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.
Thursday, 11 November 2010
Thursday, 4 November 2010
Walking meditation
My preferred form of meditation is to walk.
The basic elements occur naturally, one following-on from another. By focusing first on the breath, it will dictate an open upright posture, and balance will come from knowing that the centre of the body resides in the diaphragm along with the breath. In motion the focus shifts when the eyes are allowed to rise naturally to the open horizon; not a point of constant attention, but the place they come back to, again and again, as you let-go of distracting emotions and thoughts - from a past which is gone, and a future that is unknowable. With the eyes to the horizon and with good posture, then the feet will start to follow the contours of the ground and as if by magic, a ‘bodyscan’ occurs all on it’s own, as the right muscles are stretched, then relaxed along with stressful feelings and thoughts. A ‘mantra’ can be found in the pace and rhythm of the stride, but it must be flexible enough to change in an instance, for walking consistently and repetitively down a ‘made’ road may bring a kind of temporary bliss, but will soon narrow the horizon and an open future.
The basic elements occur naturally, one following-on from another. By focusing first on the breath, it will dictate an open upright posture, and balance will come from knowing that the centre of the body resides in the diaphragm along with the breath. In motion the focus shifts when the eyes are allowed to rise naturally to the open horizon; not a point of constant attention, but the place they come back to, again and again, as you let-go of distracting emotions and thoughts - from a past which is gone, and a future that is unknowable. With the eyes to the horizon and with good posture, then the feet will start to follow the contours of the ground and as if by magic, a ‘bodyscan’ occurs all on it’s own, as the right muscles are stretched, then relaxed along with stressful feelings and thoughts. A ‘mantra’ can be found in the pace and rhythm of the stride, but it must be flexible enough to change in an instance, for walking consistently and repetitively down a ‘made’ road may bring a kind of temporary bliss, but will soon narrow the horizon and an open future.
Tuesday, 2 November 2010
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.
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.
Monday, 1 November 2010
Homelessness and mental health
Sometimes you just have to be outside.
Those who are homeless and have mental health problems, have different needs from those who don’t. Like other people who are homeless they are highly likely to be users of street drugs and alcohol, they may have been forced from home due to various forms of abuse, relationship breakdown or for economic reasons. Nonetheless their priorities are often different, and almost certainly different from those charged with helping them.
Social workers, social services, the police and more specialised outreach workers often just don’t ‘get’ why someone wouldn’t want even the most basic of accommodation. But that’s not to say they don’t welcome the right kind of help.
Mental distress and a sense of confinement go together. The opportunity to escape, sometimes at a moment’s notice, for longer or shorter periods may be paramount. For some that requires physical space and even an open horizon.
Prior to the current recession the homeless had been becoming less visible than at any time in the last thirty years or more, not simply as a result of economic prosperity, but because of concerted efforts by various authorities to tidy-up social spaces - 24 hours a day. A combination of the police moving the homeless on from town and city centres, plus government and charities providing more hostel beds and more flexible forms of social housing, meant that to be on the streets by choice became more and more difficult. Rough sleepers had to become more discrete. Road and railway cuttings, embankments and bridges - rather than railway stations and town centres. In fields and hedgerows, rather than within the village.
Despite the impression often given in the media, most homeless people/ rough sleepers/ young runaways/ missing people tend to stay within their own territory. And although the population is much more mobile than it once was, it is still the case that a homeless person is likely to remain within a few miles of the home they felt forced to leave. A runaway from a Devon village is quite likely to meet an ex-Royal Marine whilst kipping on a south Devon beach! (Although some younger people undoubtedly do head for the capital, most of London’s rough sleepers are Londoners. At one point people joked that there were more outreach workers at London mainline stations than runaways).
Now the homeless population is growing again - but are they really more conspicuous or less easy to ignore? It is often argued that the general population becomes easily desensitised to their presence. Well, we can block-out all sorts of things, and when we do, that simply forces the rough sleeper to seek out better locations for spot-begging. The portal of an ancient church, which just happens to be en-route for some of the more well-heeled commuters at eight in the morning in my local city - is much favoured. Enterprise is often rewarded. But for others, crowded streets are as much a nightmare as a spacious night shelter may be - too confining by virtue of the company you’re forced to keep. But just to be seen alone is perceived as a threat by some, and a reason for others to impose help. A trusted companion may be welcomed at times, but only for certain things. Physical freedom, in town or country, in order to pursue any activity, unaccompanied or unsupervised, is at an all time low. Space is not free but certain spaces are left vacant at certain times of the day and night. Rough sleepers will commute into towns to beg from commuters and just as purposefully leave again.
