Our social:

TAG: Mental Health

Saying Donald Trump is mentally ill is unethical, inaccurate and unhelpful

John McGowan asks if it’s OK for mental health professionals to give opinions on Donald Trump’s mental health?

 

Someone asked me what I thought about Donald Trump the other day. I was about to give a fairly obvious reply when the earnest tone and questioning look made me pause. As the penny dropped I realised I wasn’t being asked my opinion as a person, I was being asked what I thought as a psychologist. Did I think the US president was mentally unwell and thus not fit for the office he holds?

POTUS’ mental health has been attracting attention since the campaign. But it was after the US woke up to a Trump presidency on November 9th 2016 that things really got going. In a letter to President Obama in December (reported in the Huffington Post), three psychiatry professors asked for a ‘medical and neuropsychiatric’ evaluation of the then president-elect. This was followed by a welter of similar concerns including: a letter to the New York Times signed by 35 psychiatrists, psychologists and social workers; a petition on Change.org signed by more than 57,000 mental health professionals, and even a congressional proposal to have a White House psychiatrist.

The main diagnosis mentioned is ‘Narcissistic Personality Disorder’ from the DSM, the main manual of psychiatric classification in the US. You might be able to see why this has been a popular label. ‘Antagonism’, ‘grandiosity’, ‘attention seeking’, ‘impairments in empathy’ and a ‘sense of entitlement’ might be your conclusions too after a brief appraisal of the president’s Twitter feed. I appreciate how tempting it is to make such a diagnosis. It really may seem obvious. However, there are three areas where offering a clinical opinion, even of a controversial figure like Trump, gets sticky: ethics, accuracy, and the extent to which it is helpful. For anyone.

So is this armchair (or keyboard) diagnosis ethical? For psychiatrists in the US the official answer is ‘no’. Recently there has been much angsting about the so-called ‘Goldwater Rule’. This is the informal name for a section of the American Psychiatric Association’s ethical code, which precludes this kind of public pronouncement without direct knowledge of the case and without the consent of the person concerned. Appropriately enough this rule emerged from the 1964 Presidential campaign when US psychiatrists gave a similarly remote opinion on Republican presidential nominee Barry Goldwater. The authors of the letter to President Obama were clear that they were not actually diagnosing from a distance, but really this seems something of a fig leaf covering an ethically questionable stance as the hints they gave as to their opinion were heavy. The Goldwater Rule does not place any restriction on a psychiatrist expressing an opinion about particular politicians or policies. Neither does it stop them from discussing issues related to mental health more generally. However, there is big jump from that to speculating about formative experiences, subjective distress and other matters that you don’t have direct knowledge of.

And it’s not just explicit rules that come into play. While UK codes of conduct (e.g. from The Royal College of Psychiatrists, The British Psychological Society and the Health and Care Professions Council) don’t have a ‘Goldwater’ clause, they do contain references to respect, competence and the avoidance of harm to those who use health services. It’s hard to see how effectively weaponising your clinical opinion can be justified within these frameworks either, especially as the intention does actually seem to be to cause some kind of harm – to Trump’s career at the very least. It may be of course that these clinical opinions have been offered in a respectful and helpful spirit, in which case I stand corrected.

Some might of course answer to this ethical criticism by saying that the institutions and freedoms of the a country, the world even, are facing an existential threat. Screw the niceties! Some mental health professionals have asserted that it’s not only their right but their duty to call things as they see them at such a moment. When their country is threatened people have, after all, done a lot more than violate their professional codes. So, if the shoe fits…

Does it though? Are these clinical judgements accurate appraisals of the President’s functioning? Maybe, but a significant problem with mental health judgements is that they are somewhat subjective. One person’s depression may be another’s sadness, and professionals often don’t agree. Taking the DSM categories as an example, agreement between clinical practitioners after a clinical examination varies hugely according to the particular diagnosis being applied. While using highly structured assessment tools improves this somewhat, going the other way and relying on CNN, social media, and a good dose of partisan feeling, is not likely to produce the greatest reliability and accuracy. Dr Allen Frances, the editor of the fourth edition of the DSM, is one of the most prominent dissenters from public statements about Trump’s mental health. He suggested in his his own letter to the New York Times that efforts to diagnose the president were so poor as to amount to little more than ‘psychiatric name-calling’. Of course, as professionals we all may feel our own judgement is unlikely to be skewed by personal feeling, but this risk of bias is very good reason for observing the Goldwater clause. Just in case we’re wrong.

However, let’s say for a moment that we can get over any ethical scruples, put our prejudices to one side and make an accurate and reliable clinical diagnosis. Even from a distance. Let’s say, just for now, that we accept President Trump has a serious mental illness and we agree what that is. Where does that leave us? Well perhaps no more informed we were. Do the clinical opinions offered simply tell us any more than we already know? The President is antagonistic and attention seeking! I think many people may feel that they have worked that out.

