of course mindfulness!) Distraction is sorely tempting, like transcribing and publishing the audio recordings I have (conversations with 2 clients, a nurse, 2 support workers, a student and an educator.) The passage of time and an already tested form of presentation takes care of any confidentiality issues. Come to think of it, this is more than a Masters thesis, more like a PhD!

(I ought to hurry up though, because I want to claim for myself the phrase Ways Of Being With, and the concept of Social Craftsmanship.)

Of course, real intellectual confidence would be not feeling the need to do any of it. The most obvious recent example being flash Dave. In the course of doing a first degree you realise you’ve already proved to yourself your capability to do this kind of stuff and your attention shifts. Just how long does it take to become Prime Minster? And remember, political careers always end in failure, so at the first major mistake, get the hell out and find something better to do!

[1] Ranadive, V and Maney, K (2012) The Two-Second Advantage

[2] Plummer, K (1983 & 2000) Documents of Life

[3] Feynman, R. P (1999) The Pleasure of Finding Things Out 

Bibliography of the half-written!

Never say never again - inpatient 2016

The view of Haytor from the Haytor Unit, a view I'd first seen 22 years before when it was called the Edith Morgan Centre (did the 45 mile version of Ten Tors in 1977.) (photo by Nick Hewling)

Luckily I was transferred to the old Cypress Independent Hospital within the week (Community Care Trust as was.) (photo by Nick Hewling)

Some argument about Wordsworth, probably me saying something about always read the original and remember the context - wild daffodils, between the edge of the mere and the tree line. (photo by Nick Hewling)

Not difficult to scare oneself (photo by Nick Hewling)

Still had to serve-out 28 days, part of deal, still cheers! (selfie by Nick Hewling)

 

Time and space - inpatient 2014

Location on, screenshot by Nick Hewling

Tortured by the view, photo by Nick Hewling

Selfie, clearly I had more kit than 'they' did, photo by Nick Hewling 

1.12.2014 10,48 food obsessed, photo by Nick Hewling

2.12.2014 17,00 must have been out, photo by Nick Hewling

Where my head is at now

For my most recent mental health writing see Natural Mental Health. Everything else promised on this site is coming, and more besides, eventually!

New header photo 2019 (photo by Nick Hewling)

The man with no name (updated 2014)

(This piece first appeared in a local newsletter in 2008. At that time I slightly censored my original text but restored the cuts and updated the content when it was first posted here in January 2010. Now I’ve briefly added more text in italics at the end which brings it up to date again! When it first appeared some readers wondered if the other person referred to was real, I can assure you he is).

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 an 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’).

(Now it is 20 years since we first met, and I haven’t seen him for a couple of years – which doesn’t necessarily mean he is not around, just that our awareness’s have changed. I know mine have and I suspect his have too. First there was the time I saw him working in an out-patient art therapy room, absorbed in a very elaborate large drawing. Then months later he had a dog in tow, he was still walking but obviously the pace and priority had changed. Then came the van, the woman and the child. One day the van was parked outside the café – the first time we had been stationary in the same space for more than fifteen minutes, ever! Finally the last time, all three were dressed as if part of a wedding party, on their way to a local music festival.)

Bus shelters are often effective barriers for forcing a 'pattern break' from one kind of a 'trance' like state to another involving more 'reality testing'.

The Recovery Movement (part three)

What looks and feels radical to those attempting to bring about change from within an organisation often appears to outsiders as the mildest of reforms. As a general rule, groups - which share a collective self-interest - do not correct errors and the world of mental health is no exception. Groups self-perpetuate until external pressures cause them to collapse.

This post looks at Recovery in practice, first at what workers using the approach actually do, and secondly at how services have sort to reorganise themselves. In my local area I was on the receiving end, as a client, of two attempts aimed at introducing Recovery focused care; one a largely bottom-up and partially successful community movement, the other a top-down formal reorganisation by an NHS Trust which made very faltering progress.

