[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.
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:
- 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.
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