An especially relevant issue with mental health diagnosis is that it may have very little to tell us about a person’s competence either. We’ve established that those doing the diagnosing may have no more data to draw on than the rest of us, but also the diagnosis doesn’t say anything about whether qualities such as antagonism or grandiosity make him bad at his job. Some of us may think they obviously do, but others might argue that some of his attributes are more common in authority figures than we might think. Perhaps they may even be necessary for some kinds of leadership? A diagnosis of Trump may be no more or less informative when it comes to competence than the mental health labels retrospectively applied to Churchill or Lincoln.

It’s also been pointed out by many people that, as well as being relatively uninformative, using diagnosis in this way is actually stigmatising for people who are struggling with mental health problems. Is this because they are being associated with Trump? Well that may be unpleasant for some, but a more important reason is that offering a mental health problem as a reason why a person cannot perform may leave someone who is struggling not to be defined by their diagnosis in an even tougher spot.

Of course what is being sought in all of this is a way of stopping someone because of serious concerns about his ability. Will someone step in and remove him please? In an ordinary job being judged as not up to it can be relatively straightforward. The person concerned might have a manager and an organisation may have policies around this kind of thing. The idea of such policies is usually, partly, to support employees to do better but also to protect the people they serve when they do not do their job adequately. What on earth do we do though if we think a head of a government isn’t up to it? Who judges someone with no superiors? Who guards the guards? It’s an age-old problem. ‘Performance issues in great ones must not unwatched go’ as Claudius might have said of Hamlet in a more PC version of medieval Denmark. Concerns over how to deal with kingly incompetence ran through the whole of Shakespeare’s history plays starting with the overthrow of Richard II. He was a poor king but was there a legitimate way to get rid of him? That question underlies the two parts of Henry IV and the dramas of the corrupted body politic that followed.

The Plantagenets largely solved capability worries via swords and bloodshed. These days we have elections. So, if a head of government has a boss it’s surely us. That is if we can agree sufficiently to replace one leader with another. The results of elections can be tough to swallow, though, when we can’t agree and our fellow citizens vote for the wrong person. If we can’t usefully pathologise our leaders we may have to turn our attention to our compatriots who messed it up. I mean Trump! Who on earth voted for him? They clearly need their heads examined!

The eighteen fifties: A time to talk?

Was mental health care in the past as barbaric as we might think? John McGowan finds out about some innovators of the Victorian era.

What do we think of mental health treatments in the 19th century? My own mind conjures up shocking images of asylums, like the one where people were caged up in the film Amadeus, or the ‘Madhouse’ of Bedlam in Hogarth’s A Rake’s Progress (pictured above). Both were actually set in the 18th Century but it’s all folded into a general impression of imprisonment with some torture thrown in. (Bedlam, incidentally, is a corruption of the name of The St. Mary of Bethlehem Hospital in London which still exists, though we now know it as The Bethlem.)

However, my view of the 19th Century in particular may be somewhat selective. It was a time that also saw the beginning of psychotherapy (most prominently in the work of Sigmund Freud), and of what we might recognise as modern psychiatry (often traced back to Emil Kraepelin). Whatever you think of these developments, it’s clear that, in the 19th century, mental health care was part of the innovative sprit of the age.

The Bethlem Hospital of the time was not immune from a desire to change practices either, as I recently found out via the play Talk by Mark Wilson. Set in the Bethlem’s wing for the ‘criminally insane’ in the 1850s, the play tells the story of two doctors with different visions of how to reform the treatments of the time. Beauty, art and even (a radical idea) talking, were part of their new direction. I spoke recently  to Mark about the play, mental health in the 1850s era, and how ideas from the Victoria era may influence us today.

 

DOTW: Your plays have ranged across a wide range of subject matter, from gangsters to Vivaldi. What drew you to the story you tell in Talk?

Mark Wilson: The idea for the play, originally presented to me as a Radio 4 commission, was not so much a story as a character: Richard Dadd, a Victorian artist who had murdered his father. My task was to find a story to put him in.

What struck me almost straight away was not so much the actions of the main character but the fact that, in what could be described as a brutal and unforgiving age, he had not been hanged for the crime. This suggested the presence of, at least to a degree, an enlightened understanding of the ‘criminally insane’ and, if that was the case, the high probability that a different, and less compassionate, understanding existed too. It also struck me that this same tension between compassion and something more punitive continues within society up to the present day.

The research very quickly bore this out. The treatments prescribed in cases of mental illness in the 1850s appear medieval in their barbarity. The fact that they seem to have been administered with a strong sense of belief in their positive contribution towards an inmate’s well-being only make them more so. At the same time, figures such as Charles Hood, the Chief Superintendent Physician at The Bethlem (where Dadd was initially an inmate), worked to initiate a more benign regime based upon the restorative effects of exposure to art and music. The story would be a conflict of ideas, with Richard Dadd as its unwitting focus.

Further themes that emerged were the opportunity provided by a mental illness for a husband to rid himself of his wife and, for adult children to hasten their inheritance by the removal of a ‘difficult’ parent. Thus I created the character of Emily Clayton, a poet, who would promote the idea of a link between our past experience and its impact upon our current behaviour. She also captures something about the sexism of the age, describing The Bethlem as being, ‘part of a system in which a man can be incarcerated for losing his mind, whilst a woman can suffer the same fate for daring to demonstrate that she has one.’

