Mental health services - the future

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

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

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

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

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

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

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

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

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

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

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

Social enterprise and social entrepreneurship

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

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

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

Mental health organisations

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

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

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

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

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

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

Mental health clients and carers

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

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

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

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

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

So what is wrong with me?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stephen Fry And I - self-stigmatisation?

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

Goffman and Becker; stigma and labelling

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.

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 the Isle of Unst, one of the Shetland Isles, 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.

(photo via Wikipedia)

 

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 it 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!