This post on the Recovery movement should be read in conjunction with part one (January 2010) and part two (November 2010).

From 2005 onwards, the Community Care Trust (CCT) began to adopt a Recovery approach and its employees tentatively began to change their attitudes, if not at first their actual behaviour. They signed-up to the national Support, Time and Recovery Worker programme (STR or STaR) and during 2007-8 I undertook some STR training too.

From STR Worker to Recovery Coach

For a brief description of the STR role go to NHS Careers. For more detailed accounts see Huxley et al (2006) and the National STR Handbook (Hope 2008).

Before the national programme ended approximately 400 people within the county of Devon had received some basic STR or other form of Recovery training. At the time the Community Care Trust employed the equivalent of 70 full-time staff with a mix of STR and mental nurse training. Later an additional internal programme of training in ‘recovery coaching’ was added. I was a client of CCT between 1999 and mid-2007 and retain close links with some of the staff and many of the clients. Today a few workers appear to pursue the Recovery approach in the fullest sense envisaged by Shepherd et al (2008) and Slade (2009), others barely at all - but they all speak the language of Recovery!

Huxley et al (2006) in describing what his research subjects did, provides a useful summary of the STR role as originally conceived.

‘..STR workers achieve [..] through engaging in practical and emotional support to increase people’s participation in daily life through accessing further education and training, obtaining and holding down a job, participating in leisure activities, coping with personal financial matters, or finding their way through the welfare and health systems. One of the effective ways that STR workers achieve these ends is, by dint of their maturity and personal experience, teaching the service user to do practical things for themselves, so they have the confidence to go and do it in the future.’ (para.3.2  p.9)

‘The STR worker establishes (where appropriate) a pattern of activity, first working for service users and then with service users…This leads to situations where service users are ready, and/or want support with, and/or teaching of, practical skills. This in turn leads to increased social skills and/or activities which lead to independence and then greater interdependence with other people.’ (para.3.3  p.10)

During the time I’ve been able to observe CCT workers, the focus of support has shifted away from the practical and interventionist, towards an emphasis (as highlight in part two) on the idea of a non-directive worker, and a self-managing client. (Workers remain particularly sensitive to how the prescriptive nature of pre-Recovery ‘therapeutic’ interventions often appeared to add to the problems faced by their clients.) Whilst STR practitioners are confident of the effectiveness - plus the political, moral and ethical appropriateness of their work - nonetheless they have great difficulty in articulating their approach. They have problems in describing their one to one interactions with the users of services; how they do what they do, from whom they have learnt what they do, and what is effective in a given situation. Equally, clients often cannot describe what ‘makes a difference’ to the resolution of a crises. So although comfortable with the language of Recovery, developed over more than twenty years, which most workers claim they apply in practice, they seem unable to demonstrate its meaning in action.

The test of any approach of course must be how far its values and ethos are embodied in the way its practitioners actually behave. The Recovery workers I’ve met, like many occupational groups in health and social care, play down or sometimes actively avoid interpersonal skills training and any attempt to modify their own non-verbal communication. Instead there is a huge bias towards explicit cognitive tools, especially language use, which is presumed to lead to change.

My abiding image is of an incongruence between the content of what is spoken by workers and their body language (tone of voice, gestures, facial expression, eye and head movement, posture and body movement). Nonverbally there is always an urgency to empathise (feel what another person is feeling), not just to establish an initial connection or rapport, but as a regular strategy - which too often ends up with them mirroring the disconnectedness between emotion and reason displayed by the client!