The Bethlem in 1860. From the Illustrated London News.

While I realise that the play is not necessarily supposed to be a historical document, you’ve indicated it involved a fair amount of research into the history of psychiatric hospitals. Can you say more about that?

The research revealed the 1850s as being a time that saw a considerable number of alternative experiments – some of them quite bizarre – in the treatment of mental illness. This was the case in this country and abroad; one thinks of the innovative work of Jean-Martin Charcot at the Salpêtrière in Paris. I was immediately struck by the enlightened thinking of Charles Hood and his belief in the restorative power of the arts and of treating people as cultured beings deserving of respect. Contrast that with the more traditional strapping inmates to bedframes or plunging them into baths of freezing water. What I found extraordinary was that the belief systems that promoted these very different types of approaches existed at the same time. It was a profound experience to research this conflict and tell the story of the the very different results each set of treatments produced.

The research also suggested a tendency on both sides towards doubt in their own methodology. I wanted to present all of the characters as essentially fragile and to deny the audience any sense of certainty as to the play’s outcome. I imagine Hood, for example, as a man not without his moments of despair. One can read his case notes on Richard Dadd written in his own hand in large leather-bound ledgers stored at Bethlem’s current location. The early notes are detailed and refer to small signs of improvement in Dadd’s condition. However, as the months and years go by, we read on page after page the simple statement: ‘No change.’ I could almost hear him sigh as he blotted the page and closed the book.

Richard Dadd. The painting in shot, ‘Oberon and Titania’ suggests this was taken in the 1850s.

The play is set in a ward for the ‘criminally’ insane. Were there other sorts of wards too, or were people who were mad simply assumed to be, if not always bad, then at least dangerous?

The criminally insane – those whose acts defined them as a potential risk to others – were kept apart from other inmates. However, their treatment under Hood’s regime was similar to that of the other patients. They enjoyed art on the walls of their parts of the hospital, the installation of aviaries – so convinced was Hood of the restorative power of birdsong – and participation in evenings of dancing and music.

Do you feel that Dadd’s difficulties, which would probably be classed as schizophrenia or psychosis in the present day, were related to his work (which often featured mystical and magical themes)?

Dadd’s artistic talents were evident well before the onset of his illness. He was made a member of the Royal Academy and was appointed artist in residence on Sir Thomas Phillips’ tour of the Middle East during which his use of hashish has been seen as one possible cause of his mental illness. I don’t detect an obvious shift in his working style as his illness became more pronounced. Perhaps his best-known piece, The Fairy Feller’s Masterstroke (on show at Tate Britain) is significant for its extraordinary detail. The build-up of layers of paint brings it to the point where it almost appears to be a piece in 3D. However, when set alongside his work painted at roughly the same time it appears quite unique as opposed to being part of a discernable trend. Perhaps the result of a particular episode? His series entitled ‘The Passions’ is highly representational. One of its pieces showing a man cowering in chains seems quite clearly to be a perfectly sane expression of his own situation.

You’ve said Charles Hood was something of an innovator at the time. What would we would think of his views and practices now, I wonder?

The fact that the Government-appointed Lunacy Commission was willing to support Hood’s approach to the point of funding the creation of a new hospital complex with him at its head (at Broadmoor in Berkshire) is evidence of a considerable shift in both attitude and expectation. I can only think that, as the period saw huge advances in science and in the treatment of physical illnesses, the time was right for those advocating new approaches in all sorts of areas. This was a wave that Charles Hood was able to ride.

Broadmoor in 1867. From the Illustrated London News.

As for how we would view his approach now, we would surely want ‘evidence of impact’. In itself, we know that playing music to people with mental health problems will probably not bring about a cure. However, in an age in which it has been suggested to patients suffering depression that they might benefit from watching the James Stewart film, ‘It’s a Wonderful Life’, Hood’s approach does perhaps have a place.

The other doctor in the play, George Haydon, is in many ways positioned as a forerunner of the kind of psychotherapies we might recognise in the present day. As well as being slightly ashamed I’d never heard of him, it left me wondering why he seems to have been forgotten?

I took some poetic license with George Haydon. He was in fact the Hospital Steward at Bethlem, not a doctor. Had I left him in that role he would have simply been made to stop his ‘talking with patients’ by Charles Hood, his obvious superior.

 In order to create the possibility of tension between them and thus broaden the play’s emotional scope, I had to adjust their relative hierarchical positions. That’s why I ‘promoted’ him. I also wanted to add the dynamic of an increasingly strained friendship and professional partnership of these two young Turks challenging the established order as they gradually go their separate ways. It would have been rather two dimensional to have had Hood and Haydon firmly of the same mind from beginning to end. Indeed it would have removed the need for Haydon as a presence within the play’s structure.

After his retirement from The Bethlem in 1889, the real George Haydon was often recalled with fondness both by staff and inmates, many of them making reference to his ‘talking with patients.’  He died in 1891. Nine years later, Sigmund Freud published ‘The Interpretation of Dreams’ and the importance of the therapeutic encounter between doctor and patient became established.

