As users of mental health services we end up ‘performing’ to a kind of script. Such is the way services are organised, we find ourselves telling our story over and over again to a variety of workers as part of our treatment. A small minority of us have also told aspects of our ‘personal journey’ during training sessions for workers. But including the humour of your situation, doesn’t often go down well. Or maybe it’s just me and the way I tell it, since it does tend to be quite black!
So whilst there is often humour in mental distress, you don’t often get the chance to share it. Take for example suicide, finding others who are happy to discuss such thoughts and actions is rare, having the opportunity to add the humour too, is rarer still. Occasionally wonderful things will happen, like the time I was in a café with a small group of fellow clients, plus a couple of workers, and the guy next to me started to peel of his shirt to show me the consequences of failing to hang himself. We laughed together for a moment whilst the others sat in stony silence. But what we were laughing about was not so much the absurdity of an incident that had happen six months before, but that he had found himself laughing about it within half an hour of it happening.
When suicide is the subject there seem to be two sources of potential amusement; the absurdities and contradictions of the situation itself, and the ideas and language that mental health professionals bring to it. And the two may seem to bare very little relation to each other - providing an ironic twist.
Like the identification of suicide ‘hot spots’ which are then fenced-off with the occasional telephone provided, leading to the action simply moving elsewhere. How studies of ‘suicide by train’ highlight platform behaviour whereupon the potential suicide just moves further on down the line. The very rigidity of the professional’s model of ‘suicide prevention’ (while we have a ‘duty of care’ we never leave the client alone), which leads us to lie about getting better. And how for the last fifty years they have rolled-out prevention training (to which the experienced client is almost never invited), which often includes how to spot the deceiving client! But such ‘arms races’ arise out of the contradictions of the situation.
The simple fact is that the clients intend to kill themselves, but fail due to incompetence. They then learn from experience, as do those who seek to prevent them. And that game (for it does appear to have rules) can go on for decades, leading to bizarre and absurd behaviour by clients, carers and workers - played out in domestic and clinical settings. Ridiculous because eventually everyone has to be left alone, and even the most confined and watched person can still exert choice. Thankfully when peer supports peer, there is the opportunity to create a space to talk about the real issue - is life worth living? The chance to create distance from the pressures of daily life, time to create more choice, more freedom to act, be in a new situation in which the world looks different (you do an activity with your peer today, which shows the world to be a less fearful place) - where the supporter takes the responsibility and where only very occasionally will their role be to clean up afterwards.
Humour can be an acceptable way of educating and getting information into the public arena - if you’re a ‘jumper’, height is important. Choosing a multi-story car park may well mean ‘a one-way ticket to Stoke Mandeville!’ If it’s to be a hanging, then consider the ‘drop’. No drop and it’s up to half an hour of slow strangulation; with a drop, the length required varies with build and body weight - and will what you’ve attached the rope to, take the strain?
A year or so ago the stand-up comedian Mackenzie Taylor (http://news.bbc.co.uk/local/berkshire/hi/people_and_places/arts_and_culture/newsid_8701000/8701610.stm) developed a routine, based around his history of mental distress, and one particular suicide attempt, entitled No Straightjacket Required which he performed at the Edinburgh Fringe. I was lucky enough to see a preview in which he made some telling observations on; the therapist who never laughs, the distressed mind being like Jazz with eight things happening at once, how political correctness led the BBC to deem ‘brainstorming’ offensive, how the NHS made him a ‘client’ but never ‘wined and dined’ him, how you may have to wait for the second train since the first may be coming to a halt, on why he seemed so happy beforehand (because he had a plan which would bring all his troubles to an end), why the right combination of pills and booze might be thwarted by what you’d eaten before…
‘What's funny about a man who tried to kill himself because his unstable mental condition had pushed him to indescribable lows? Well, the answer is a surprising amount. Mackenzie Taylor tells the audience all about his attempted suicide at the end of last year's Brighton Festival, never shying away from the often incredibly harrowing details of what brought him to try and end it all. It is this completely honest, open discussion of mental health which really makes this an interesting show, not straight forward stand-up, yet not quite help-group. A show that challenges our approach to laughing at mental health, and the darkness that lurks within all of us. Go see it, or he might try it again!’ - Three Weeks
Saturday, 17 July 2010
Friday, 16 July 2010
Sex and mental health
The character and diversity of sexual relationships found amongst people in the mental health industry are much the same as in the wider world. This should surprise no one. Just as people often meet their future partners in the workplace, some relationships of enduring emotional and or sexual attachment have always existed - and will always exist - between clients, staff and carers.
However, even more than the neglect of client’s spiritual needs, mental health workers make no attempt to routinely address the problems their clients have in the conduct of sexual relationships. If you have had a useful and productive talk with a mental health worker about sexual concerns, then you are the exception. Most workers have a set of priorities for clients that place addressing sexual needs at the end of a very long list. Yet if the objective is to promote positive change; well, what does most to boost your self-confidence? What is one of the key motivations in life?
Much of what follows is obvious, but needs to be spelt-out, for one should never underestimate the capacity of mental health services to take the commonplace and complicate it with the dead-hand of specialist trainers, rules of ‘best practice’, and endless committees obstructing by arguing about appropriateness. I made the assumption many decades ago that when it came to the treatment of mental distress, I would come across those people with the best communication skills - how innocent of me!
(I’m reminded of the old story of the sociologist who wants to study prostitution spending years raising a grant of tens of thousands of pounds, hiring assistants to find and survey a random sample - when all he needed to do was take a train to the city of his choice, go to the first taxi on the rank, and tell the cabbie to drive him around for an hour. He might not even have had to ‘frame a question’ at all!)
The central problem for most clients is that they do not see successful personal and sexual relationships around them in their everyday lives - they have nothing to learn from, to model or imitate. Even the conversational conventions between men and women, whether partners or not, are often unobserved because clients spend so little time in ordinary social spaces. Equally within organised activities provided by mental health services, it is very rare to find a couple working together.
