Professional Abuse

You couldn’t say: It’s not my fault. You couldn’t say: It’s not my responsibility. You could say: I will deal with this. You didn’t have to want to. But you had to do it. A Hat Full of Sky by Terry Pratchett I take part in conversations about mental health because of my experiences as […]

You couldn’t say: It’s not my fault. You couldn’t say: It’s not my responsibility. You could say: I will deal with this. You didn’t have to want to. But you had to do it.

A Hat Full of Sky by Terry Pratchett

I take part in conversations about mental health because of my experiences as a child when one of my parents became unwell. At the time I commented a lot on parallels between totalitarian regimes, human rights abuses and mental health services. I am still thinking about these everyday ways of enabling and allowing abusive behaviour. I just want to own that perspective and its limits. An Enormity of Unbelief is the post where I think a bit about that event. I blog to make sense of my feelings and thoughts from that time. This means that I am informed and interested but much less well-informed or interesting than the many people who blog who are using the system currently, either as people who experience distress/ altered states, professionals or both. On a lighter note I am also exploring the idea that anything I want to talk about can be summarised in a Terry Pratchett quote.

Twitter is an interesting place. Partly because people talk about things that they might not talk about face-to-face. I do get quite upset when talking about mental health as so many people seem to have had so many bad experiences. I’ve started to get my head around the reasons why the things I hear upset me for instance in Why I don’t like easy stories… , Small, sad stories (1) and Small, sad stories (2). One of the reasons these experiences do not seem to get resolved is that the people who are reporting feeling harmed by interactions with professionals are not believed and are not respected. This seems to me to be a subtle form of violence; precisely because people are in pain and struggling, their reports of feeling harmed are undermined. In general, officials seem to react to feedback and complaints by attacking the validity and meaningfulness of the client/patients as a knower of their own experience. In my view this is professional abuse. It is also a lost opportunity for professional to learn how to be with and alongside people in extreme states and to develop better understanding.

These discussions seem to me to be highlighting a concept which is notable by its absence in discussions between professionals or in general conversation about care, whether in the domain of physical or mental health. The absence of professional abuse as a concept that is actively named and confidently discussed, in contexts where one person is extremely vulnerable and the other has relative power, seems strange to me. My take on it is that it makes no sense for this to be a concept that isn’t acknowledged when the explicit aim of the professional is to promote the best interests of a vulnerable person. If we do not and cannot talk about how and when this goes wrong, we are making an environment where it is more likely that the harm will happen. It seems to me being able to talk about it would help the relationship or support safer and feel safe. Like many things in mental health I think the absence of the concept itself and also the absence of upfront conversations about the concept tells us something very eloquently. Silence speaks. As people and as a society we need to start to hear silence, as around any form of abuse there is avoidance and denial. These are active, but not necessarily conscious, processes which lead to silencing. Around any form of abuse there are collective distortions in the sense-making of those involved in the situation. These distortions can be very subtle but the underlying message is often similar. People involved professional abuse are likely, in some way, to put up a shield. The shield looks like this:

  1. Act as though it didn’t happen or you don’t care
  2. Say that the client/ patient is lying (even when there is a lot of evidence for their point of view)
  3. Blame the victim (‘It was the client/patient’s fault’, ‘They made me do it.’ ‘They may not like it but it is in their best interest.’)
  4. Minimise the harm their actions had (‘It wasn’t that bad.’, ‘It’s over now.’, ‘Why are you making so much fuss?’)
  5. Become angry (‘You are always blaming people.’, ‘You aren’t being fair.’ etc.)

Interestingly, these tactics fit pretty exactly with how people react when they are denying feeling a core sense of shame. They are the same behaviours for those who harm across different types of abuse in different contexts too. I will have to think a bit more about how shame and the ability to hurt others might link together specifically for professionals who harm. This is because I had always thought that professions who act in harmful ways do it because it satisfies some need in them, but now I am considering what else might be going on. This is a website link which goes into more detail about shame. http://oohctoolbox.org.au/trauma-and-shame

Professional Abuse is about harming someone in ways that are only abusive because the person doing the harm is a professional in a professional relationship with the person they are harming. A consensual sexual relationship between two adults is OK, unless it is between two people who have a professional relationship, for instance. It is also a type of harm that can only happen because one person is offering professional skills to help another person. For instance, only a doctor or nurse could sew up a serious cut. This becomes professional abuse when the same standards of care and support are not offered because the healthcare provider is providing this service to someone who has self-harmed, for instance.*