The principal tools used by the Recovery worker today are; the Wellness Recovery Action Plan (WRAP), personal stories, mindfulness, formalised peer support, traditional non-directive counselling plus some group social activities. However the emotional content of what Recovery workers do as expressed through their body language remains not only tacit, but almost entirely unexamined. Yet, workers put a premium on genuineness and sometimes claim not to be playing any role at all other than being themselves. They also recoil at the idea that they should teach, model or demonstrate any desired or more effective behaviour for a client to follow. They believe they should and can work with almost anyone who walks through the door. Equally, they feel that if only they can escape the organisational constraints placed upon them, and just be themselves, then that in itself is therapeutic for the client. They have an extremely ambiguous relationship with their own training, believing that they can embody the values and attitudes of Recovery without having practiced anything other than making verbal affirmations of their approach.

This can be a disaster for the client, who is desperate for practical help from someone with whom they feel physically and emotionally safe, and from whom they can gain confidence. Still today, workers often appear to want to climb into the ditch with the client, empathising beyond establishing a connection (which at most takes a few minutes), and help through reason and rational talk, whilst their bodies display something other than the social competency and lack of fear that their client craves.

When assessing themselves workers ask the client to self-report using written questionnaires which - in contrast to their claims about practice - are highly directive, designed and targeted at what they presume to be the priorities and concerns of clients. There is a tendency to drop the word Recovery into any and all questions, as in: ‘How has such-and-such contributed to your Recovery?’ They seem to lack awareness of a loaded question, of when they do lead, leaving one sceptical of their claim that they know how not to in practice!

Organisational Recovery

The Recovery approach began as a bottom-up community movement gradually seeping into policy through word of mouth. In the case of CCT it began in an organic way before becoming systemised, however as it was adopted as policy by the NHS (Shepherd et al 2008, Slade 2009), a much more top-down, designed approach was taken.

Traditional occupational groups such as mental health nurses, psychiatrists, occupational therapists, social workers and others have been asked to ‘unlearn’ or ‘let go’ of established professionalised practice (SCMH 2009).

In my local area the principal statuary provider, Devon Partnership NHS Trust (DPT) adopted Recovery focused care in the context of trying to move workers from being highly bureaucratised helpers and administrators to networking coaches. Many responded as if this was an attempt to deskill them. Yet this occurred in the context of community psychiatric nurses spending about fifty per cent of their time on administrative tasks, and of ward nurses spending an even greater proportion of their time at nursing stations! Even student mental nurses are lucky if they can achieve two hours contact time with clients during a seven and a half hour shift.

At all levels there was a resistance to new learning; anything new was taken as criticism of current practice, an encroachment of and threat to someone‘s territory, someone’s job, and the defensive response was always the same - experience tells us it is not practical to change (and it costs too much). And besides, our clients are different than the model suggests and won’t respond!

Consultation, and then implementation, was placed in the hands of managers who had first trained as nurses many years before, often espousing a version of Recovery learnt from reading policy documents rather than practice, to younger workers who daily met with clients and were more in touch with their circumstances. There were a number of ‘team leaders’ who bonded as students whilst ‘necking and decking’ in the old asylums who appeared to undergo weekend conversions to the Recovery approach. Much organisational change was put on hold whilst they were trained-up.

There is a sense in which mental health workers are more risk averse than their clients. I sat for eighteen months or so, on a DPT implementation committee for my local area. After an initial false start however, an outsider was appointed who didn’t carry the baggage of longer serving employees. However she was only appointed on a one year contract and much of what she did was subject to both conscious and unconscious obstruction – many simply did not appreciate that the Recovery approach, whatever its weaknesses, nonetheless was a challenge to the appropriateness of established practice and required a change in personal conduct.

Committees are often the death of change, the quasi-democratic structure of NHS management based on professional group demarcations plus some user consultation gives all interested parties their own five minutes, but when interests conflict, as they must, the chair can reinforce the status quo whenever they choose. Authority in hierarchy, rarely trumps professional demarcation and autonomy in practice.

Equally, in the bureaucracy of mental health, where there is no clearly defined product or outcome, then it is the amount of visible activity which is used as a substitute for real achievement, success being measured by the size of a budget and the number of staff employed.