A person in mental distress is pre-occupied with self, and needs to let go of that a little before the reciprocity required in normal relationships can be ‘seen’. Equally they often don’t understand how relationships have to be made and negotiated, how giving your partner what they want, will get you what you want. Users of services often believe that ‘romance’ happens by chance and then proceeds in some automatic or natural way. They don’t know how much there is to learn and to practice in order to acquire social and physical skill.
Even more than the rest of humanity they have lived vicariously, but without trying to imitate and test, so retain the expectations of Hollywood and the media’s imagined world of celebrity - the dramatic contrasts between idealised romantic love, and varieties of extreme dysfunction. So, whilst it is true to say all clients have experienced the real world as traumatic in some way, often in close relationships, they may at one and the same time have an expectation of ‘more of the same’ coupled with - inevitably - unrealistic expectations of how different and successful the situation of others is. Like everyone else they grew-up believing what they witnessed in childhood was the norm and however well educated now, may still expect the same, sometimes playing-out a self-fulfilling prophecy. But in addition have a profoundly distorted fantasy as to what happiness, fulfilment, contentment or excitement are, or can be.
Most clients who are in the system for many years experience long periods of celibacy punctuated by a series of short, mutually unsatisfactory relationships most of which occur with other clients. As we know, what attracts people are perceived points of similarity, for those who’s social world is so restricted, it is often clients with similar problems who find each other - they share the same strengths, but also the same weaknesses. In such situations little that is new can be learnt - other than how to move in ever decreasing circles.
To achieve any kind of ‘recovery’ requires teaching in the possibilities of intimacy. And opportunities are forever being lost due to the fear and timidity of workers or their managers. A classic example is the so called ‘predatory male’ patient on a hospital ward. Imagine the following scenario. Staff notice a male patient taking a particular interest in a female member of staff; if she is noticeably younger than him and relatively inexperienced, alarm bells will ring. The woman concerned will report that she has noticed his attention because it does not lead to an ordinary two-way interaction, he is overtly interested but stand-offish, not demanding nor conversational, he just always seems to be around, which makes her uneasy. The behaviour is interpreted by staff as inappropriate and as possibly indicative of some covert sexual intent. The action taken is to separate the two people. The male patient then participates less in the activity of the ward, becomes less cooperative or positively hostile. This is seen as confirmation that the staff’s interpretation of the situation was correct and the right decision made.
Wrong. The male patient may well be less cooperative, he’s been rejected again. The staff reaction may well create more extreme behaviour in the future. The male patient looks menacing and predatory because of his incompetence, he’s never had the chance to learn the skills of normal social interaction, how to approach and begin to build an intimate relationship. A major opportunity is lost because the female member of staff is the person he feels most attracted by or attached to - he is motivated by her. In other words, she is the person in the most powerful position to affect change in him! She, whatever her job or status, should be the one to work with him. If the woman is confident enough in her sexuality, then she can enter into a contract with him, which stated crudely would say; you can’t have me, but we can spend a certain number of hours together. We can hang-around so you can get comfortable being around women, and I’ll teach you what a woman like me, wants and expects in a relationship - I’ll show you how to approach a woman like me.
Real outcomes have to be made, and in specific social situations; aggression, violence and abuse arise - like fun, happiness and contentment - as a result of the interaction between people. No one person is ever the sole cause of anything. Just as the way someone is treated in the first few hours of contact with mental health services may set the pattern for years to come, anyone who is trapped or confined by others will, sooner or later lash-out. But equally someone who is confident but non-threatening, can begin the process of change in others.
However, even more than the neglect of client’s spiritual needs, mental health workers make no attempt to routinely address the problems their clients have in the conduct of sexual relationships. If you have had a useful and productive talk with a mental health worker about sexual concerns, then you are the exception. Most workers have a set of priorities for clients that place addressing sexual needs at the end of a very long list. Yet if the objective is to promote positive change; well, what does most to boost your self-confidence? What is one of the key motivations in life?
Much of what follows is obvious, but needs to be spelt-out, for one should never underestimate the capacity of mental health services to take the commonplace and complicate it with the dead-hand of specialist trainers, rules of ‘best practice’, and endless committees obstructing by arguing about appropriateness. I made the assumption many decades ago that when it came to the treatment of mental distress, I would come across those people with the best communication skills - how innocent of me!
(I’m reminded of the old story of the sociologist who wants to study prostitution spending years raising a grant of tens of thousands of pounds, hiring assistants to find and survey a random sample - when all he needed to do was take a train to the city of his choice, go to the first taxi on the rank, and tell the cabbie to drive him around for an hour. He might not even have had to ‘frame a question’ at all!)
The central problem for most clients is that they do not see successful personal and sexual relationships around them in their everyday lives - they have nothing to learn from, to model or imitate. Even the conversational conventions between men and women, whether partners or not, are often unobserved because clients spend so little time in ordinary social spaces. Equally within organised activities provided by mental health services, it is very rare to find a couple working together.
A person in mental distress is pre-occupied with self, and needs to let go of that a little before the reciprocity required in normal relationships can be ‘seen’. Equally they often don’t understand how relationships have to be made and negotiated, how giving your partner what they want, will get you what you want. Users of services often believe that ‘romance’ happens by chance and then proceeds in some automatic or natural way. They don’t know how much there is to learn and to practice in order to acquire social and physical skill.
Even more than the rest of humanity they have lived vicariously, but without trying to imitate and test, so retain the expectations of Hollywood and the media’s imagined world of celebrity - the dramatic contrasts between idealised romantic love, and varieties of extreme dysfunction. So, whilst it is true to say all clients have experienced the real world as traumatic in some way, often in close relationships, they may at one and the same time have an expectation of ‘more of the same’ coupled with - inevitably - unrealistic expectations of how different and successful the situation of others is. Like everyone else they grew-up believing what they witnessed in childhood was the norm and however well educated now, may still expect the same, sometimes playing-out a self-fulfilling prophecy. But in addition have a profoundly distorted fantasy as to what happiness, fulfilment, contentment or excitement are, or can be.