Professional Abuse can be more subtle and hard to spot when it is about interpersonal boundary violations. Some people have blogged about the persistent derailment that people who have been in contact with services get when they raise concerns. This blog is very useful http://sectioneduk.wordpress.com/2013/08/16/00but-were-not-all-like-that/ **. I am also starting to comment on specific forms of this phenomenon, for example in the post It’s not why we trained. These derailments are also professional boundary violations, when they happen in the context of a professional relationship. In my view, when these derailments happen on Twitter or general conversation, they just indicate an acceptance of bad practice. Depending on exactly how the derailment happens, they also add to the dynamic of collective silencing of professional abuse. I increasingly take the view that because ethical values and principles underpin professional practice, derailment by professionals is also an issue of professional abuse. However, boundary violations in a professional relationship can be more subtle than these derailments and include behaviours such as excessive personal disclosures by the professional, role reversals in therapy, the therapist/ provider failing to take a report of an adverse experience by a client to supervision, breaches of confidentiality and treating people without respect. Boundary violations in and of themselves are always a betrayal of trust in a professional relationship.

One way professional abuse continues is that it is not challenged by staff when it happens. The behaviour is not named for what it is and the links between specific actions, ethical principles, values and rules are not made clear. In some ways staff seem to have no official, accepted protocol or script for helping each other to maintain professional boundaries. My observation is that what seems to happen instead is that all staff join in with collective distortions in their thinking. They seem to also identify with the staff member not the client/ patient/ service user. Indeed, this happens even though in all professional settings, the professional might be in the client/ patient role at a different time. It seems that this is linked to the ‘Them’ and ‘Us’ culture which seems so strong in mental health discussions. In some ways it seems like it could be a defence against staff knowing that they could be on the receiving end of their own behaviour if they ever became vulnerable. A clear indication of this is the use of the pronoun WE in contexts where there is a disagreement or a complaint is being made. The organisation seems to act as one to protect the professionally abusive actions of staff. I was surprised during a conversation on Twitter recently when a Tweep reported* that when she was sutured after self-harming the nurse made a complaint about the doctor who did this without providing anaesthetic. I might have had serious questions about to what extent the nurse failed in her professional duty and was indeed professionally abusive in not stopping the doctor from suturing without anaesthetic at the time. Nevertheless, the behaviour is still unusual in that it happened at all. It should be celebrated and breaks down the ‘Them’ and ‘Us’ culture which seems to permeate mental health services. The nurse’s behaviour made a lot more sense to me when the Tweep made it clear later in the conversation that the nurse was an agency one – not likely to be around for long. This made me think about the bystanders professionally abusive behaviour. In most codes of ethics allowing others to continue to abuse is not allowed. It seems that staff are most likely to recognise, name and act to stop professional abuse when:

  • they are not themselves reliant on the organisation e.g. for pay or promotion
  • they are not themselves part of the organisation e.g. agency staff
  • they are new to the organisational culture and so have not come to see the organisation in the same way as other staff
  • they do not identify with the organisation
  • the member of staff complained about is already isolated within the organisation
  • the member of staff complained about is already being bullied within the organisation

I guess that it might not be a great idea for people who are in contact with ‘services’ to talk about professional abuse or put it on the radar for conversations, as lots of judgements which might not be helpful are likely to be made about them. If you are a service user reading this and it chimes with you, be wise, be safe, take care of yourself. However, I do think it is professionals’ job to talk about this concept and topic. I do think it is the job of bystanders to these conversations to make the radical move of naming professional abuse and linking professional behaviours to ethical values, principles and rules. Society needs to learn how to encourage everyone to query behaviour when it does not seem to reflect these core elements of human decency and morality. This is an act that has its dangers. I predict that when anyone makes the links between ethics, behaviour and professional abuse explicit, the shield will come up. That ‘shield’ is not neutral, as like any form of defense it works best if it is an attack. It is weaponised. The only way abusers can continue their behaviour is to destroy the person who is trying to stop them – destroy them as valid knowers, destroy their strength to carry on or destroy their social support. It makes sense then, doesn’t it, that the staff who act to stop professional abuse do so as whistleblowers, after it happened, when they have left the situation and not at the time. Like the nurse in the Tweeps story.

*I have asked the Tweep concerned if I can use her Twitter story and she agreed it was OK.