Most helpers want to put back together that which is perceived as having fallen apart. Most obviously in the case of children there is the insistence on returning them to the source of their distress after they have taken the constructive step of removing themselves from perceived danger - which often leads to worsened circumstances. But the same thinking is applied to adults too, albeit through ‘expert’ advice rather than the force of the law. People make themselves homeless when there is ‘nowhere else to go, and no one left to turn to’. But when life at ‘home’ becomes impossible and individuals feel forced to leave, family and professional helpers do conspire - made possible by the distressed person’s inability to explaining themselves to others.
It’s more difficult to jump trains (fare-dodge) than ever before. And of course it was never possible to be a ‘hobo’ on the UK rail network (jump freight cars and be a seasonal agricultural labourer - outside, and on the move). Equally the ancient art of hitching lifts on roads has died-out, unless you are clearly identifiable as a fellow member of a very small number of occupational groups. Railways however have a traditional, although dwindling connection with homelessness in the UK. And that connection is linked inevitably with the number of suicides that have occurred on or around railways. I’ve written elsewhere on this blog about suicidal thoughts and actions, but there is one exception to the views I’ve already expressed and that is what has become known as ‘suicide by train’. My sympathy goes out-the-window when someone attempts or succeeds through such a method. If you are determined to make life as unpleasant as possible for the largest number of people by your voluntary death, then suicide by train is the way to do it.
Choosing suicide by train in the mistaken belief that death is both instantaneous and easy; the track-walker, platform or bridge-jumper, when successful, dismembers themselves and leaves the greatest possible mess for others. And when the British Transport Police, for it is their formal responsibility to clean up, euphemistically refer to the ‘torso’, they simply mean the biggest bit they can find. Of the many people potentially traumatised by such an act, the train driver often suffers the particular experience of witnessing the before, during and after of an act in which they are both involved but powerless. There have been some initiatives in the UK to provide counselling for drivers, and training for station staff in suicide prevention. However the modest amount of research into suicide by train has principally been undertaken in Canada and Sweden.
But what is really missing is an appreciation that homelessness is not just a precursor to suicide for many with mental health problems, but a process in which an individual my progressively loose their adaptability to modern living and revert to more fundamental and natural behaviour. For although suicide may be unnatural, choosing the time and place of one’s own death may not be. The suicidal person often expresses the belief that they have become useless to their nearest and dearest, that those they care about most, would be better-off without them. They cut themselves off, mental and sometimes physically, becoming outsiders to their own group. In this way someone, whatever their age, may in their thoughts and actions come to resemble the elderly. Equally, there may be parallels with our ancient ancestors. In modern Christian mythology, death is about ‘crossing the river’. In a hunter-gatherer ‘form of life’, a natural lifespan comes to an end when you can no longer cross the river without endangering the lives of your family and group. I’ll end therefore with a quote from Jacob Bronowski in The Ascent of Man, reflecting on an incident recorded whilst filming the nomadic and pastoral Bakhtiari of northern Iran in 1970.
‘Who knows, in any one year, whether the old when they have crossed the passes will be able to face the final test: the crossing of the Bazuft River? Three months of melt-water have swollen the river. The tribesmen, the women, the pack animals and the flocks are all exhausted. It will take a day to manhandle the flocks across the river. But this, here, now is the testing day. Today is the day on which the young become men, because the survival of the herd and the family depends on their strength. Crossing the Bazuft River is like crossing the Jordan; it is the baptism to manhood. For the young man, life for a moment comes alive now. And for the old - for the old, it dies.
..What happens to the old when they cannot cross the last river? Nothing. They stay behind to die. Only the dog is puzzled to see a man abandoned. The man accepts the nomad custom; he has come to the end of his journey, and there is no place at the end.’
Support Railway Children http://www.railwaychildren.org.uk/?lpos=fromtheweb - a charity started by UK railway workers, which raises funds for projects principally in India, East Africa and the UK. Includes help-lines, outreach work, family support, education programmes, the recruiting of former street children as peer supporters, plus in the last few years, research. For the Off The Radar (2009) report, 100 experienced UK child rough sleepers were interviewed; 2 out of 3 experienced violence on the streets, 1 in 10 had been sexually abused at home, 2 out of 3 had mental health problems, and almost all had been excluded from school.
Those who are homeless and have mental health problems, have different needs from those who don’t. Like other people who are homeless they are highly likely to be users of street drugs and alcohol, they may have been forced from home due to various forms of abuse, relationship breakdown or for economic reasons. Nonetheless their priorities are often different, and almost certainly different from those charged with helping them.
Social workers, social services, the police and more specialised outreach workers often just don’t ‘get’ why someone wouldn’t want even the most basic of accommodation. But that’s not to say they don’t welcome the right kind of help.
Mental distress and a sense of confinement go together. The opportunity to escape, sometimes at a moment’s notice, for longer or shorter periods may be paramount. For some that requires physical space and even an open horizon.