 

Talk is being performed at the Marlowe Studio in Canterbury from 27th to 29th July 2017. You can find further details here.

The Bethlem Museum of the Mind has a blog and a Twitter feed where you can read more about the history of the hospital and look at images from their photo collection.

Your policy is my life

In the latest in our occasional ‘Long Reads’ series, Mark Brown considers mental heath professionals and political commitment

[NOTE: The following piece originated as an address to clinical psychologists, but also is highly relevant to others working in mental health]

Right now there’s a lot of people losing hope. If clinical psychology is the industry of the promotion human wellbeing, there’s a lot of people in need of your goods and services. I’ve been asked to discuss what happens when clinical psychology gets beyond the therapy room. So first, a little scene setting. Imagine this as the pre-credits sequence where the camera zooms across the landscape giving us a sense of the scale and scope of the story we’re about to see unfold. In just what kind of a land is this therapy room situated? Who are its inhabitants? What’s the story? You can hum your own suitably stirring theme music. Or perhaps the Benny Hill theme if you’re not as impressed with the direction I’m taking.

 

Your policy is my life

People with long term mental health difficulties are some of the most vulnerable in society. And we hate it. We hate feeling that so much of our life depends on policy made in Whitehall or discussed in №10. We can’t pull off a magic trick and become not-unwell.

Even when we’re doing well it’s often because we’re getting the right help. That isn’t an argument for the removal of that help; it’s an argument for its continuation. While mental health as an issue has developed a growing profile in public debate; little of it has risen above ‘be nicer to people with mental health difficulties; moar hospitals!’.

Whether the focus on mental health sticks will depend on whether our new government cares enough about mental health to do the one thing that governments can do apart from trying to pass laws. It depends on whether they are prepared to spend money. It’s easy to look like savings are being made if you find ways of shifting costs off the balance sheet. It’s always possible to shift the costs of not investing in mental health and mental wellbeing off the balance sheet; to say that it’s the fault of individuals for not getting better, not making the best of what is on offer.

Mental health isn’t just something that is about treatment. For those of us that experience difficulties with our mental health, they’re something that tend to seep into all areas of our lives. In common with other disabilities, mental health difficulties tend to make many areas of life more difficult. The ways in which those areas are difficult depend on the world that we live in and the people around us.

Strong social protections; benefits that offset the greatest hardships that come from having difficulties with your mental health; strong rights to treatment, support and to quality of life: all of these things safeguard the wellbeing of people with mental health difficulties. While mental health difficulty might happen in our heads; the solutions and causes are not purely in the individual.

What I’ve seen, and experienced myself, is that everyday life with a mental health difficulty is often a struggle. One that isn’t obvious; isn’t headline grabbing; but one that makes a mess of lives if there isn’t support, help and protections. And those messes, and people’s lives, get worse. We know that having a mental health difficult means that you are more likely to end up poor. What it means to be poor changes depending on the prevailing political and social winds. Mental health difficulties can often make you feel vulnerable because when you are having difficulties you are more at the mercy of those prevailing winds. Having a mental health difficulty makes things more difficult.

Many people with mental health difficulties have lost the sense that it is possible to trust this, or any, government to put their rights on the agenda. The fact that with the right support, help and changes in circumstance some of us will be able to gain and stay in paid employment is used to suggest that others of us are malingers or just aren’t trying hard enough. People have seen the accessibility of treatment they need reduced; seen the benefits they have been receiving both in-work and out of work dwindle; seen the fabric of local voluntary and statutory services and organisations fray and in some places collapse. Mental health began austerity in a condition of under-investment.

When someone first falls ill or is having problems our automatic response is to think ‘there should be someone to help with this’ but increasingly, as cuts hollow out social protections — regardless of whether they are provided by the private, public or voluntary sector — people are finding that the help that every thought should be there just isn’t.

When we’ve lived with mental health difficulties for a while; our hope is that the crises will be further apart; that help and support will make sure that we don’t lose sight of what we want our lives to be about. When we’ve got the right treatment; the right support, enough money to live on and a balance between stretching ourselves and feeling safe — even then we’re often just managing to keep our heads above water. The margin between doing OK and not doing OK can be very slim. Even a tiny policy change can tip life from being manageable into life being impossible.

Even when everything is in place we can still become ill. Mental health difficulties tend to be treacherous like that. When that happens we need to feel that it’s possible to access help quickly before everything that we’ve managed to build up is washed away.

But remember: mental health treatment and support needs to a be a partnership. You can’t ‘do’ mental health to people. It’s not a ‘pull your socks up’ situation. This government needs to rebuild that lost trust if it is to get anywhere with people with mental health difficulties. As much as we may want to be self-reliant, we also have to rely on the society in which we live.

Many people feel this acutely. People are scared and worried that what little security they’ve managed to achieve in the face of mental health conditions that make a mess of the things you might want to do can be swept away by a single policy announcement, an edit to a cell in a spreadsheet, a policy focus on one aim rather than another.