** I have permission from @sectioned_ to post the link to her blog here

The systemic is sort of individual

You can either be on the stage, just a performer, just going through the lines… or you can be outside it, and know how the script works, where the scenery hangs, and where the trap doors are.

Maskerade by Terry Pratchett

I was engaged in a Twitter conversation that really distressed me. I had Tweeted something that wasn’t that controversial to me along the lines of ‘Most mental health professionals are pretty incompetent and out of their depth‘. I just believe it is true, it’s my view, born out of my experience.  I was also responding to someone’s comment about an insensitive remark by a mental health professional and felt momentarily despondent. Actually, as it was someone else sharing their story I think a professional who commented said something much more helpful than I managed to. I will learn and I am learning. But really context people! So when another Tweep added in their view that ‘People generally attempt to do a good enough job‘ and they are not ‘bad people’. I had quite a strong reaction.

It boils down to that suggestion, which she expanded on in her blog post, just being beside the point. It is beside the point that she has a dual role as a professional and as a service user/ client/ patient, that she has (in her current service) had a good enough experience of care, that she feels (right now) that she has a voice in her care, just as it’s beside the point that I too agree that many professionals are well-intentioned and doing their best. It’s beside the point because the system still does a lot of harm and that harm happens precisely because it is the system that is doing the damage as much as individuals.

So it is hard to convey systems understandings in a tweet, or even in a blog post. We seem to believe in systems as machines, arranged with the management organising things and a body of workers that carries out the actions of the system. This means our cultures believes lots of things like:

  • if we tell people how to change, they will use those instructions to change
  • if we criticise and frighten people in organisations they will be motivated to change
  • that problems happen because the organisation is not designed correctly

In a way this gets individual mental health workers off the hook. If the problem is that the organisation is not designed correctly, then the organisation is experienced by them as either neutral or something that stops them doing their job the way they would like. If everyone else agrees with them, then they are an actor on the stage. The play is set, they just carry out the scripts. They don’t need to think about the stage or the production. There is an alternative view. That people make organisations because organisational systems are created by people’s relationships with one another. They are living human systems. The beliefs associated with this are different:

  • appreciation of what people are trying to do helps them to grow towards that appreciation (this is not the service users’ responsibility, or the outside observers’ responsibility by the way)
  • as we interact with the organisation/ professional culture we are likely to produce a change in the organisation
  • how we talk about our organisations changes things, though unfortunately, we tend to see the world as we talk about it
  • imagination can be used to create desirable objectives and this makes changes in behaviour as it becomes organised to achieving that outcomes
  • language is creative and can create change
  • the stories we tell about our organisations matter

The system is it not quite individual. It happens in the networks of spaces between people.

The people who really run organizations are usually found several levels down, where it is still possible to get things done.

Small Gods by Terry Pratchett

So if I get frustrated with ‘It’s not why we trained’ or ‘See it from my point of view’ (see blog post It’s not why we trained)  it is because these conversations aren’t  just a one-off, they are repeated and they create organisational cultures. I am not part of your culture, or your mental health service, as a user or as a professional. In terms of ways I can influence, I’m fairly far down the food chain. All I can do is pick up the patterns on Twitter and say- Why don’t Mental Health Professionals centre the concerns of users? Why do you centre positive experiences when at times people need to think about how to make sense of and respond to negative ones? Why don’t you even acknowledge that negative interactions happen?

If you are telling stories about; how in Mental Health Services professionals are powerless to do better, or that professionals are powerless to do what they trained for, or powerlessness to act ethically, or powerless to stop their human rights abuses, or stories which say that however many stories there are of hurtful practice, well, there are other places where bad things don’t happen, then those stories have power. Oh and yes- it is not all Mental Health Professionals. I’ll get onto that later. I am starting to find ways to (gently- I hope) cast a light on all those organisational stories. I would add that many professionals who I pretty much feel do an honest and committed job contribute to these stories in ways that I think are problematic.

And I maintain that if the issue is one of Professional Abuse, Mental Health Professionals have no opt outs, it is an ethical obligation (if not yet always legal one) that you act to stop the abuse. There are no excuses on that one.