Most clients who are in the system for many years experience long periods of celibacy punctuated by a series of short, mutually unsatisfactory relationships most of which occur with other clients. As we know, what attracts people are perceived points of similarity, for those who’s social world is so restricted, it is often clients with similar problems who find each other - they share the same strengths, but also the same weaknesses. In such situations little that is new can be learnt - other than how to move in ever decreasing circles.
To achieve any kind of ‘recovery’ requires teaching in the possibilities of intimacy. And opportunities are forever being lost due to the fear and timidity of workers or their managers. A classic example is the so called ‘predatory male’ patient on a hospital ward. Imagine the following scenario. Staff notice a male patient taking a particular interest in a female member of staff; if she is noticeably younger than him and relatively inexperienced, alarm bells will ring. The woman concerned will report that she has noticed his attention because it does not lead to an ordinary two-way interaction, he is overtly interested but stand-offish, not demanding nor conversational, he just always seems to be around, which makes her uneasy. The behaviour is interpreted by staff as inappropriate and as possibly indicative of some covert sexual intent. The action taken is to separate the two people. The male patient then participates less in the activity of the ward, becomes less cooperative or positively hostile. This is seen as confirmation that the staff’s interpretation of the situation was correct and the right decision made.
Wrong. The male patient may well be less cooperative, he’s been rejected again. The staff reaction may well create more extreme behaviour in the future. The male patient looks menacing and predatory because of his incompetence, he’s never had the chance to learn the skills of normal social interaction, how to approach and begin to build an intimate relationship. A major opportunity is lost because the female member of staff is the person he feels most attracted by or attached to - he is motivated by her. In other words, she is the person in the most powerful position to affect change in him! She, whatever her job or status, should be the one to work with him. If the woman is confident enough in her sexuality, then she can enter into a contract with him, which stated crudely would say; you can’t have me, but we can spend a certain number of hours together. We can hang-around so you can get comfortable being around women, and I’ll teach you what a woman like me, wants and expects in a relationship - I’ll show you how to approach a woman like me.
Real outcomes have to be made, and in specific social situations; aggression, violence and abuse arise - like fun, happiness and contentment - as a result of the interaction between people. No one person is ever the sole cause of anything. Just as the way someone is treated in the first few hours of contact with mental health services may set the pattern for years to come, anyone who is trapped or confined by others will, sooner or later lash-out. But equally someone who is confident but non-threatening, can begin the process of change in others.
Sunday, 4 July 2010
Eye movements and mental distress
Don’t you just love it when someone’s eye movements tell you what’s going on in the rest of the room and what they feel and think about it?
An outrageous claim? Yes, but only if you claim too much.
We take cues from everywhere, so quickly and usually unconsciously that the world around us seems seamless and our thoughts and feelings seem to come from within ourselves. But of course our mental map is not the territory itself, and whilst we can consciously cope with 40 pieces of information per second, our unconscious can handle 11 million. Our motivation to act and most of our learning comes from others. Facial expressions and tone of voice give us the vast majority of our information about others emotions. Language, spoken and accompanied by hand and other gestures, or written down, gives us all the cognitive stuff. Posture, our distance from others, and the degree of touch - tell us our relationship to another in any one moment. But all this information has to be structured in some way in order for us to navigate in the world, and there the eyes have it.
The eyes constantly make small scanning movements, the brain seamlessly puts the composite picture together so we have the complete illusion rather than the more prosaic view seen down a pair of binoculars. But those kind of eye movements can for most practical purposes be ignored, what concerns us here are two types of eye movements which we make in response to the actions of others - both involuntary and initially unconscious but which we habitually tell ourselves, after the fact, were a deliberate choice that ‘I’ made.
Trust your unconscious, it knows more and better than ‘you’ do. Whatever you are thinking and feeling in any given moment is being cued by something in the environment around you. (Remember, sensory deprivation is the fastest way to create madness!)
So, first your eyes will notice (recognise) something in the environment of others and track it before you are conscious of it. You feel a sudden emotion and may even have time to wonder why, before realising who has walked into the room ‘unnoticed’ by you a few seconds earlier. You may think about something from the past, little realising you are watching it happening to others in the present moment. (Afterwards many people will consciously attribute magical or other-worldly explanations to these real, commonplace, and mundane activities of the unconscious parts of the brain).
When observing others eye movements we can see what they notice, consciously and unconsciously, but those movements are overlaid with a second set which indicate their response to what they have noticed.
And it’s at this point that I must be especially careful about what I write, since people have got into all sorts of trouble by overstating the meaning of such phenomena which have been observed over many thousands of years. The problem is that many have wanted to explain the ‘what’ and ‘why’, rather than stick to questions of ‘how’. For the meaning of these second kind of eye movements, often called ‘eye accessing cues’ are almost entirely context specific, dependant on the how well you actually know the person you’re looking at, and of course how well you know yourself - since you are, by virtue of your very presence, cueing them!
The claim is that once you’ve controlled for eye movements in response to activity in the environment, then other movements will indicate how an individual is responding cognitively and emotional to the action around them - how they are thinking and feeling about you!
Now, what follows is my version, and compared with many others, a mild and tentative version, but it’s what my experience tells me is reasonable to claim. First is the observation that there is a marked tendency for people’s eyes to move in one direction (left or right) when trying to access memories, and in the opposite when constructing a thought - imagining some future action. The second observation has been that eye movements tend to stay either level or rise in an upward direction when thinking (particularly visualising), whilst tending to drop below the horizontal when feeling emotions (as bodily sensations, but also as felt in the sounds of the human voice).
When you combine the two elements you get a tendency to visualise thoughts about the future looking up in one direction and about the past in the other. A tendency to imagine future feelings through constructed internal dialogue when looking down in one direction, and remember emotions through the sounds of others speech when looking down in the opposite direction - both with, or without bodily sensations.