If the scale of cuts suggested is to put into action; the human cost of those cuts aren’t collateral damage. The human costs of those cuts are the core business of any government: the duty to protect its citizens or subjects. And for many who feel closest to those cuts, the prevailing wind is bringing not a warm breeze of spring but a harsh chill of a never-ending winter.

 

The frontline

So, our scene is set, some, not all, of the people of the land are losing hope: but what is the role of our glorious saviour Clinical Psychology? Where does she fit? Discussions about mental health and wellbeing during times of austerity become discussions about preserving the frontline. We’re watching ideas of a mental wellness services slowly changing into a mental illness services and then often not even that. It’s all about the frontline. Save the frontline. Hold the frontline. But just where is the frontline for mental health and wellbeing? Can we really, given the fact that frontline is a military metaphor, really reduce the battle against mental illness and the battle for mental health to a series of of dug in trenches where we battle fixed enemies until they are all gone?

I think the frontline in mental health is a bit more complicated, the frontline of wellbeing even more so. The frontline is everywhere for mental health and wellbeing because mental health and wellbeing happens between people and the environments in which they they find themselves, backwards and forwards, all of the time.

There is nothing that doesn’t have a bearing on mental health and wellbeing. For clinical psychology; the entire world is outside of the therapy room. But what should you do? The therapy room is safe. People pay you money to do a job and you do it. But you want more. Your conscience tells you that there is more that can be done. But what?

 

We always vote for ourselves

If clinical psychology wants to step out of the therapy room and provide a further service to the people of this country and to the people of the world it needs to work out where best to help and how best to do so.

Clinical psychology is not just a field of work; it’s also a field of knowledge and experience and skills. All of you who can describe yourself as clinical psychologists have tied up in you a huge pile of different resources that can be put to uses other than the thing you get your pay cheque for at the end of the month.

There’s an interesting thing that happens in every single discussion of the future of mental health, from dystopian visions of psychologically tortured ghost people walking mechanically around an ultra-consumption based techno dictatorship to discussions of a post scarcity future where every person can unlock the inner potential, overcome their trauma and awake each morning as a fully actualised human being, leaping out of bed to carry out superhuman feats of compassion and productivity and artistry. Regardless of the tone, regardless of the context, the conclusion is the same: what we need is more people from our profession doing more of the job our profession does.

Through the work we have been trained for, and the work we feel confident in carrying out, we shall redeem the world from its fallen state. If we just had more clinical psychologists, then eventually we wouldn’t need clinical psychologists because everyone would be better. Eventually. While it’s entirely understandable to feel that the work we do is indispensable and to champion its role in the world, it’s not correct to see that as being the only way that we can use our skills to make change happen. In part this way of thinking comes from being unable to see what clinical psychology might contribute beyond staying in the therapy room where it’s comfortable.

But to what other ends should we put those resources to? How would you decide? I think there’s a number of things we need to think about. Clinical psychology, and the wellbeing of people both collectively and individually do not happen in a vacuum.

 

We need new helpers not new leaders

One of the challenges of thinking about how clinical psychology might better serve society is that it’s very hard to think of yourself as a helper not a leader.

More than ever we need people who can bring understanding into the mainstream of trauma, of difficulty, of sadness, of frustration, of despair, of prejudice and marginalisation and being thwarted at every turn in the attempt to have a better life. We need people who help people with power to understand not just the positive effects of their actions but also the negative. We need people to put the humanity back into the understanding of the effects of policy and practice.

We need a new generation of public professionals and a resurgence of older ones. We need people powered by psychological knowledge who can hold the world to account and say ‘hang on, stop acting like utter dicks’. In a country that seems to many to either be becoming more polarised or more unequal depending on who you talk to; we need people who can speak up for people’s wellbeing.

We need, more than ever, public professionals who can help us to understand and public professionals who can help support the legitimacy of the problems raised with society from those with least power and least influence. As professionals and as people we need more who:

  • Listen,
  • speak with respect and care,
  • know their subject,
  • don’t talk about the benefits of their work without discussing its limitations,
  • don’t think they know everything,
  • who are proud of their job but not blind to its failings
  • and who are advocates for the best of possible worlds by understanding where things are worst.

One of the first things that needs to happen is that clinical psychology needs to be of this world. It needs to be rooted in the actuality of people’s lives. People are glorious, confusing, challenging, infuriating, amazing things. It needs as much as possible to, as we say in design, get out of the office. It needs to hang out with people. If you know me as @markoneinfour off of twitter, you’ll know that social media are great places to do some of that hanging out.