So if you are a professional, in order to start to change the conversation, why not stop with the ‘It’s not all mental health professionals’. Instead take a breath.  If you want to talk about how good your practice is – great. If you have a dual role and want to talk about having had good experiences great. Start a thread, write a tweet, post a blog. It’s useful to know that some people have good experiences or are committed to good practice. However, take your defensiveness, whether you have dual role or a single role and park it. Think about how in that conversation you can change what is being done to replicate the culture of Mental Health Services. You know what? Practice choosing not to engage with those powerful stories. Learn to change them. I cannot do that for you, you have to do it yourselves.

If you are a Mental Health Professional here are some tips:

  1. Offer empathy and understanding. Dare to recognise the poor practice in clear, unequivocal words. ‘I believe you’, however it is expressed, matters. Acknowledging what happened and the impact it had it important. Try expressing empathy for people’s feelings of being harmed or hurt. Try actually feeling the pain not pushing it away because it is uncomfortable for you. I do notice when professionals do this. Examples from professionals on Twitter:                                                                           Oh my. That was so scary. That was a very insensitive and unhelpful remark.                                                         That is not care, that is abuse.                                                                                                     You should not have had to experience that.                                                                             It is sad that I have to acknowledge that I have colleagues that I would not want to be cared for by if I became distressed.
  2. If you have a dual role, before you tweet, try thinking about which role you are speaking from. Identify that and which role other people might think you are speaking from. Think about where the person you interact with is coming from. I am clear that I am speaking as someone harmed. My twitter handle is pretty unequivocal.
  3. Create your own space to blog about your own good practice, or start your own threads about good practice. It’s good to hear about it. A good example is @drmikepsych.
  4. Ask some more interesting questions instead. Recasting the conversations as ‘What can I do to improve what I do in every interaction‘. Try asking people who are talking about their experiences what is giving life to the system from their point of view, not your old ‘See it from my point of view‘ stance. Be careful with this as it is not people’s job to educate you when they are on Twitter. Develop your questioning skills so you don’t ask questions instinctively, but thoughtfully and yes! this can work even on Twitter. Who knows, you might actually learn something. For me, I know sometimes people have good experiences. Too many people don’t. If people are talking about a ‘not so good’ experience,  I’m not that interested in hearing about good times elsewhere just then – I’m interested in thinking about what might change things so the bad parts of the system are less bad. Try questions that are reflexive (yes, there are questions other than open or closed ones);

-If a professional were to impress you with how they handled a concern, what would they be doing?

-If you could offer a piece of advice to me about how to respond better, what might it be?

-What might professionals need to do to convince you that they welcome feedback?

-If I was able to convey to you how important it was to me that we got it right, what might that be like?

and (if someone happens to be talking about a time they  felt a professional handled a concern really well)

-What sticks most vividly in your mind about that time? What might move me/ my team towards working in that way more?

If you think my interactions aren’t that good, this is my response it, I AM NOT A MENTAL HEALTH PROFESSIONAL. I am not claiming to be one. My other point is that I am practicing talking about extremely difficult subjects, ones where anyone with any human understanding would get that it will be hard for me. I will improve. Watch this space.

And by the way, if I have to write a blog post like this, well I feel quite justified in my comment ‘Most mental health professionals are incompetent and out of their depth‘. I have set the bar high. The professional needs not only to understand things at the individual level, the service level and the organisational level, but also the systems and systemic level. They also need to have the courage to do something about it. I absolutely believe that if they are not doing that they have not earnt the trust they demand from the people who need them. Some professionals on twitter show the skills they need. Most don’t. Just saying.

 

References

Appreciative Enquiry for Change Management: Using AI to facilitate organizational development by Sarah Lewis, Johnathan Passmore & Stefan Cantore

 

 

She didn’t do what was nice…

“You taught me to be nice, so nice that now I am so full of niceness, I have no sense of right and wrong, no outrage, no passion.” Garrison Keillor

I remember when my parent was in hospital I was always being asked to be nice. Be nice to the nurses. Be nice to the doctors. Be nice. My mother knew exactly how I felt about the staff. She wouldn’t talk about how they were treating my father and so why I had a problem with the workers behaviour was ignored. She would admit that she thought they weren’t that nice, but wanted me to be nice to them anyway. She had the ultimate punishment if I tried to explain why I was upset at the way people were treated by staff in the ‘horrible place’. She could say I was not being nice enough and she could refuse to take me with her when she visited. “If you can’t be nice, it’s because you can’t cope. Everyone will understand that it’s too much for you, I won’t take you.” Learning to be nice, I guess, is about experiencing what it is like when people with power find very reasonable ways, that sound nice, to not be nice at all.