Strangely mental health organisations often operate in an information vacuum, this may strike the outsider as incomprehensible since there has never been a period when so much mental health information is so easily available, yet many professionals are ignorant of it. In order for one professional group to assume expertise in one particular area requires seeding authority to other groups in other areas. This can be a disaster if there are no generalists left, how many front line mental health workers, pursuing a Recovery approach or otherwise, know that experimental psychology, neuroscience and forensic behavioural science have made much of their work irrelevant and or potentially damaging to their clients?

One simple training initiative proposed by myself to allow those less experienced in Recovery practice, though formally more senior, to see Recovery in practice (me as client in interaction with an experienced Recovery worker) once a week for forty-five minutes during a lunchtime at a local community mental health centre was brushed aside as being only appropriate in a formal training setting, run by trainers on official ‘away-days’, in other words costing thousands of pounds instead of nothing at all. In such small ways does the NHS forever expand, create needless jobs and financially become a bottomless pit.

In recent years most service user participants have become explicitly incorporated into the hierarchy and bureaucracy of DPT; as trainers on courses for clients rather than staff, as peer supporters supervised by nurses - which becomes absurd since the whole point of a peer supporter is that they do something a nurse cannot do, nor understand in the fullest sense. Managers want the credibility of association with those with ‘lived experience’ without the need to fundamentally challenge their own behaviour.

But all this pales into insignificance alongside some of the larger absurdities. The headquarters of DPT remains within the last local example of a Victorian asylum, one of the ‘back wards’ has been used for many years as the showcase inpatient Recovery unit where clients can stay for up to a year! Managers will tell you they have been unable to do otherwise because of the way the building was gifted to the Crown (for the expressed use of mental patients) way back in the days of the formation of the NHS. But those senior managers, doctors and nurses who push for a Recovery approach were not born and brought in Exeter. Digby and Exminster hospitals may had been the long stay ‘bins’ from which your relatives never returned, but Wonford House – the building in question - was the first port of call for anyone taken off the streets, or from their homes. The location, one word in fact, Dryden (as in Road/Lane/Clinic) was enough to stigmatise anyone. Well over a million pounds must have been spent on Recovery by now, but a lot more could have been done to aid the community, as well as clients, by simply hiring a cheap suite of offices in the centre of the city. Equally, the Trust had a free hand to develop a two hundred acre rural site a few miles away on the coast, yet chose to take the Home Office’s money to build a new secure hospital for the prison service.

Equally it was the police service which insisted that the statuary provider finally do something about providing a ‘place of safety’; a pilot scheme was initiated (actually two rooms from an existing psychiatric ward), STR support laid on to be alongside potential patients whilst they were being assessed and sure enough the number of people actually admitted to hospital fell. After six months however the money stopped and was diverted to pay for an extra approved mental health professional (someone legally sanctioned to 'section' people). Now a couple of years on a different scheme is being tried as an alternative to hospital, but that’s prompted now by the shortage of beds.

It was when someone within DPT said, ‘..it takes ten years to bring about real organisational change’, that I knew it was time to absent myself from any further involvement!

Conclusion - the paradox of ‘control’

Now the game has changed. DPT having attempted to manage change, rather than allow it to evolve organically from the bottom-up, has seen what Recovery focused care there was eroded by the external pressure of severe budgetary constraint. The irony is that the Recovery approach only really costs money if you see it as a top-down process of managing organisational change! CCT was also forced, late-in-the-day, to reduce the scale of its activities due to a reluctance to compete for contracts. Recovery is on hold.   

In day to day interactions between workers and clients the focus has become more and more on the construction or reconstruction of an individual’s personal story or emotional journey.

Some people feel it is enough to vomit their personal distress over a keyboard, a therapist or an audience; that others acceptance and validation is the therapeutic goal. But that is not storytelling in the true sense, for there is nothing necessarily useful in sharing for sharing’s sake, all it does is attract the empathy of those who have been there too, who are equally distressed. It offers nothing that makes it easier for the author or their audience to get up tomorrow.