If you are in a normal state, that is not mentally distressed, these processes may be so seamless, unconscious, complete and taken-for-granted that you would wish to question their existence. But then you probably exist very efficiently in the world and are genuinely bewildered by the apparent psychological troubles of others. However if you have experienced periods of intense stress and consequent distress, or been witness to them over an extended period of time, and perhaps empathised with those around you a little too much, then you may have noticed the gap, or window that can open-up. Brief moments in which the very construction of social interaction can be seen and felt. The ‘digitised’ bites of which they are made up. A bit like those classic illusions used when being taught about visual perception, or when tiredness late at night causes you to loose the ability to synchronise the pictures and sounds coming from your TV.
But that’s as far as I go, others have and do claim a lot more - as a simple search of the web will reveal. Needless to say that with a lot of testing and matching with both the content of speech and the universal emotions all sorts of possibilities open-up.
Oh! I almost forget - if you are genuinely left-handed (one of the 10 to 13%) then all the above may be reversed, and happen in the opposite direction to the majority! Incidentally, did you know that it you have a diagnosis of Bipolar you are 3 times more likely to be left-handed than the general population…
An outrageous claim? Yes, but only if you claim too much.
We take cues from everywhere, so quickly and usually unconsciously that the world around us seems seamless and our thoughts and feelings seem to come from within ourselves. But of course our mental map is not the territory itself, and whilst we can consciously cope with 40 pieces of information per second, our unconscious can handle 11 million. Our motivation to act and most of our learning comes from others. Facial expressions and tone of voice give us the vast majority of our information about others emotions. Language, spoken and accompanied by hand and other gestures, or written down, gives us all the cognitive stuff. Posture, our distance from others, and the degree of touch - tell us our relationship to another in any one moment. But all this information has to be structured in some way in order for us to navigate in the world, and there the eyes have it.
The eyes constantly make small scanning movements, the brain seamlessly puts the composite picture together so we have the complete illusion rather than the more prosaic view seen down a pair of binoculars. But those kind of eye movements can for most practical purposes be ignored, what concerns us here are two types of eye movements which we make in response to the actions of others - both involuntary and initially unconscious but which we habitually tell ourselves, after the fact, were a deliberate choice that ‘I’ made.
Trust your unconscious, it knows more and better than ‘you’ do. Whatever you are thinking and feeling in any given moment is being cued by something in the environment around you. (Remember, sensory deprivation is the fastest way to create madness!)
So, first your eyes will notice (recognise) something in the environment of others and track it before you are conscious of it. You feel a sudden emotion and may even have time to wonder why, before realising who has walked into the room ‘unnoticed’ by you a few seconds earlier. You may think about something from the past, little realising you are watching it happening to others in the present moment. (Afterwards many people will consciously attribute magical or other-worldly explanations to these real, commonplace, and mundane activities of the unconscious parts of the brain).
When observing others eye movements we can see what they notice, consciously and unconsciously, but those movements are overlaid with a second set which indicate their response to what they have noticed.
And it’s at this point that I must be especially careful about what I write, since people have got into all sorts of trouble by overstating the meaning of such phenomena which have been observed over many thousands of years. The problem is that many have wanted to explain the ‘what’ and ‘why’, rather than stick to questions of ‘how’. For the meaning of these second kind of eye movements, often called ‘eye accessing cues’ are almost entirely context specific, dependant on the how well you actually know the person you’re looking at, and of course how well you know yourself - since you are, by virtue of your very presence, cueing them!
The claim is that once you’ve controlled for eye movements in response to activity in the environment, then other movements will indicate how an individual is responding cognitively and emotional to the action around them - how they are thinking and feeling about you!
Now, what follows is my version, and compared with many others, a mild and tentative version, but it’s what my experience tells me is reasonable to claim. First is the observation that there is a marked tendency for people’s eyes to move in one direction (left or right) when trying to access memories, and in the opposite when constructing a thought - imagining some future action. The second observation has been that eye movements tend to stay either level or rise in an upward direction when thinking (particularly visualising), whilst tending to drop below the horizontal when feeling emotions (as bodily sensations, but also as felt in the sounds of the human voice).
When you combine the two elements you get a tendency to visualise thoughts about the future looking up in one direction and about the past in the other. A tendency to imagine future feelings through constructed internal dialogue when looking down in one direction, and remember emotions through the sounds of others speech when looking down in the opposite direction - both with, or without bodily sensations.
If you are in a normal state, that is not mentally distressed, these processes may be so seamless, unconscious, complete and taken-for-granted that you would wish to question their existence. But then you probably exist very efficiently in the world and are genuinely bewildered by the apparent psychological troubles of others. However if you have experienced periods of intense stress and consequent distress, or been witness to them over an extended period of time, and perhaps empathised with those around you a little too much, then you may have noticed the gap, or window that can open-up. Brief moments in which the very construction of social interaction can be seen and felt. The ‘digitised’ bites of which they are made up. A bit like those classic illusions used when being taught about visual perception, or when tiredness late at night causes you to loose the ability to synchronise the pictures and sounds coming from your TV.
But that’s as far as I go, others have and do claim a lot more - as a simple search of the web will reveal. Needless to say that with a lot of testing and matching with both the content of speech and the universal emotions all sorts of possibilities open-up.
Oh! I almost forget - if you are genuinely left-handed (one of the 10 to 13%) then all the above may be reversed, and happen in the opposite direction to the majority! Incidentally, did you know that it you have a diagnosis of Bipolar you are 3 times more likely to be left-handed than the general population…
Thursday, 1 July 2010
A Desired Outcome
What will you feel, see, hear, smell and taste when you have achieved it?
You can bet your life a mental health worker won’t frame the question in such a way, although an NLP practitioner might - that is, what would be the sensory or experiential evidence? Rather your average worker would want some rational, cognitive (rather than emotional), probably written, description of a desired outcome to a well defined problem, which can then be made a measurable target - whether it be on a care plan, a WRAP or as a homework assignment for CBT.