What I learnt was that people can hide a lot behind nice words. Nice words are like smoke, confusing and blurring what is really there.

Esme Weatherwax didn’t do what was nice. She did what was needed.

The Shepherd’s Crown by Terry Pratchett

I read a lot at that age, not having too much in common with my friends and it was a good escape. I knew that ‘nice’ really meant ‘accurate’ as does ‘subtle’. I decided that I was being very nice as I was being accurate in what I observed and subtle in how I behaved.

“He fell,” the Nurses said, when I pointed out bruising on his upper arm.

“They fall a lot, the patients here,” I said.

“Well, a lot of them are very old,”.

I did think that about 50 years old or more was VERY OLD. “He didn’t get bruises like that if he fell at home.” I felt stubborn, looking directly at something that was happening that I could not quite see, but somehow being pushed away and back by niceness. Persistance felt like some sort of victory.

When people fall the bruising is all down one side where they landed, not on one or both sides at the top, with finger marks. I noticed. I drew a picture of the outline of the body and marked the bruises on it. Over time, there were lots of little diagrams like that in my notebook.

I sat in the Day Room and noticed the absence of the nurses (Why was I in the day room on my own? Who knows… Mum might have been with Dad?). I sat in the Day Room and noticed Patients sitting staring into space. A lot of people had strange movements in their limbs and were drooling, when they walked they shuffled, but then again, nobody moved or spoke much. It was oppressive. I didn’t write anything down in my notebook about that, as there wasn’t much happening. I just guessed this was how the illness progressed. Sometimes the harm is so thoroughly hidden that you can’t see it.

I did notice some other things. I noticed that the nurses only turned up if someone started making a lot of noise and movement, then they turned up en masse and the person was removed very quickly. I wrote it down in my notebook.

Sometimes patients were in the Day Room, sometimes they were not. If you asked after them, there was never any answer about where they were, from Nurses or Patients. I thought this was weird. I would have thought people would have said, “Oh, they went home”, or, “Oh, they were in their room, so don’t bother them”. Sometimes it feels like something is up, but you can’t note anything in your notebook.

Once I was in the Day Room and called out ‘No’ when one of the nurses tried to pull someone up by the wrist of one arm. I knew you could do damage handling someone, especially that particular patient who seemed frail, that way. As I moved quickly across the room to show the Nurse how to help someone up, a lot of nurses turned up, looked at me, told me to be quiet and to my relief went away. I felt frightened. Did these people demand absolute silence? Why was it quieter than the school Library? If I made too much noise, what would they do to me? What did they do the patients when they made too much noise? I wrote it down in my notebook.

I was with my Mum and younger sibling. Dad’s room was in a mess, sheets all over, bed pushed away from the wall. He sat in the corner, being very quiet, he didn’t seem to be ‘with us’ though. He was a very tidy person so the room puzzled me. The person he shared a room with wasn’t around either which was unusual. Mum quickly sent me and my younger sibling out. I wrote it down in my notebook.

My younger sibling caught some Nurses talking to our Dad. They had found out that if they saluted him, he stood up and saluted back saying, ‘Captain’ and they were laughing. Dad thought he was back in the army, which he had hated and where he had especially disliked his Captain. He told me that he had survived the army by doing what he was told and keeping his head down. This was one of the stories Dad had told me often, usually in an effort to get me to keep my head down, which he felt would be a good life skill for me to grasp. I wrote it down in my notebook.

Over some time, I came to some conclusions:

  • there were no activities and nothing to do, even though there was an activity schedule on the wall it never changed. Patients looked blank when I talked about it.
  • there was a kitchen for families and patients, but it was always locked for some reason
  • the door to the garden was always shut and locked so everyone was always inside
  • the nurses turned up if there was any sound at all and never came alone
  • when people had more strange movements in their limbs they were more likely to get up and call out, then many Nurses turned up at once and took them away
  • the bruises on my Dad all the time were not consistent with a fall

One day I found a Psychiatrist in the Office, I had been looking for one but Psychiatrist’s seemed even more scarce than the Nurses. The Nurses had told me the Psychiatrist was in charge when I asked questions, as they thought I should speak to him, not them a bout any concerns I had. I hoped he could change the things that were bothering me. I showed him my notes. He took my book, flicked through the pages and said, very gently “Well, it’s up to the nurses how they do their job. I prescribe the medicine, they give it. Don’t you want your Dad to get better?” My Dad didn’t seem to be getting better, he seemed to have suddenly got a lot worse. The Psychiatrist left, taking my book with him. His answer was more puzzling than my observations though. In my teens I didn’t understand what medication and treatment could have had to do with a silent day room, an intolerance for even a normal amount of noise, poor skills in handling and lifting, no activities, persistant patterns of unexplained bruising, a closed garden, a shut up kitchen, intimidating gangs of nurses and messy rooms.