Prior to the current recession the homeless had been becoming less visible than at any time in the last thirty years or more, not simply as a result of economic prosperity, but because of concerted efforts by various authorities to tidy-up social spaces - 24 hours a day. A combination of the police moving the homeless on from town and city centres, plus government and charities providing more hostel beds and more flexible forms of social housing, meant that to be on the streets by choice became more and more difficult. Rough sleepers had to become more discrete. Road and railway cuttings, embankments and bridges - rather than railway stations and town centres. In fields and hedgerows, rather than within the village.
Despite the impression often given in the media, most homeless people/ rough sleepers/ young runaways/ missing people tend to stay within their own territory. And although the population is much more mobile than it once was, it is still the case that a homeless person is likely to remain within a few miles of the home they felt forced to leave. A runaway from a Devon village is quite likely to meet an ex-Royal Marine whilst kipping on a south Devon beach! (Although some younger people undoubtedly do head for the capital, most of London’s rough sleepers are Londoners. At one point people joked that there were more outreach workers at London mainline stations than runaways).
Now the homeless population is growing again - but are they really more conspicuous or less easy to ignore? It is often argued that the general population becomes easily desensitised to their presence. Well, we can block-out all sorts of things, and when we do, that simply forces the rough sleeper to seek out better locations for spot-begging. The portal of an ancient church, which just happens to be en-route for some of the more well-heeled commuters at eight in the morning in my local city - is much favoured. Enterprise is often rewarded. But for others, crowded streets are as much a nightmare as a spacious night shelter may be - too confining by virtue of the company you’re forced to keep. But just to be seen alone is perceived as a threat by some, and a reason for others to impose help. A trusted companion may be welcomed at times, but only for certain things. Physical freedom, in town or country, in order to pursue any activity, unaccompanied or unsupervised, is at an all time low. Space is not free but certain spaces are left vacant at certain times of the day and night. Rough sleepers will commute into towns to beg from commuters and just as purposefully leave again.
Most helpers want to put back together that which is perceived as having fallen apart. Most obviously in the case of children there is the insistence on returning them to the source of their distress after they have taken the constructive step of removing themselves from perceived danger - which often leads to worsened circumstances. But the same thinking is applied to adults too, albeit through ‘expert’ advice rather than the force of the law. People make themselves homeless when there is ‘nowhere else to go, and no one left to turn to’. But when life at ‘home’ becomes impossible and individuals feel forced to leave, family and professional helpers do conspire - made possible by the distressed person’s inability to explaining themselves to others.
It’s more difficult to jump trains (fare-dodge) than ever before. And of course it was never possible to be a ‘hobo’ on the UK rail network (jump freight cars and be a seasonal agricultural labourer - outside, and on the move). Equally the ancient art of hitching lifts on roads has died-out, unless you are clearly identifiable as a fellow member of a very small number of occupational groups. Railways however have a traditional, although dwindling connection with homelessness in the UK. And that connection is linked inevitably with the number of suicides that have occurred on or around railways. I’ve written elsewhere on this blog about suicidal thoughts and actions, but there is one exception to the views I’ve already expressed and that is what has become known as ‘suicide by train’. My sympathy goes out-the-window when someone attempts or succeeds through such a method. If you are determined to make life as unpleasant as possible for the largest number of people by your voluntary death, then suicide by train is the way to do it.
Choosing suicide by train in the mistaken belief that death is both instantaneous and easy; the track-walker, platform or bridge-jumper, when successful, dismembers themselves and leaves the greatest possible mess for others. And when the British Transport Police, for it is their formal responsibility to clean up, euphemistically refer to the ‘torso’, they simply mean the biggest bit they can find. Of the many people potentially traumatised by such an act, the train driver often suffers the particular experience of witnessing the before, during and after of an act in which they are both involved but powerless. There have been some initiatives in the UK to provide counselling for drivers, and training for station staff in suicide prevention. However the modest amount of research into suicide by train has principally been undertaken in Canada and Sweden.
But what is really missing is an appreciation that homelessness is not just a precursor to suicide for many with mental health problems, but a process in which an individual my progressively loose their adaptability to modern living and revert to more fundamental and natural behaviour. For although suicide may be unnatural, choosing the time and place of one’s own death may not be. The suicidal person often expresses the belief that they have become useless to their nearest and dearest, that those they care about most, would be better-off without them. They cut themselves off, mental and sometimes physically, becoming outsiders to their own group. In this way someone, whatever their age, may in their thoughts and actions come to resemble the elderly. Equally, there may be parallels with our ancient ancestors. In modern Christian mythology, death is about ‘crossing the river’. In a hunter-gatherer ‘form of life’, a natural lifespan comes to an end when you can no longer cross the river without endangering the lives of your family and group. I’ll end therefore with a quote from Jacob Bronowski in The Ascent of Man, reflecting on an incident recorded whilst filming the nomadic and pastoral Bakhtiari of northern Iran in 1970.