But the real issue however, when trying to help someone in mental distress by asking them to set goals, aims or outcomes, is what I call the ‘future orientation’ problem. The worker is desperate to give hope (the promise of better times to come) and is often relentlessly positive. They ‘see’ the client’s negativity and respond by setting expectations which are too high for the client - today. The client then thinks I cannot possibly achieve that, I could barely get through the door to the appointment. Expectations or future tasks, like the skills and demands of any job, have to be set at just above the person’s current level of functioning. Something that is doable tomorrow!
At 17 (in 1976) I saw the world like Reggie Perrin. In his great speech to the British Fruit Association at Bilberry Hall, Reggie declares:
‘I know that I don’t know and believe in not believing. …Would the sun shine less brightly if there was no purpose in life? Would the nightingale sing less sweetly? Would we love each other less deeply? Man’s the only species neurotic enough to need a purpose in life.’ (David Nobbs 1975 The Fall and Rise of Reginald Perrin)
The problem is that if a mental health worker asks a client outright about their aims and goals they are likely to receive the reply; ‘I don’t have any’, or ‘I don’t know’. For every client I’ve ever met has been preoccupied with the near future - they don’t believe they have a long-term future - and equally have never been able to live ‘in the moment’. It is the potential disasters of the next week and their inability to get out of bed tomorrow which concern them. And with good reason. Mental health has been slow to understand the underlying rationale of positive psychologies. The point being that a normal person sees life a little too positively, with a level of optimism high enough to ride the waves of unpredictable events, but always believing in a brighter future and their ability to influence the outcome. The depressed person (all clients are a little depressed, whatever their diagnosis, due to their isolated situation) is actually more realistic, stares life in the face - is distressed because they see only too clearly. A situation in which the client may see their objective circumstances and limited opportunities more readily than the worker. It is with such basic insights that some experimental psychologists have embarked on ‘happiness’ research - and been blithely ignored by mental health services.
However, a virtue of the ‘define your desired outcome’ approach is that it may allow the brain to better identify anything which might bring you closer to it - opportunities only exist after they’ve first been recognised as opportunities!
Also if you know the who, what, when, how and why - then you can start to rehearse for it. Equally you should be able to identify someone who already has what you want and begin to imitate them. It is certainly easier to move towards something you want, than away from what you don't want (where your attention will inevitably stay on the undesired).
So how does one get around the paralysing belief of not knowing what you want? Easy. Outcomes are invented and if you don’t already have one, you make one up. (The real objective after all is the pay-off that comes from purposeful activity itself). Desired outcomes are just plans and fantasies about the future - conceits, albeit occasionally useful ones. They become useful (potentially real) if you can already see a series of actions you would need to take to bring them closer, rather than needing others to act for you. Is there something you can do tomorrow which will bring the desired outcome closer?
But it all starts to unpack when you consider achievability - or indeed ask yourself, how would I know when I had achieved my outcome? (Hence the question at the beginning of this post). The future is unknowable, you are not in control of the environment of others - now is actually all there is. The effective helper is one who acts today to make it easier for the client to get up tomorrow. The idea of ‘outcomes’ is only useful beyond today if it is flexible enough for a particular outcome to be changed in the light of unpredictable events (which occur often) but in the face of which other people’s response will, from habit, be to try to reproduce today, the world as it was yesterday.
Much better to follow an evolutionary social model of human behaviour as argued for elsewhere on this blog and understand that as social animals our motivation can only come from others. Seek movement and change, be always in the moment, let go of both the past and the future. Travel in the hope of never arriving, allow the brain and body to take you where it pleases. And never for a moment believe that the ‘I’ or ‘me’ of the so-called ‘self ’ is fixed forever. Outcomes? Like the past, the future is just an evolving story we tell yourselves about a person on a journey.
You can bet your life a mental health worker won’t frame the question in such a way, although an NLP practitioner might - that is, what would be the sensory or experiential evidence? Rather your average worker would want some rational, cognitive (rather than emotional), probably written, description of a desired outcome to a well defined problem, which can then be made a measurable target - whether it be on a care plan, a WRAP or as a homework assignment for CBT.
But the real issue however, when trying to help someone in mental distress by asking them to set goals, aims or outcomes, is what I call the ‘future orientation’ problem. The worker is desperate to give hope (the promise of better times to come) and is often relentlessly positive. They ‘see’ the client’s negativity and respond by setting expectations which are too high for the client - today. The client then thinks I cannot possibly achieve that, I could barely get through the door to the appointment. Expectations or future tasks, like the skills and demands of any job, have to be set at just above the person’s current level of functioning. Something that is doable tomorrow!
At 17 (in 1976) I saw the world like Reggie Perrin. In his great speech to the British Fruit Association at Bilberry Hall, Reggie declares:
‘I know that I don’t know and believe in not believing. …Would the sun shine less brightly if there was no purpose in life? Would the nightingale sing less sweetly? Would we love each other less deeply? Man’s the only species neurotic enough to need a purpose in life.’ (David Nobbs 1975 The Fall and Rise of Reginald Perrin)
The problem is that if a mental health worker asks a client outright about their aims and goals they are likely to receive the reply; ‘I don’t have any’, or ‘I don’t know’. For every client I’ve ever met has been preoccupied with the near future - they don’t believe they have a long-term future - and equally have never been able to live ‘in the moment’. It is the potential disasters of the next week and their inability to get out of bed tomorrow which concern them. And with good reason. Mental health has been slow to understand the underlying rationale of positive psychologies. The point being that a normal person sees life a little too positively, with a level of optimism high enough to ride the waves of unpredictable events, but always believing in a brighter future and their ability to influence the outcome. The depressed person (all clients are a little depressed, whatever their diagnosis, due to their isolated situation) is actually more realistic, stares life in the face - is distressed because they see only too clearly. A situation in which the client may see their objective circumstances and limited opportunities more readily than the worker. It is with such basic insights that some experimental psychologists have embarked on ‘happiness’ research - and been blithely ignored by mental health services.