When we got home my Mum was fierce. In a rare moment of clarity, she held me by the shoulders against the front door and shook me.

“Why did you do that? You’ll make it even worse for him.” she hissed. “Be nice.”

Then the clarity subsided back into silence and stories about how the way they were treating him was necessary and helpful. I could see one story sliding out of her mind as she shook me and the easy story rising up to take its place.

Many years later at Univeristy my friend who was studying psychology and I had an argument one evening about schizophrenia, the dopamine hypothesis and anti-psychotics. I learnt then that brutality enforced by law is based on a highly contested viewpoint. The extent of the lie and the extent of the abuse that the lie can allow hit home, the image of the Day Room and the patients, the meaning of what the Psychiatrist had said and fragments of memory came together and pushed me away from the world. I was aware that my friends were talking, trying to get me to give them my attention but I repelled the society we lived in away from me and as I did so their voices became distant as did the lounge I was in. I couldn’t be there in the world we had made, so I went away. I didn’t respond to anyone for several days while I processed the answers to the questions I had been trying to ask in my notebook. When I came back from wherever my mind had been driven to, there was a row of mugs of cold tea outside the door of the spare room where my friends had put me, my best friend was lying next to me reading and some anxious whispering was going on in the lounge. I didn’t really have anything to say about it when I came downstairs though, as there is just not really much to say about a lie that big and that catastrophic.

It’s well known abuse causes trauma. Psychiatric patients are traumatised by inhumane and degrading treament when they experience it and some survivors talk of this experience as torture. Witnessing abuse also causes trauma, in everyone that witnesses it, including those who take part in abuse. It was the State and its Officials who traumatised me. I won’t call them Mental Health Professionals, I am absolutely certain that until they sort out the coersion and Human Rights Abuses underpinning their professional practice, that they don’t deserve it. They have not earnt the right to the word ‘health’ or the word ‘professional’.

They never imposed a diagnosis on me, though they could have

“You’re basically good,” said Magrat. “The good are innocent and create justice. The bad are guilty, which is why they invent mercy.”

Witches Abroad by Terry Pratchett

One of the good things about Twitter is that you can have conversations which make you think. I’m not an expert on the debates around diagnosis, although I am well informed. Certainly a blog post cannot do it justice. Try following Drop the Disorder on Facebook or Twitter (@dropthedisorder) to inform yourself even more. You don’t have to agree, just entertain alternative ideas about how NHS and mainstream services make sense of distress. Just to be clear, if you believe in your personal diagnosis and it helps you, I am just happy that you find it useful.

A reason a Tweep gave for trusting the service she was engaged with was something like, ‘They never imposed another diagnosis on me, even though I am sure they could have.’ This is a good thing and a one very valid reason why she has every right to trust and value her care team. There is evidence is that services do add diagnosic labels- and that when services do start piling on a lot of labels they may have lost any understanding of that person’s needs. This leads the service to fail to provide help.

My view is that the labels I have received have been meaningless and useless […] Calling it autism or ASD, ADHD, schizoid personality disorder, dysthymia or anything else has not led to any clinical utility, quite the reverse […] Each person I have seen has adhered to their little hobby horse; my interests, needs and preferences have been ignored. In each instance no one has done a follow-up and no one seemed interested in how I got on. Brian McCabe

Furthermore, psychological research backs up these views, suggesting that psychiatric diagnosis in and of itself can be a distraction from interventions that might help.

The findings in these two research studies show that medical labels can be an obstacle not only to the treatment process and outcome, but can also be problematic to how the individual being labelled perceives him or herself as a person. The label is “sticky” and stigmatising, hard to remove and is unlikely to be helpful to the individual’s understanding of {their} mental health problem.” BT UK News online 18-08-2015

Though of course, the easy story for the service in that sitution seems to be that the person is so complex and impossible to understand that it is their own fault that there are bad outcomes- though, given the evidence that diagnosis itself can cause complexities, that would be an unscientific (and an unethical, blaming and professionally abusive) conclusion.