‘Who knows, in any one year, whether the old when they have crossed the passes will be able to face the final test: the crossing of the Bazuft River? Three months of melt-water have swollen the river. The tribesmen, the women, the pack animals and the flocks are all exhausted. It will take a day to manhandle the flocks across the river. But this, here, now is the testing day. Today is the day on which the young become men, because the survival of the herd and the family depends on their strength. Crossing the Bazuft River is like crossing the Jordan; it is the baptism to manhood. For the young man, life for a moment comes alive now. And for the old - for the old, it dies.
..What happens to the old when they cannot cross the last river? Nothing. They stay behind to die. Only the dog is puzzled to see a man abandoned. The man accepts the nomad custom; he has come to the end of his journey, and there is no place at the end.’
Support Railway Children http://www.railwaychildren.org.uk/?lpos=fromtheweb - a charity started by UK railway workers, which raises funds for projects principally in India, East Africa and the UK. Includes help-lines, outreach work, family support, education programmes, the recruiting of former street children as peer supporters, plus in the last few years, research. For the Off The Radar (2009) report, 100 experienced UK child rough sleepers were interviewed; 2 out of 3 experienced violence on the streets, 1 in 10 had been sexually abused at home, 2 out of 3 had mental health problems, and almost all had been excluded from school.
Sunday, 12 September 2010
Mental health in Groups
Groups went out of fashion in the world of UK mental health for more than twenty years. Now they are re-emerging in a looser form, often as part of wider social networks - an inevitable, if unacknowledged recognition of their role as basic units of society. The new form they take is a reaction against their perceived over prescriptive character in the past, particularly in psychodynamic psychotherapy. However, although the need for group work has become explicit again, those who construct them remain largely ignorant, as in other areas of mental health practice, of progress made in the life sciences, on understanding natural human groups and the ‘social brain’.
My first taste of group work was in 1988, a year after my first admission to a psychiatric hospital. The clinic was a converted country house several miles from the city centre. It was traditional group therapy, in a relatively controlled environment. A large living room, in which 10 easy chairs placed in a circle fitted easily, in a quiet and remote location. It was thought a virtue that we were away from a normal environment, but actually it was so untypical that I soon came to question its relevance to our real world problems.
I realised almost immediately I’d need time, both before and after the weekly one and a half hour sessions, to adjust to the difference with the outside world - sometimes up to half an hour to get my head together. It began as a closed group of 8 clients with 2 nurse therapists as facilitators (smaller groups were thought too intimate, larger increased the likelihood of two conversations developing). When someone failed to turn-up the empty chair was left as it was. The facilitators were there when we arrived and stayed seated until we left. They sat across from each other - an obvious way to ‘cover’ the room and cue each other! (It was easy to start thinking like that because they were so ‘non-directive’, many of the clients in contrast were actively looking for advice and direction). They rarely intervening, but most members wanted explanation, insight and leadership. The group didn’t remain closed for long however because people steadily dropped-out. For newcomers it was more difficult to join an established group. I remained for eighteen months.
The idea of a Group as presented to us was that in such controlled circumstances, the masks we presented to the world, or screens we hid behind, would be removed; problems we hid from ourselves and others would be revealed, the unconscious forces that led us to replicate mistakes exposed. We would be encouraged to express both positive and negative feelings as they occurred, and have those thoughts and feelings accepted by the group. We would be helped in learning how to express emotion.
I discovered later that the therapists had been trained in a psychodynamic approach, although there were no explicit references to transference relationships (let alone counter-transference), defence mechanisms or indeed a group dynamic. We were however gently reminded of how we might be bringing past and present relationships ‘into the room’ replaying them or acting them out. We all found it difficult to articulate problems in front of the group and cope with the reaction of others, but the desire to ‘do archaeology’ (dig-up the past) was strong, in preference to confronting what was happening between us in the ‘here and now’. But it always remained the assumption of the therapists that what we were doing was seeking insight, and that that in itself would provoke behavioural change.
Pre- and post-group meetings between members were not allowed, but they took place nonetheless. Indeed these encounters led in time to my being a guest at the family home of one of the older male clients on several occasions, and to my meeting outside the group with one of the younger female clients. Also, with a third member, I had one of those moments of disbelief upon meeting someone you have heard talked about incessantly, in this case the person’s partner, and immediately concluded they’re not a bit like you’ve been led to believe!
I found the therapy sessions often quite exciting but emotionally draining, a tension between what I was observing and feeling. People would try to sit in the same seat every week, and become quite disconcerted when I didn’t. The ninety minute sessions were not at all egalitarian, clients competed for time for themselves, some tried to ‘hog the limelight’; others more subtly, would seek to shift the conversation in the directions they wanted to go, some sought alliances, some to mediate, some seemed to just want to belong, others to be accepted as they were. Within a session there were short periods of half an hour or so when real work seemed to be done in a mutually supportive way. But the events within the group were much less dramatic than those recalled by the members from their lives outside it.