However, a virtue of the ‘define your desired outcome’ approach is that it may allow the brain to better identify anything which might bring you closer to it - opportunities only exist after they’ve first been recognised as opportunities!
Also if you know the who, what, when, how and why - then you can start to rehearse for it. Equally you should be able to identify someone who already has what you want and begin to imitate them. It is certainly easier to move towards something you want, than away from what you don't want (where your attention will inevitably stay on the undesired).
So how does one get around the paralysing belief of not knowing what you want? Easy. Outcomes are invented and if you don’t already have one, you make one up. (The real objective after all is the pay-off that comes from purposeful activity itself). Desired outcomes are just plans and fantasies about the future - conceits, albeit occasionally useful ones. They become useful (potentially real) if you can already see a series of actions you would need to take to bring them closer, rather than needing others to act for you. Is there something you can do tomorrow which will bring the desired outcome closer?
But it all starts to unpack when you consider achievability - or indeed ask yourself, how would I know when I had achieved my outcome? (Hence the question at the beginning of this post). The future is unknowable, you are not in control of the environment of others - now is actually all there is. The effective helper is one who acts today to make it easier for the client to get up tomorrow. The idea of ‘outcomes’ is only useful beyond today if it is flexible enough for a particular outcome to be changed in the light of unpredictable events (which occur often) but in the face of which other people’s response will, from habit, be to try to reproduce today, the world as it was yesterday.
Much better to follow an evolutionary social model of human behaviour as argued for elsewhere on this blog and understand that as social animals our motivation can only come from others. Seek movement and change, be always in the moment, let go of both the past and the future. Travel in the hope of never arriving, allow the brain and body to take you where it pleases. And never for a moment believe that the ‘I’ or ‘me’ of the so-called ‘self ’ is fixed forever. Outcomes? Like the past, the future is just an evolving story we tell yourselves about a person on a journey.
Sunday, 27 June 2010
'Them And Us' In Mental Health
When I was a user of services I was often criticised by workers for having an out-of-date and undesirable ‘them and us’ view of the world of mental health. It bugged the hell out of me, because for years I had been trying to act from the opposite perspective (I still am) - but then something would happen that sent me back to thinking ‘they’ occupied some other world. In my everyday life I try to let-go of preconceptions, but then someone says or does something, which shows they still perceive, believe in, or approve of some basic divide.
Now of course, it must be to some extent what I choose to notice, and we all have a tendency to notice differences rather than similarities. However it is unfortunate that most of the time it is workers who are inclined to assert there is no more (or should not be any more) ‘them and us’. I’m also as aware as anyone that amongst workers there is a range of ‘lived experience’ - I myself, between my first and second admissions, was briefly a student mental nurse.
The answer to why a ‘them and us’ situation (and it is a social situation, not an attitude) persists, and perhaps must persist, despite the increasing dialogue between workers, users and carers is really very simple. But first, a look at the proposition:
‘As part of the human condition, we are all engaged in the same daily struggles to maintain our wellness. There are no “them” and “us” - just us. Commonality between us all is emphasised rather than differentiation. Some of us may need more robust wellness strategies than others, but the process is similar for us all. Our daily routines, our relationships and our levels of resilience become very important in maintaining our wellness.’ (Devon LIT Workforce Development Group Recovery - Concepts and application Version 2. 10.4.08)
(This is the missing item referred to in my January post - The Recovery Movement [part one] )
A few years ago I came to the conclusion that as part of my own self-management I had to treat every encounter, every relationship as personal. For the irony is, that the mental health system has traditionally been structured around providing impersonal, bureaucratic care for clients whose very problems manifest themselves in an inability to maintain intimate relationships! My only solution, to guarantee that I act for the right reasons, and feel the right emotions - is to only turn-up to do something today, because someone I care about has asked me to be there, or because I am likely to meet someone I’m attached to.
The fundamental building blocks of ‘them and us’ are the Mental Health Act and client confidentiality. By virtue of being a user it is so easy for workers to maintain the notion that you’re the one with the problem. You feel constrained in the way you are with them - I must look calm, not agitated, the things I say must sound reasonable. Because you know the person you’re talking to only has to make one phone call, express their ‘concern’, and a whole chain of events may lead to the use of the Act. It’s a sense of vulnerability that persists despite it being over five years since my last admission. I know my self-management skills are excellent, that there is no need for me to ever be an in-patient again, but nonetheless, the feeling remains that the obligation is on me to conform to their perceptions of reality. In a sense, my fear still allows ‘them’ to define what ‘appropriate’ behaviour is!
Client confidentiality is presented as protection for the client, but it’s convenient for them too. Remember, in the vast majority of encounters it is we who disclose not them, and our notes usually record what they choose to record. They decide what can be kept confidential and what they are ‘obliged’ to share with other workers and agencies. Equally, you inform them about concerns regarding yourself, and occasionally other clients, and they choose whether to act. And there need be no comeback for them. Because you are seen as the one with the problem the quality of your knowledge and judgement is rarely acknowledged, let alone acted upon.
There is however a third factor which helps to maintain them and us, it is the way that Involvement (public participation and feedback) is organised. Involvement procedures have become as bureaucratic as the rest of the mental health industry. The rules and regulations, intended to be objective, calculable and de-personalised in order to treat everyone the same, with fairness and equality, mean the individual can rapidly be lost - more remoteness is the last thing someone needs who has become ‘ill’ as a result of a lack of communication skills in interpersonal relationships!
No one service user’s view becomes any more valid than that of another on any particular issue. Although we have differing skills, this counts for nothing - we are all ‘experts by experience’. So when at a meeting each of us gets an equal opportunity to state our views and we say different things, the consensus seeking Chair (having allowed us to ‘let of steam’) need take forward to others - what? One mechanism of bureaucratic control is to be told that whatever your view is, though legitimate, is yours alone - a cause for individual complaint or change in treatment, but not a reason for workers to question their working practices.