Clinical psychology is all about people; but ask yourself: how close do you actually feel to the people your profession is attempting to help? When we don’t feel an authentic connection to the people we are trying to help we are subject to idealisations, to fantasies, about what they might want and how they might be and what they might find helpful. We are subject to our ideologies overtaking our experiences. One of the things I’ve noticed is that often someone will meet a particular group of people who experience mental health difficulty or a particular approach developed slightly outside of the mainstream of standard practice and that, for them, will become their ‘answer’. The wish to do right be these people who initially opened our eyes to suffering or desire grows in fervour. ‘I’ve spoken to service users and this is what they tell me they want,’ the newly converted radical will say. But people get stuck having found their radical path. They change from someone questioning to becoming someone dogmatic. They get stuck with one perspective that they feel replaces their old, authoritarian or inflexible model with a new one. This might be their first exposure to the pain or the enthusiasm of some people who seem closer to the problem than they do. They become fixated on the the truth and rightfulness of this alternative, the ‘user perspective’, forgetting that this is one view amongst many and that people’s views about what is best or what is desirable won’t be fixed over time.

In an area of activity that is all about people, we sometimes for entirely honourable reasons manage to leave people out of our thinking. In our discomfort with our paternalism, with our authority we seek to salve our conscience by promoting one ‘service user’ cause or another, getting stuck in a position of trying to advocate for what once was a radical idea but which has now been superseded by other ideas.

 

Just outside the therapy room door

So, what’s outside the therapy room, if you edge open the door and peer through a little gap? The organisations that people work in, of course. Which are also the organisations that people use. And people are losing trust in the idea that they might ever have lives that are better and are looking at lives that seem to be getting progressively worse; they have lost hope.

If we do ask questions about services in which some of us work we often ask them in terms of ‘how can we make sure this services helps people more?’

Regardless of what services an organisation is providing, it has the capacity to either give hope or take it away. When we’re talking about hope, I think it’s more instructive to ask ‘In what ways might this service make us worse by removing our hope that things can change?’

In many senses, people take a risk in hoping that services will be able to help them. In other words, they place their trust in services. Hope that you can be helped is an act of trust, and based on my attempt to define hope above, the extent to which you receive positive reinforcement of that trust defines how likely you are to remain hopeful.

Services often forget that while their job might only begin when someone arrives at their door, it actually represents the end of a journey of hope for the person who has just arrived in front of them. They have turned up precisely because they hope that a service will be able to help them.

From that point on, the service can either support and nourish the hope that someone feels, or it can take a series of witting or unwitting actions to stunt or completely snuff out that hope.

Services can dispel hope in thousands of ways. One rude member of reception staff can undo a week of therapy. A couple of unreturned telephone calls can leave someone feeling ignored. A badly worded letter can give entirely the wrong impression of what might happen.

All of these things are rarely picked up in satisfaction surveys, because satisfaction surveys only ask whether the service is serving its purpose, not how it serves its purpose.

These trust destroyers are the cumulative effect of services that forget that they’re actually working for people. This kind of thing happens because there is diffused responsibility for making sure that people have the best experience that they can of a service and what it offers. Such trust destroyers are especially prevalent in services that themselves feel lacking in hope, services that feel ignored, overworked, misunderstood, unrewarded. Services that don’t believe things can be better tend to communicate that belief to the people who trust in them to make things better. When individuals raise these issues, the despairing organisation rejects them as criticism rather than recognising them as offers to provide advice about ways in which they can stop destroying hope.

Low expectations and unreasonably high expectations can remove hope from people: Low expectations by actually arguing against someone’s hopes and forcing them to question them; unreasonably high expectations by ignore the realities of someone’s life and again forcing them to question their hopes.

When an organisation, usually by imperceptible increments, begins to slide into despair itself it actually reduces its ability to be effective by managing to destroy hope rather than creating it.

So, clinical psychology can’t just relax and say ‘we are but a cog in a machine’. It needs to be asking ‘what does this machine do? Who made it? Who is controlling this machine? Is this even the right machine at all?’

 

Gap between politics and practice

In mental health I’ve met many people who battle on a daily basis with the gap between their politics and the practice. That’s room for table thumpers. There’s also room for smooth influencers. And committed researchers. And people who do any of the tiny day-to-day things that add up to making profound changes happen.

Often in mental health our head tells us one thing but our gut tells us another. I’ve always been surprised by the amount of people who have told me that they’ve never been able to reconcile their political beliefs with what they do or have experienced in mental health. In mental health I often see a lot of assertions about how the world ‘should’ work which are met with equally emphatic responses about how the world ‘does’ work. Often this obscures how something could be made to work.

We can often find our discussion agreeably taking flight to the realm of principles and abstractions, taking refuge in debating room victories and bracing academic bunfights while out in the real world people try to live decent lives in a world of broken systems, ever increasing pressures and real unmet needs. It’s easy to win an argument in abstract and easy to fail someone in real life.

A potential way through this is using wellbeing as a way to understand the effects of decisions, events and policies on people. But, I’m sorry folks, but we’ve been losing the wellbeing war, especially in mental health. The chief medical officer Sally Davies declared last year in her annual report that she refuses to take a leap of faith and to trust in the idea that attempt in public health to raise the wellbeing of all will reduce the amount of new cases of mental condition. Public mental health, where and if it remains after local authority public health cuts has become about targeted interventions ‘we know work’. Fair enough you might think, until you realise that these targeted interventions are interventions you’ll get if you like them or not based on whether you’re on a list of people ‘at risk’. And as someone at risk; you probably won’t be getting a choice.