It is now well established that each time we remember we update our memory within the present context – what we are recalling from several years ago, is actually the version we told ourselves a few weeks ago, the last time we recalled it! Your carefully constructed personal story is always out of date. Much better to keep a journal. Record a little regularly, then set aside. Going back to a journal after a number of months or years gives a measure of change. The ‘making sense of the world to yourself’ or ‘discovering what you’re thinking by writing’ is of the moment, a process not of fixing, but of letting go.

Journals take you back to a present moment, removing a large element of reconstruction, illuminating what change has occurred, been forgotten, then occurred again – all in a world of uncertainty where the resilience or robustness of a ‘personal story’ is brittle and likely to collapse at any time.

Recovery is based on an old existentialism as manifested in 1940’s humanist psychology, updated with a 1980’s post-modern frame of reference. Large dosages of political correctness, of rights and entitlements, but increasingly bureaucratised at the same time as advocating social networking. There is certainly a phenomenon which might be called Recoveryism, the assumption that the pursuit of a Recovery approach is a virtue, in and of itself. An inward looking-ness, which hates feedback as much as those traditional approaches it once criticised.

The desire for control by workers, clients and carers - achieved through rational, cognitive tools - to deal with emotional uncertainty - leaves everyone just as vulnerable to inevitable external change as ever before.

The Recovery Files - in need of editing and re-filing!

Model STR Worker Quits

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

The incident has stuck in my mind as amusing, though in an ironic way. For one, the researchers were not very good, their subsequent report would have barely passed as part of an undergraduate dissertation; two, the trainer knew that the skills the model worker had acquired had very little to do with his input, but had been largely self-taught from the bottom up. The boss thought the Recovery approach had to be taught, and that someone could not have worked it out independently for themselves. I, as a client of mental health services, and having known this person for almost twenty years now, know that what he does owes very little to training, in Recovery or anything else.

Now he is leaving his post and I won’t be seeing him again as a client. Everyone feels very emotional about this - he’s almost universally liked by both clients and workers. A familiar character known to all, respected for being good at what he does and popular also with outsiders such as workers from other agencies and students on placement.

We’ve always got on too, but we really only have one thing in common - we both failed our ‘eleven plus’ examination at school and therefore drew the short straw in what was then a much more selective school system. He came from a working class background and left school at sixteen with minimal qualifications, whilst I had a middle class upbringing and eventually got a university education. These days we would both have undoubtedly been diagnosed as dyslexic. It was his eldest child who became the first in his family to go to university. But that bit of shared background has given me the legitimacy to challenge him from time to time on his reading and writing skills and the psychological barriers that schools often erect. (There was nothing Recovery-like about the way I manipulated him into learning to write emails!) But then I’ve always known ‘he’s everything I’m not, and I’m everything he’s not’, in those situations, so long as you keep talking, you can make it a win-win situation, where ‘the whole is greater than the sum of the parts’. 

As a young man he joined the Merchant Marine and during the Falklands War found himself stuck in mid-Atlantic aboard a tanker deployed to refuel the naval task force. There he acquired the ability to maintain his physical and mental balance on deck in the face of the heaviest swells that could be tolerated whilst transferring fuel via a pipeline suspended on a line to another ship. That’s a skill I’m convinced is not unrelated to being able to ‘hold the centre’ when in a confined space full of constantly moving people in varying degrees of mental agitation and distress. When he started supervising group activities with mental health clients in day-centre settings he had no mental health training and no experience.

He married a local girl who’d been to the same school as he, has continued to live, work and raise a family in the town in which he was born and brought up. As a mental health worker he walks the same streets as his clients, and it doesn’t bother him if he runs into them on any day of the week. Such a situation is actually very rare, most mental health workers don’t live in the same place as they work and don’t know their client’s territory.