The workforce however is divided into professions with what are thought to be unique sets of knowledge and skills (the specialised division of labour) which they must maintain, or lose their value in the job market. There are good reasons therefore for them not to work collaboratively, and management may also concur, not wanting their workforce to identify a collective interest with each other. The Involvement worker stands between client and service provider or commissioner, describing themselves as facilitators or trainers (training staff how to Involve, and clients how to become involved) but may in reality act as ‘gatekeepers’. They will encourage the client to see beyond their own problems and learn the manners of consultation and compromise. But often what occurs is a process of incorporation, whereby the powerful group facing opposition seeks to incorporate the members of opposing groups into their own organisation as a way of nullifying that opposition. Such individuals often rapidly take on the values of the group to which they were formally opposed, and indeed can then be used as a channel for ‘selling’ the dominant group’s set of values back to opposition groups as a whole. As Involvement develops, as users and carers sit on various NHS committees, it is unclear whether they sit there in their own right or as in some sense ‘representatives’ of their own groups or networks. A few years ago my local mental health trust formalised its payment policy for Involvement. (Workers are always keen that the ‘contribution’ of clients and carers be recognised; in their turn some will refuse to attend unless they are paid). The Trust recognised three levels of payment, each with its own mini ‘job description’ on the expectations and obligations of the role, from simply turning-up, to doing work for and being responsible to a particular committee whilst at the same time being a ‘representative’ of, and feeding back to, any user or carer group the individual might belong to!
Involvement activity also has something of the character of ‘consumer rights’ or political ‘special interest’ groups. In a them and us situation you are not only the victim of the powerful in terms of rights and resources, you also allow them to define the terms of the debate and the ‘world view’ you have of yourself. For example, complaining that the experts aren’t expert, but instead of taking back power, simply demanding better experts! And in forming networks and lobby groups there is also the danger that ‘complaining and campaigning’ becomes an end in itself - a different kind of dependency where you remain tied to those who seem to oppress you rather than seeking a genuine alternative. Worse still, in trying to be an effective opposition, the way your own group is organised may come to look much like those you seek to challenge. There is the phrase ‘grievance gravy train’ (first used in New Zealand) to describe the activities of individuals and special interest groups who used employment, welfare and equal rights legislation; not just for the resolution of individual disputes, but for the building of careers, organisations and political influence for their own sake. (New Zealand also provided the term ‘Pro-sumer’ - meaning a professional consumer of health and social welfare services).
The reason such processes as bureaucratic control, incorporation and special interests occur and serve to further underpin ‘them and us’ is that health authorities are not actually prepared to negotiate with those they seek to help. Nowhere in law is anything conceded apart from the right to be consulted. Through Involvement activities you can turn yourself into a professional patient, rewarded for conforming (accepting training in how to ‘present’ your experiences, or how to become a quasi worker by formalising peer support!) At worst Involvement becomes an add-on to traditional practice, a way of making work and expanding influence. Alas during my four years involved in Involvement I cannot think of a single issue raised by users or carers in a forum which then led to a change in the way workers practiced during their day-to-day encounters with clients. But then groups being what they are, once you express such pessimism it rapidly comes to be seen as disloyalty!
Those who pursue a Recovery approach sometimes claim to have gone beyond the need for formalised Involvement because relationships are negotiated at every level between client and worker in an open and transparent way. But it remains the case with Recovery, as with any other client-centred approach, that the worker will always claim your views are valid, but only to you. They will never accept that your views could be representative. They will waste thousands of pounds on surveys designed by themselves in order to gather opinion, little realising that a few hours spent reading user’s blogs will furnish the entire range of opinion from across the globe. Equally, they will never concede that you could have superior knowledge on the causes and best treatment of mental distress - by definition the mental patient cannot have a greater insight than them, despite the common mantra that you ‘know yourself best’.
Despite all the above the relationship between user and professional may become very close. Often the same workers who have tried to support you over many years are those with whom you end-up trying to negotiate. You like and are attached to them, but they do not reciprocate the hard work you have put into trying to affect real reform. You listen to a hypocritical remark, or occasionally a blatant untruth which they have convinced themselves must be the case, and you know for certain sure, that now ‘it’s not me, it’s the others’ and that it is time to leave.
Now of course, it must be to some extent what I choose to notice, and we all have a tendency to notice differences rather than similarities. However it is unfortunate that most of the time it is workers who are inclined to assert there is no more (or should not be any more) ‘them and us’. I’m also as aware as anyone that amongst workers there is a range of ‘lived experience’ - I myself, between my first and second admissions, was briefly a student mental nurse.
The answer to why a ‘them and us’ situation (and it is a social situation, not an attitude) persists, and perhaps must persist, despite the increasing dialogue between workers, users and carers is really very simple. But first, a look at the proposition:
‘As part of the human condition, we are all engaged in the same daily struggles to maintain our wellness. There are no “them” and “us” - just us. Commonality between us all is emphasised rather than differentiation. Some of us may need more robust wellness strategies than others, but the process is similar for us all. Our daily routines, our relationships and our levels of resilience become very important in maintaining our wellness.’ (Devon LIT Workforce Development Group Recovery - Concepts and application Version 2. 10.4.08)
(This is the missing item referred to in my January post - The Recovery Movement [part one] )
A few years ago I came to the conclusion that as part of my own self-management I had to treat every encounter, every relationship as personal. For the irony is, that the mental health system has traditionally been structured around providing impersonal, bureaucratic care for clients whose very problems manifest themselves in an inability to maintain intimate relationships! My only solution, to guarantee that I act for the right reasons, and feel the right emotions - is to only turn-up to do something today, because someone I care about has asked me to be there, or because I am likely to meet someone I’m attached to.