My sense of mental wellbeing certainly improved whilst I was in that first group and for almost a year after. Since then I’ve been part of dozens of groups intended to have some sort of therapeutic effect, and structured and managed to varying degrees. I’ve come to prefer the more informal groups one can contrive for oneself with ones peers. The first thing to emphasise is that it is the activity, or the making of relationships themselves, which is important rather than some imagined product or outcome.
An old, but illustrative example from inpatient wards is what might be called, The Art Room Versus The Smoking Room; it is common for the outsider to view The Art Room as an area of calm, purposeful activity with a definite outcome. They may express surprise when after an hour’s absorption in making a painting, a client simply walks away discarding their individual effort. They may seek to praise the client’s work, suggest it be kept, or put on the wall. The client shows no interest in this - it is the hour away from his or her intrusive thoughts that is important. In contrast The Smoking Room is viewed by the outsider as the antitheses of healthy activity; dark, poorly ventilated, clients indulging their habits for nicotine and caffeine, sitting around in unfocused, purposeless conversation. Yet flow, the loss of self-consciousness first experienced in childhood, often occurs in one-to-one conversation (occasionally with more). From the client’s point of view here is the opportunity to talk to each other about the very things that they are unable to express to staff, and which other clients are better able to understand. (It’s worth noting in passing that clients will often ‘protect’ staff psychologically, by not discussing issues and behaviour they have come to know will disturb them).
Secondly real facilitators do not teach. The term has been much abused. It does not refer to someone who arrives in a group with an agenda, with things they will teach or seek to demonstrate. (They would certainly not stand-up, use a flip-chart and lecture to a group!) A proper facilitator is a member of the group, and is unlikely to intervene until they have come to know the group. They seek first and foremost to be fully in the room, sensitive to the feelings of both the group and the individuals within it. Interventions occur when they seek to redirect conversation or activity towards areas which their experience suggests are useful. Thirdly, groups always have a ‘star’, but they are not leaders appointed or accepted by the group, but the person who appears to be get most from the group, changing or benefiting the most. Other members often respond positively to that person as an example or role model, but sometimes negatively as yet another example of how they are failing!
Fourthly, since the activity of the group is all - and the ‘here and now’ a group’s proper concern - it is important to what extent someone is in the room, living in the present moment, able to let go of thoughts and feelings about the past and future and fully participate. For example, one person sits alone in a corner of the room; are they agitated and their thoughts miles away, or are they calm, quite and possibly acutely observant? Alternatively, is the person calmly absorbed in an individual task, or agitated by their observance of what is happening in the room? The person who is not participating remains an outsider. Often clients are forced to remain outsiders despite being in groups. Staff are usually part of a fixed group outside of the activities they devise for clients. They have their own professional competencies and ‘codes’ of behaviour. In so far as they bring such ‘values’ to the group, they prescribe/ pre-determine group activities and relationships before it even starts, and so always exclude clients. But staff of course then remain outsiders to the shared concerns of clients. Clients have informal codes of behaviour too, and confidences which they share only with each other - not just because they may feel misunderstood, or wish to protect, but because of the practical consequences of giving information to the mental health services which may be passed on, recorded and acted upon. Clients often form self-help groups of ‘like’ people - they gain the emotional bond of shared experience, but they also share the same strengths and weaknesses.
Fifthly, as in any social encounter what the participant remembers or ‘takes away’ from a group is rarely a precise memory of what was said. What is remembered is the atmosphere or mood, whether it was a good experience; relaxed and friendly; or anxious, hostile or perhaps aggressive - a general feeling of like or dislike for the other participants. Finally, practice has taught me that the more mobile, less routine and predictable a group’s activities can be the better; but all change, good or bad, is stressful.
However, even the very basic level of interpretation I’ve given to group activities is often frowned upon these days within the mental health industry - giving choice to the client and upholding ethical and sometimes political values, means not seeking to understand social processes. (The very antithesis of what this blog is about). Social networks are thought okay and their voluntary nature emphasised, but at times even encouragement to join is thought too prescriptive. If only mental health professionals were more aware of the content of genuinely peer organised activity, or indeed online activity! But the basic drive to belong is recognised, and loose open groups with no fixed location guard against dependency and institutionalisation. Changing your environment and finding new people to motivate you, are the only elements that will break old habits by replacing them with new more useful ones - the brain is just like that.