We first met back in 1994 when my new CPN dutifully took me on a tour of local social activities for those with mental health problems, my friend was running a group in a rundown school building twice a week, he was offering conversation over the newspapers, a cooked lunch and a video to watch in the afternoons. The first thing I noticed about him, apart from his distinct accent, was how upbeat he was. We didn’t meet regularly for some years, but it soon became apparent from occasional encounters that he was relentlessly positive. At the time I was prone to a lot of depression and found the habit extremely annoying, to my mind it was mindless optimism. In the years to come, on almost every occasion we met, he would suggest activities I might wish to become involved in, nine times out of ten I turned him down. He’s never lost that positive attitude, but these days his expectations are more sensitive to his audience.

Another annoying habit was calling everyone mate or matey! However it soon became apparent that this was because he had difficulty remembering people’s names - I must confess that in recent years I’ve found myself adopting those very words! More endearing is his addiction to anything free, he had a run of luck a few years ago when he seemed to be winning a radio phone-in competition almost every week. He’s been quite clever at supplementing a modest income with various extras for the family. Thankfully he’s quite strict with himself when it comes to gambling, but more than once, when I’ve been early for an appointment, I’ve been able to find him in the betting shop.

A hallmark of those early years was the ‘Misery Tour’, formally organised days-out using a hired coach which would pick up clients from day centres, half-way houses and residential care homes. You might end up anywhere from Lyme Regis to Plymouth, possibly via Dartmoor. For clients however the scenery was never the priority, nor was the opportunity to meet new people. On alighting from the coach there were only ever three concerns - food, alcohol and or tobacco. For the supervising workers, watching the ‘crocodile’ wind off along the pavement, it was the terror of losing people that was uppermost in their minds. Nonetheless, although social activities have changed a lot since then, the instinct was right, for the value lay in their social nature, a protection against the emotional isolation at the heart of mental distress.

We met one-to-one, once a week, for about five years. We would talk in a café or pub, or while out walking, in any one of four or five local towns. From meeting at the agreed rendezvous to saying goodbye, would be about an hour and a half. But like more formal counselling or psychotherapy the encounter had a pattern to it from the initial tentative exchanges, leading to more focused and intense concentration on an issue, followed by winding down to a ‘closure’ with which both parties were comfortable. The real work might happen over a period of only twenty minutes, but the challenge was getting there.

Very quickly our encounters stopped being dominated by me talking about myself and became a conversation. His style was to be anecdotal, the points he wanted to make came in the form of what I think of as ‘pub stories’ with a moral delivered with a laugh and a smile. In contrast, I like to form explanations of human behaviour and ask questions that challenge. The common ground between was that we both based what we said on observation and our own examples. His positive outlook however comes with a kind of fatalism, though he would ‘spin it’ as acceptance! Things are just the way they are, people are just like that, but there is good in everyone! He is ‘non-directive’ by instinct. Equally, he would never use a phrase like ‘unconditional positive regard’, but he claims to have it. I tackled him once, saying it was totally unrealistic, implying as it does that you can like anyone who walks through the door! He countered that he did like almost every client, that there was virtually no one he couldn’t work with. I think he is fooling himself, and what he means, with the benefit of hindsight, is that he can come to like almost every client, that the more he can understand someone, the more he can like them.

We have argued a lot, though in a good natured way. We often talked about other clients and other workers - on the understanding that the conversation remained just between ourselves. That’s how we came to learn so much from each other. Strictly speaking, he broke the rules in numerous other ways too. It is tempting to think that we developed some kind of ‘special relationship’. Was he ‘inappropriate’ with other clients, or just me? But then there really are limits to worker/ client relationships, and those who seek to eliminate the ‘them and us’ attitudes in mental health would do well to remember them. (At one point he was concerned about my mental state and by contacting my then CPN, set in train a series of events which led to me being picked up by the police on a 136, and later detained in hospital - one day I’ll try and find it in my heart to forgive him! A detailed account of that period of my life is the subject of several future blog posts.) But I know many of his other clients too. If I asked him about our relationship in contrast to others, I know what he would say: ‘Everyone is unique mate.’ And of course I’d be saying to myself: ‘Is that it? Is that the sum total of your accumulated wisdom?’  