The fundamental building blocks of ‘them and us’ are the Mental Health Act and client confidentiality. By virtue of being a user it is so easy for workers to maintain the notion that you’re the one with the problem. You feel constrained in the way you are with them - I must look calm, not agitated, the things I say must sound reasonable. Because you know the person you’re talking to only has to make one phone call, express their ‘concern’, and a whole chain of events may lead to the use of the Act. It’s a sense of vulnerability that persists despite it being over five years since my last admission. I know my self-management skills are excellent, that there is no need for me to ever be an in-patient again, but nonetheless, the feeling remains that the obligation is on me to conform to their perceptions of reality. In a sense, my fear still allows ‘them’ to define what ‘appropriate’ behaviour is!
Client confidentiality is presented as protection for the client, but it’s convenient for them too. Remember, in the vast majority of encounters it is we who disclose not them, and our notes usually record what they choose to record. They decide what can be kept confidential and what they are ‘obliged’ to share with other workers and agencies. Equally, you inform them about concerns regarding yourself, and occasionally other clients, and they choose whether to act. And there need be no comeback for them. Because you are seen as the one with the problem the quality of your knowledge and judgement is rarely acknowledged, let alone acted upon.
There is however a third factor which helps to maintain them and us, it is the way that Involvement (public participation and feedback) is organised. Involvement procedures have become as bureaucratic as the rest of the mental health industry. The rules and regulations, intended to be objective, calculable and de-personalised in order to treat everyone the same, with fairness and equality, mean the individual can rapidly be lost - more remoteness is the last thing someone needs who has become ‘ill’ as a result of a lack of communication skills in interpersonal relationships!
No one service user’s view becomes any more valid than that of another on any particular issue. Although we have differing skills, this counts for nothing - we are all ‘experts by experience’. So when at a meeting each of us gets an equal opportunity to state our views and we say different things, the consensus seeking Chair (having allowed us to ‘let of steam’) need take forward to others - what? One mechanism of bureaucratic control is to be told that whatever your view is, though legitimate, is yours alone - a cause for individual complaint or change in treatment, but not a reason for workers to question their working practices.
The workforce however is divided into professions with what are thought to be unique sets of knowledge and skills (the specialised division of labour) which they must maintain, or lose their value in the job market. There are good reasons therefore for them not to work collaboratively, and management may also concur, not wanting their workforce to identify a collective interest with each other. The Involvement worker stands between client and service provider or commissioner, describing themselves as facilitators or trainers (training staff how to Involve, and clients how to become involved) but may in reality act as ‘gatekeepers’. They will encourage the client to see beyond their own problems and learn the manners of consultation and compromise. But often what occurs is a process of incorporation, whereby the powerful group facing opposition seeks to incorporate the members of opposing groups into their own organisation as a way of nullifying that opposition. Such individuals often rapidly take on the values of the group to which they were formally opposed, and indeed can then be used as a channel for ‘selling’ the dominant group’s set of values back to opposition groups as a whole. As Involvement develops, as users and carers sit on various NHS committees, it is unclear whether they sit there in their own right or as in some sense ‘representatives’ of their own groups or networks. A few years ago my local mental health trust formalised its payment policy for Involvement. (Workers are always keen that the ‘contribution’ of clients and carers be recognised; in their turn some will refuse to attend unless they are paid). The Trust recognised three levels of payment, each with its own mini ‘job description’ on the expectations and obligations of the role, from simply turning-up, to doing work for and being responsible to a particular committee whilst at the same time being a ‘representative’ of, and feeding back to, any user or carer group the individual might belong to!
Involvement activity also has something of the character of ‘consumer rights’ or political ‘special interest’ groups. In a them and us situation you are not only the victim of the powerful in terms of rights and resources, you also allow them to define the terms of the debate and the ‘world view’ you have of yourself. For example, complaining that the experts aren’t expert, but instead of taking back power, simply demanding better experts! And in forming networks and lobby groups there is also the danger that ‘complaining and campaigning’ becomes an end in itself - a different kind of dependency where you remain tied to those who seem to oppress you rather than seeking a genuine alternative. Worse still, in trying to be an effective opposition, the way your own group is organised may come to look much like those you seek to challenge. There is the phrase ‘grievance gravy train’ (first used in New Zealand) to describe the activities of individuals and special interest groups who used employment, welfare and equal rights legislation; not just for the resolution of individual disputes, but for the building of careers, organisations and political influence for their own sake. (New Zealand also provided the term ‘Pro-sumer’ - meaning a professional consumer of health and social welfare services).
The reason such processes as bureaucratic control, incorporation and special interests occur and serve to further underpin ‘them and us’ is that health authorities are not actually prepared to negotiate with those they seek to help. Nowhere in law is anything conceded apart from the right to be consulted. Through Involvement activities you can turn yourself into a professional patient, rewarded for conforming (accepting training in how to ‘present’ your experiences, or how to become a quasi worker by formalising peer support!) At worst Involvement becomes an add-on to traditional practice, a way of making work and expanding influence. Alas during my four years involved in Involvement I cannot think of a single issue raised by users or carers in a forum which then led to a change in the way workers practiced during their day-to-day encounters with clients. But then groups being what they are, once you express such pessimism it rapidly comes to be seen as disloyalty!
Those who pursue a Recovery approach sometimes claim to have gone beyond the need for formalised Involvement because relationships are negotiated at every level between client and worker in an open and transparent way. But it remains the case with Recovery, as with any other client-centred approach, that the worker will always claim your views are valid, but only to you. They will never accept that your views could be representative. They will waste thousands of pounds on surveys designed by themselves in order to gather opinion, little realising that a few hours spent reading user’s blogs will furnish the entire range of opinion from across the globe. Equally, they will never concede that you could have superior knowledge on the causes and best treatment of mental distress - by definition the mental patient cannot have a greater insight than them, despite the common mantra that you ‘know yourself best’.
Despite all the above the relationship between user and professional may become very close. Often the same workers who have tried to support you over many years are those with whom you end-up trying to negotiate. You like and are attached to them, but they do not reciprocate the hard work you have put into trying to affect real reform. You listen to a hypocritical remark, or occasionally a blatant untruth which they have convinced themselves must be the case, and you know for certain sure, that now ‘it’s not me, it’s the others’ and that it is time to leave.
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