Throughout recorded history there can be found observations by the socially curious on what might be the natural or optimal size of a human group. At the lower end groups begin at around 5 - the basic family unit. More than that and two ‘conversations’ emerge, at around 8 to10 a group begins to have divided loyalties. At the upper end it has long been noted that where people live, work and play together then at between 100 and 130 they will split into two new groups. Doomsday Book gives you an average size for a village of 130, recent archaeology offers a similar figure for earlier Anglo-Saxon settlements. The necessity for battalions, the imposition of a chain of command to control numbers larger than the basic unit of a ‘company’, emerged in Roman times. Today, some isolated religious communities with long traditions will anticipate a split, and plan for the division of resources, as their numbers approach 100 - one of the new groups will relocate locally, but separately. Promising small businesses which expand rapidly are notorious for failing when the number of employees exceeds about 130 if they don’t radically devolve away from the ‘hands-on’ day-to-day personal control of one individual or family. (The late Wilbert Gore, he of Gore-Tex fame, allegedly built factories with only 150 parking spaces - when people started parking on the grass he knew it was time to add a new small plant elsewhere rather than expand on the same site). Whilst for ‘bandits’, or other family-controlled outlawed groups, then holding the group together may become their principal preoccupation!
The key recent insight has come from Robin Dunbar (Dunbar 1992, 1996) in his study of grooming behaviour in primate groups. Having observed the stable group sizes of other primates - the number that any one individual can effectively groom - he made the intuitive leap that the natural size of social groups is directly proportional to brain size (more specifically the neocortex, the cognitive processing bit!) What followed was a complicated statistical exercise, including making allowance for brain size relative to body size, which hypothesised an upper limit for a human group holding together of around 150 (mean group size 147.8). (Indeed amongst the 21 modern hunter-gatherer groups Dunbar considered, the average size was 148.4).
One shouldn’t underestimate the implications of ‘Dunbar‘s number’. We are social animals and whilst we can recognise thousands of faces, our brains have a limited memory and processing capacity - there are only so many people we can truly ‘know’; both in the sense of cognitively knowing enough to understand and therefore have a relationship with, but more fundamentally, the capacity to feel for, care about and be emotionally attached to. The ‘bands’ in which our distant ancestors lived were of course comprised of their closest genetic relatives. There was no distinction between those with whom they lived and worked (shared a culture with) and those with whom they had a strong genetic attachment or attraction to. In our world we are very unlikely ever to meet those closest 150 relatives for whom our brains are forever searching.
However, it remains the case that our loyalties are limited; to be cautious or even hostile to outsiders or strangers is normal, so is discrimination and exclusion. As you get to know too many people it is common to ‘become a stranger to’ someone you once knew well. Equally, we should be wary of those who claim to be entirely ‘open’ people and a friend to all the world. There are some things we cannot succeed at, we are severely weakened if we are not either fully participating in our own groups or are over ambitious (compromising our chances of survival) and try to embrace beyond the capacity of our own brains for emotional attachment. The benefits of training, education and the ‘collective brain’ offered by computer technology cannot override the social brain. We do better when we recognise fundamentally different or opposing interests and negotiate with other groups with different interests and loyalties, rather than pretend we can embrace the whole of humanity. We should suspect delusion in those who espouse selflessness and claim self-sacrificing devotion to too many. We may well have a primal drive to belong, but only to our own group.
(Note - I’m only implying ‘group selection’ in cultural and not biological evolution, none of the above contradicts neo-Darwinism which I take as a given in everything written on this blog).
Dunbar R (1992) ‘Neocortex size as a constraint on group size in primates’ in Journal of Human Evolution vol. 20 pp. 469-493
Dunbar R (1996) Grooming, Gossip and the Evolution of Language Faber & Faber: London
My first taste of group work was in 1988, a year after my first admission to a psychiatric hospital. The clinic was a converted country house several miles from the city centre. It was traditional group therapy, in a relatively controlled environment. A large living room, in which 10 easy chairs placed in a circle fitted easily, in a quiet and remote location. It was thought a virtue that we were away from a normal environment, but actually it was so untypical that I soon came to question its relevance to our real world problems.
I realised almost immediately I’d need time, both before and after the weekly one and a half hour sessions, to adjust to the difference with the outside world - sometimes up to half an hour to get my head together. It began as a closed group of 8 clients with 2 nurse therapists as facilitators (smaller groups were thought too intimate, larger increased the likelihood of two conversations developing). When someone failed to turn-up the empty chair was left as it was. The facilitators were there when we arrived and stayed seated until we left. They sat across from each other - an obvious way to ‘cover’ the room and cue each other! (It was easy to start thinking like that because they were so ‘non-directive’, many of the clients in contrast were actively looking for advice and direction). They rarely intervening, but most members wanted explanation, insight and leadership. The group didn’t remain closed for long however because people steadily dropped-out. For newcomers it was more difficult to join an established group. I remained for eighteen months.
The idea of a Group as presented to us was that in such controlled circumstances, the masks we presented to the world, or screens we hid behind, would be removed; problems we hid from ourselves and others would be revealed, the unconscious forces that led us to replicate mistakes exposed. We would be encouraged to express both positive and negative feelings as they occurred, and have those thoughts and feelings accepted by the group. We would be helped in learning how to express emotion.