What I do know is that I give value for money in a way other clients don’t. I have a lot of knowledge and expertise that others have not had the opportunity to acquire. Challenging others however, requires hard brain work and intellectual confidence. Which is not to say of course, that at other times I can be as non-responsive as the next client.

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

One survival from the old days was the attempt by my friend, once or twice a year, weather permitting, to get as many clients and workers as possible to undertake a big country walk, with the promise of a pub lunch before the return leg. It was on such occasions that, out of their normal environment, you see most clearly the contrast between those in mental distress and others in the community. The way mental ill-health disables physical health, and vice versa. You also notice the contrast between workers and clients more clearly. The natural answer is to imitate the healthy, that’s if you can bring yourself to discriminate between the two, something almost all have had trained out of them. Try telling anyone that the easiest way up a hill is to follow the arse of the fittest female!  A few years ago it was decided to impose a gender divide in community social activities, women’s and men’s networks. The recognition that many clients problems were intimately tied to past traumatic experiences with the opposite sex, led to a cop-out. One ‘well fit’ female worker, for whom I have the greatest respect, refers to men’s network activities as, ‘The Jolly Boy’s Outing’. Now, I can think of various names for female only activities, but then I’m ‘pushin’ it’ already!

He was never much of a one for keeping notes. (When I stopped being a regular client, I was able to acquire the file the organisation had kept on me for ten years or so.) However, when it mattered;

‘20.1.04 NICK TALKED ABOUT MEDITATION TODAY AND DIFFERENT LEVELLS of CONSESNESS, STATES of MIND AND THE CONCEPT of BRIEF THERAPY THE IMPORTANCE of THE HEAR & NOW. A VERY POSITIVE CONVERSATION ENSUED, NICK EXPRESSED HE WAS FEELING GOOD.’

‘3.2.04 TODAY WE TALKED ABOUT SUBJECT’S FROM LITERATURE TO DEATH AND MORTALITY AGREED TO MEET SLIGHTLY EARLIER NEXT WEEK’

‘8.6.04 NICK SAID HE WAS FEELING LOW TODAY AS PAINTING HIS FLAT AND THE HOT WEATHER WAS GETTING HIM DOWN. TALKED ABOUT STRATAGIE’S TO AliviATE THIS. Nick SAID HE WOULD Like THE TRAIN JOURNEY TO TOT NES. AND IS GOING TO FinLAKE ON THE 24^th’

Perhaps the best way to sum-up the difference between me, the client of services and my friend the worker, is to recall an incident that occurred not so long ago. We were out for a walk with another client who is famous for being quite uninhibited in saying out loud every thought that comes into his head. Sometimes he seems aware of what he does, and able to choose whether to control it, sometimes not. Unless you have been in and out of psychosis many times, much of what he says is incomprehensible. But all of it is spoken using the most explicit language! ‘Hey, keep it down mate! You know I’ve known you ____ all these years and I still don’t understand a lot of what you say’. I couldn’t help interrupting their conversation by asserting: ‘That’s the difference between us, I do understand what he is saying, but don’t want to; whilst you don’t understand, but want to!’

Despite having received care from workers using the Recovery approach and undertaken some training in it myself; I am not a fan, as readers of other posts on this blog will be aware. I would not wish to work in the same way as my friend does, even if I had the skills. Nonetheless, I am in a ‘unique’ position to confirm, what others could only hope was true, that he has indeed been an effective helper of hundreds of people in mental distress.

Finally, here are some photos I took a while ago, they are of course in no way related to the above post…

Normal service will be resumed shortly

photo by Nick Hewling

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

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

photo by Nick Hewling

photo by Nick Hewling

photo by Nick Hewling

photo by Nick Hewling

photo by Nick Hewling