We’re losing the potential for wellbeing to be used as a prism for understanding the complex effect of people of living in what used to be called late capitalism in an austerity committed society. We’ve losing the chance of being able to evaluate the potential impact of public policies on the day-to-day wellbeing of individuals. We’ve decided, it seems, that it’s OK to make someone’s life a misery on purpose if we have ‘the angels on our side’.

Psychology gone bad and how to put it right

We live in a country that is increasingly keen to use psychological techniques but not keen to measure the psychological implications of those techniques. Travelling through the worlds of disruptive innovation and public policy as I’ve been doing for the last twenty years, first as a recipient of support then as someone who has been striving to make things happen, it’s been impossible to move for dubious applications of psychological principles and ideas. It often seems that once you belong to category of person who is considered to be a social problem, you are fair game for the deployment of a range of dubious and potentially damaging psychological tricks and schemes.

We’ve seen the weaponisation of shame as a means of reducing A+E visits. We’ve seen the process of helping find work increasingly absorb the worst of elements of the coaching world. We’ve seen nudges and gamification and activation all seen as technologies for the promotion of particular behaviours. We seen the rise of interventions, projects, programmes and products that are only measuring their positive effects; the extent to which they are proving successful or unsuccessful in achieving their stated aims but are failing to record or consider the collateral damage to individuals and to communities that results from such activities. The old medical joke about the procedure being a complete success apart from the patient not surviving rings true too often.

Psychology still has a lot of power if it picks its battles well. It’s been fascinating to see the how much coverage and credence has been given to Lynne Friedli and Robert Stearn’s “Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes” Coupled with the British Psychological Society’s call for the reform of the Work Capability Assessment this article has gone some way to legitimising the concerns and experiences of many who are involved in attempting to claim social security benefits and who are not having the best of times interacting with a harsh back to work regime.

We have a problem in mental health, as we do in society, with the question of who is considered to be legitimate in raising problems. We tend to devalue those who experience suffering when they raise points that challenge both our own position and the ideological position we hold them to occupy. In mental health, some flavours of user opinion are afforded more respect than others. We need clinical psychology wherever to help bring into public discourse the full range of human emotional responses to the profound changes our country is going through, not just the ones that fit a particular ideological position. We need allies; not saviours. We may not be comfortable with it, but the words of clinical psychologists still have power.

We need clinical psychology to help make wellbeing happen, by first always, always, always making sure that it spends enough time with people to be clear of where the problems really are. When clinical psychology can’t act directly it must help to bring into sight the suffering and the difficulties of those who are in need without shaping those needs through abstracting ideological prisms. People need help now, not in the next world.

Once you get out of the therapy room you run into the world in all of its confusing, upsetting, uplifting and beguiling glory.

And that’s where we need you. We need you to be engaged. We need your resources. We need ideas and help with ideas. We need clinical Psychology to get out of the office and beyond the therapy room because we need someone to help make the case for those who are losing out. To do that we need a clinical psychology that has political understandings but which also is close enough to people to be able to offer pragmatic support, too.

And we need a clinical psychology where it should be; hanging out with people.

The above was delivered in a slightly different form by Mark Brown to the ‘Clinical Psychology: Beyond the Therapy Room’ conference in London on Friday 12th June 2015.

A video of this speech can be found here.

Mark Brown is development director of Social Spider CIC. You can follow him on Twitter @markoneinfour. This piece also appeared on medium.com and we are grateful to Mark and to Medium for allowing us to reproduce it here

 

Podcast: Against Your Will – Compulsory Powers in the Mental Health System

John McGowan, Anne Cooke, Angela Gilchrist,  Rachel Terry and Emma Rye discuss involuntary treatment in mental health.

In this edition we discuss the compulsory powers available in the mental health system in the UK These include the Mental Capacity Act and the Mental Health Act (MHA). The regular panel is joined by Emma Rye, a Clinical Psychologist working in in the field of learning disabilities. Emma is currently in training to take up the role of a ‘Responsible Clinician’ under the MHA. We also have interviews with Dr Matthew Debenham, an NHS psychiatrist, and with service users Rai Waddingham and Raza Griffiths, both of whom discuss how compulsory powers were used in their own treatment.

As the Prime Minister has recently said she would like to ‘rip up’ the Mental Act (see below) our panel also offer Theresa May advice on what to replace it with.

The best way follow the podcast is to subscribe to our feed. You can do this by looking up Discussions in Tunbridge Wells in iTunes, SoundCloud or wherever else you get your podcasts from. Or you can paste the following link into your podcatcher of choice http://feeds.soundcloud.com/users/soundcloud:users:56544633/sounds.rss

 

As well as that you can follow us on Twitter @CCCUApppsy and on Facebook if you search for Canterbury Christ Church University Applied Psychology. You can follow Angela on Twitter @cyberwhispers,  Anne @AnneCooke14 and Rachel @rterrypsy.