I discovered later that the therapists had been trained in a psychodynamic approach, although there were no explicit references to transference relationships (let alone counter-transference), defence mechanisms or indeed a group dynamic. We were however gently reminded of how we might be bringing past and present relationships ‘into the room’ replaying them or acting them out. We all found it difficult to articulate problems in front of the group and cope with the reaction of others, but the desire to ‘do archaeology’ (dig-up the past) was strong, in preference to confronting what was happening between us in the ‘here and now’. But it always remained the assumption of the therapists that what we were doing was seeking insight, and that that in itself would provoke behavioural change.
Pre- and post-group meetings between members were not allowed, but they took place nonetheless. Indeed these encounters led in time to my being a guest at the family home of one of the older male clients on several occasions, and to my meeting outside the group with one of the younger female clients. Also, with a third member, I had one of those moments of disbelief upon meeting someone you have heard talked about incessantly, in this case the person’s partner, and immediately concluded they’re not a bit like you’ve been led to believe!
I found the therapy sessions often quite exciting but emotionally draining, a tension between what I was observing and feeling. People would try to sit in the same seat every week, and become quite disconcerted when I didn’t. The ninety minute sessions were not at all egalitarian, clients competed for time for themselves, some tried to ‘hog the limelight’; others more subtly, would seek to shift the conversation in the directions they wanted to go, some sought alliances, some to mediate, some seemed to just want to belong, others to be accepted as they were. Within a session there were short periods of half an hour or so when real work seemed to be done in a mutually supportive way. But the events within the group were much less dramatic than those recalled by the members from their lives outside it.
My sense of mental wellbeing certainly improved whilst I was in that first group and for almost a year after. Since then I’ve been part of dozens of groups intended to have some sort of therapeutic effect, and structured and managed to varying degrees. I’ve come to prefer the more informal groups one can contrive for oneself with ones peers. The first thing to emphasise is that it is the activity, or the making of relationships themselves, which is important rather than some imagined product or outcome.
An old, but illustrative example from inpatient wards is what might be called, The Art Room Versus The Smoking Room; it is common for the outsider to view The Art Room as an area of calm, purposeful activity with a definite outcome. They may express surprise when after an hour’s absorption in making a painting, a client simply walks away discarding their individual effort. They may seek to praise the client’s work, suggest it be kept, or put on the wall. The client shows no interest in this - it is the hour away from his or her intrusive thoughts that is important. In contrast The Smoking Room is viewed by the outsider as the antitheses of healthy activity; dark, poorly ventilated, clients indulging their habits for nicotine and caffeine, sitting around in unfocused, purposeless conversation. Yet flow, the loss of self-consciousness first experienced in childhood, often occurs in one-to-one conversation (occasionally with more). From the client’s point of view here is the opportunity to talk to each other about the very things that they are unable to express to staff, and which other clients are better able to understand. (It’s worth noting in passing that clients will often ‘protect’ staff psychologically, by not discussing issues and behaviour they have come to know will disturb them).
Secondly real facilitators do not teach. The term has been much abused. It does not refer to someone who arrives in a group with an agenda, with things they will teach or seek to demonstrate. (They would certainly not stand-up, use a flip-chart and lecture to a group!) A proper facilitator is a member of the group, and is unlikely to intervene until they have come to know the group. They seek first and foremost to be fully in the room, sensitive to the feelings of both the group and the individuals within it. Interventions occur when they seek to redirect conversation or activity towards areas which their experience suggests are useful. Thirdly, groups always have a ‘star’, but they are not leaders appointed or accepted by the group, but the person who appears to be get most from the group, changing or benefiting the most. Other members often respond positively to that person as an example or role model, but sometimes negatively as yet another example of how they are failing!
Fourthly, since the activity of the group is all - and the ‘here and now’ a group’s proper concern - it is important to what extent someone is in the room, living in the present moment, able to let go of thoughts and feelings about the past and future and fully participate. For example, one person sits alone in a corner of the room; are they agitated and their thoughts miles away, or are they calm, quite and possibly acutely observant? Alternatively, is the person calmly absorbed in an individual task, or agitated by their observance of what is happening in the room? The person who is not participating remains an outsider. Often clients are forced to remain outsiders despite being in groups. Staff are usually part of a fixed group outside of the activities they devise for clients. They have their own professional competencies and ‘codes’ of behaviour. In so far as they bring such ‘values’ to the group, they prescribe/ pre-determine group activities and relationships before it even starts, and so always exclude clients. But staff of course then remain outsiders to the shared concerns of clients. Clients have informal codes of behaviour too, and confidences which they share only with each other - not just because they may feel misunderstood, or wish to protect, but because of the practical consequences of giving information to the mental health services which may be passed on, recorded and acted upon. Clients often form self-help groups of ‘like’ people - they gain the emotional bond of shared experience, but they also share the same strengths and weaknesses.
Fifthly, as in any social encounter what the participant remembers or ‘takes away’ from a group is rarely a precise memory of what was said. What is remembered is the atmosphere or mood, whether it was a good experience; relaxed and friendly; or anxious, hostile or perhaps aggressive - a general feeling of like or dislike for the other participants. Finally, practice has taught me that the more mobile, less routine and predictable a group’s activities can be the better; but all change, good or bad, is stressful.
However, even the very basic level of interpretation I’ve given to group activities is often frowned upon these days within the mental health industry - giving choice to the client and upholding ethical and sometimes political values, means not seeking to understand social processes. (The very antithesis of what this blog is about). Social networks are thought okay and their voluntary nature emphasised, but at times even encouragement to join is thought too prescriptive. If only mental health professionals were more aware of the content of genuinely peer organised activity, or indeed online activity! But the basic drive to belong is recognised, and loose open groups with no fixed location guard against dependency and institutionalisation. Changing your environment and finding new people to motivate you, are the only elements that will break old habits by replacing them with new more useful ones - the brain is just like that.
Throughout recorded history there can be found observations by the socially curious on what might be the natural or optimal size of a human group. At the lower end groups begin at around 5 - the basic family unit. More than that and two ‘conversations’ emerge, at around 8 to10 a group begins to have divided loyalties. At the upper end it has long been noted that where people live, work and play together then at between 100 and 130 they will split into two new groups. Doomsday Book gives you an average size for a village of 130, recent archaeology offers a similar figure for earlier Anglo-Saxon settlements. The necessity for battalions, the imposition of a chain of command to control numbers larger than the basic unit of a ‘company’, emerged in Roman times. Today, some isolated religious communities with long traditions will anticipate a split, and plan for the division of resources, as their numbers approach 100 - one of the new groups will relocate locally, but separately. Promising small businesses which expand rapidly are notorious for failing when the number of employees exceeds about 130 if they don’t radically devolve away from the ‘hands-on’ day-to-day personal control of one individual or family. (The late Wilbert Gore, he of Gore-Tex fame, allegedly built factories with only 150 parking spaces - when people started parking on the grass he knew it was time to add a new small plant elsewhere rather than expand on the same site). Whilst for ‘bandits’, or other family-controlled outlawed groups, then holding the group together may become their principal preoccupation!
The key recent insight has come from Robin Dunbar (Dunbar 1992, 1996) in his study of grooming behaviour in primate groups. Having observed the stable group sizes of other primates - the number that any one individual can effectively groom - he made the intuitive leap that the natural size of social groups is directly proportional to brain size (more specifically the neocortex, the cognitive processing bit!) What followed was a complicated statistical exercise, including making allowance for brain size relative to body size, which hypothesised an upper limit for a human group holding together of around 150 (mean group size 147.8). (Indeed amongst the 21 modern hunter-gatherer groups Dunbar considered, the average size was 148.4).
One shouldn’t underestimate the implications of ‘Dunbar‘s number’. We are social animals and whilst we can recognise thousands of faces, our brains have a limited memory and processing capacity - there are only so many people we can truly ‘know’; both in the sense of cognitively knowing enough to understand and therefore have a relationship with, but more fundamentally, the capacity to feel for, care about and be emotionally attached to. The ‘bands’ in which our distant ancestors lived were of course comprised of their closest genetic relatives. There was no distinction between those with whom they lived and worked (shared a culture with) and those with whom they had a strong genetic attachment or attraction to. In our world we are very unlikely ever to meet those closest 150 relatives for whom our brains are forever searching.
However, it remains the case that our loyalties are limited; to be cautious or even hostile to outsiders or strangers is normal, so is discrimination and exclusion. As you get to know too many people it is common to ‘become a stranger to’ someone you once knew well. Equally, we should be wary of those who claim to be entirely ‘open’ people and a friend to all the world. There are some things we cannot succeed at, we are severely weakened if we are not either fully participating in our own groups or are over ambitious (compromising our chances of survival) and try to embrace beyond the capacity of our own brains for emotional attachment. The benefits of training, education and the ‘collective brain’ offered by computer technology cannot override the social brain. We do better when we recognise fundamentally different or opposing interests and negotiate with other groups with different interests and loyalties, rather than pretend we can embrace the whole of humanity. We should suspect delusion in those who espouse selflessness and claim self-sacrificing devotion to too many. We may well have a primal drive to belong, but only to our own group.
(Note - I’m only implying ‘group selection’ in cultural and not biological evolution, none of the above contradicts neo-Darwinism which I take as a given in everything written on this blog).
Dunbar R (1992) ‘Neocortex size as a constraint on group size in primates’ in Journal of Human Evolution vol. 20 pp. 469-493
Dunbar R (1996) Grooming, Gossip and the Evolution of Language Faber & Faber: London
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