 

Links to things we talked about on this show:

A brief overview of the 2007 overhaul of the 1983 Mental Health Act. This 2007 update is still the dominant legislative framework today…
webarchive.nationalarchives.gov.uk/2013010…_078743

… and the Mental Health Act Code of Practice, intended to provide a guide for professionals, service users and carers on the operation of this legislation.
www.gov.uk/government/publicat…tal-health-act-1983

A useful summary of the principles of the Mental Capacity Act, which allows people to make ‘unwise’ decisions: provided they have the capacity to do so.
www.scie.org.uk/mca/introduction/…-2005-at-a-glance

Some information on Theresa May’s Mental Health Act announcement. A pledge to ‘rip it up’…
www.thetimes.co.uk/article/every-s…s-may-flm9tthf9
…and some suggestions for what might replace it.
www.theguardian.com/commentisfree/2…health-act-care

You can follow Rai Waddingham on Twitter @RaiWaddingham and find a range of resources on her website.
www.behindthelabel.co.uk/

A recent paper from the British Journal of Psychiatry suggesting that being admitted to a mental health ward may have negative consequences for suicidal risks.
bjpo.rcpsych.org/content/3/3/102

This Guardian article offers a personal account by a nurse involved in compulsory treatment.
www.theguardian.com/healthcare-netw…nts-what-choice

This short piece by legal commentator Joshua Rozenberg highlights some of the main issue in replacing European human rights legislation.
www.theguardian.com/commentisfree/2…stice-secretary

This small research study suggests quite mixed experience of involuntary detention and also addresses some of the issues in how to improve people’s experiences.
www.researchgate.net/publication/23…53059_Patients‘_perceptions_of_the_impact_of_involuntary_inpatient_care_on_self_relationships_and_recovery

Please note The views and opinions expressed in this discussion are those of the contributors and do not necessarily reflect the official policy or position of any of the contributors’ employing organisations.

We’d be interested in hearing about your experiences with these laws and with compulsory treatment. Comments below are gratefully received. 

Producer: John McGowan
Additional technical support: Saul McGowan
Music: www.bensound.com/

 

Podcast: Theresa May’s speech, mental health, and suicide prevention

John McGowan, Anne Cooke, Angela Gilchrist and Rachel Terry discuss  suicide prevention and mental health policy.

In this edition we focus on the Prime Minister’s speech making mental health policy and improved suicide prevention priorities for the UK Government.  We discuss a recent House of Commons Health Select Committee report on suicide prevention policy and the Department of Health’s updating of their Suicide Prevention Strategy (referenced in Theresa May’s speech). John also interviews Ian Marsh from our own University. Ian has written extensively about the way we treat suicide and the policy implications that result.

A transcript of this discussion is available here.

The best way follow the podcast is to subscribe to our feed. You can do this by looking up Discussions in Tunbridge Wells in iTunes, SoundCloud or wherever else you get your podcasts from. Or you can paste the following link into your podcatcher of choice http://feeds.soundcloud.com/users/soundcloud:users:56544633/sounds.rss

As well as that you can follow us on Twitter @CCCUApppsy and on Facebook if you search for Canterbury Christ Church University Applied Psychology. You can follow Angela on Twitter @cyberwhispers,  Anne @AnneCooke14 and Rachel @rterrypsy. Ian Marsh is also on Twitter @ianwmarsh

 

Links to things we talked about on this show:

The text of the Prime Minister’s speech to the Charity Commission on the 9th of January 2017.

https://www.gov.uk/government/speeches/the-shared-society-prime-ministers-speech-at-the-charity-commission-annual-meeting

 

The updating of the Department of Health’s Suicide Prevention Strategy.

https://www.gov.uk/government/publications/suicide-prevention-third-annual-report

 

The original DOH Suicide Prevention Strategy from 2012.

https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england

 

Also the recent Health Select Committee report.

 https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/inquiries/parliament-2015/suicide-prevention-inquiry/

 

Anne and Ian’s blog post looking at the Health Select Committee report.

https://blogs.canterbury.ac.uk/discursive/the-politics-of-suicide/#

 

Detail of Ian’s book can be found here.

https://www.amazon.co.uk/Suicide-Foucault-History-Ian-Marsh/dp/0521130018

 

Two research projects by recent graduates from our training scheme. Both look at health staff working with the risk of suicide:

Nalletamby, Lucie (2015) The discursive construction of ‘suicide’ and the effects for clinical practice. D.Clin.Psych. thesis, Canterbury Christ Church University.

http://create.canterbury.ac.uk/13820/

 

Crowley, Sarah (2015) Recognising and responding to suicide risk in a community mental health setting. D.Clin.Psych. thesis, Canterbury Christ Church University.

http://create.canterbury.ac.uk/13930/

 

A recent paper from the British Journal of Psychiatry Bulletin considering the degree to which suicides can be predicted.

 http://pb.rcpsych.org/content/pbrcpsych/early/2016/12/16/pb.bp.116.054940.full.pdf

 

If you are feeling suicidal you can contact The Samaritans here.

 

We’d welcome your suggestions of further reading in the comments below.

 

Producer: John McGowan

Music: http://www.bensound.com/