The picture is of course nuanced and some diagnosis seem to be more easily understood as a straightforward description of a difficulty – eating disorders for example and perhaps depression or anxiety. Other labels seem to imply a greater sense of pathology within the person such as ‘personality disorder’ or ‘schizophrenia’. Someone messaged me to say that for personality disorder the problem with the label is profound, ‘it is exactly the core of the person, the very essence of who they are, that is labelled as disordered. It is devastating to people who have often survived what many have not. It not only negates their resilience and survival, but marks them out for an often shocking degree of abuse and dehumanisation within an already paternalistic system‘. All diagnosis are not created equal. Diagnosis can be seen as a ‘sorting hat’, primarily about moral and social judgements- bad? sad? mad?. After all, if there was a disease process there would be an objective test for it- like in other well-established and understood diseases, syndromes or illnesses.

Importantly, this means that some labels seem to kill hope as soon as they are applied. These labels do harm in and of themselves. Someone messaged me that as soon as diagnosis of personality disorder is given, ‘the damage has already been done as it relates to someone’s core identity and sense of self‘. As diagnosis is claimed to be helpful, that level of harm seems deeply unethical. In medical ethics the very process of labelling someone could therefore be considered to violate the principle of Nonmaleficence – that the practitioner must not cause any unnecessary harm to the patient. There are other ethical principles in medicine, such as Beneficence and Justice which diagnosis seems to violate too. I would be interested in having conversations about these ideas to extend and inform my thinking. I have noticed that these underpinning values and principles are not often discussed by Doctors- they seem to rely on guidance which tends to be more technical and procedural, which focusses on particular situations. Interestingly is it easier to find information on Dentists talking about these underlying values and principles than Doctors… and I have found nothing by Psychiatrists. There is a good argument that if practitioners continually return to and discuss these underpining principles it helps them to avoid behaving in professionally abusive ways. I think that might be another blog post too. I think I will call it ‘Society urgently needs to talk about Psychiatric ethics‘.

They never imposed a diagnosis on me, although they could have‘ highlighted where I have entirely different standards to many people. In my view ;

– diagnosis is subjective;

– diagnosis is as way to re-story someone’s way of making sense of themselves;

– diagnosis removes the link between life events, the person’s experience and their distress/ sense of self-in-the-world;

-there is no evidence for an underlying disease process (but biomedically orientated people still have a lot of hope for one);

– diagnosis is voted into existence by (mainly) rich, white, men;

-diagnosis upholds a capitalist, western view of the world often at the expense of people who are not white and European;

-diagnosis does not lead to either medication or therapeutic interventions that work in a specific way for that difficulty;

-diagnosis overestimates the impact of the biological level and underestimates the impact of social and psychological factors;

-diagnosis is limited and contested; and

-diagnosis can do harm in and of itself.

For me, this can only mean that although some people find it helpful at times, there can be no ethical way for professionals to use psychiatric diagnostic categories.

However, there seem to be lots of practical or social reasons for diagnosis. Nevertheless, alternatives, such as formulation or straightforward problem descriptions could provide more acceptable alternatives which do not do the same harm and which have fewer of the problems associated with diagnosis. These approaches could meet the need for people to be able to access benefits. They also provide frameworks for people to negotiate the complex tension between blame and support which often surrounds mental distress or altered states. I think these approaches do have problems though, but that is (yet) another blog post.

However, currently diagnosis it is the dominant way of looking at the world. It is so popular at the moment that is is impossible to avoid if you are involved with services. Even if Mental Health Services don’t tell you that you have a diagnosistic label (or labels) by the way, staff have told me that you will have one. The computer system requires it. Some people find out later that they have been labelled in ways they didn’t know about and were surprised by. This might be general or it might only be in one NHS Trust. I don’t know. I did note the strange passive voice when the worker was talking, as though a small diagnosis fairy creeps in against everyone’s will, and by waving its diagnosis wand imposes the label irrefutabley and mysteriously. When we use language to refuse to acknowledge that people take actions which result in outcomes, alarm bells ring for me. The passive voice hides a multitude of sins. I don’t believe in the mysterious case of ‘The Computer says -yes?’. It also strikes me that when there is such a lack of transparency (which is arguably against the principles of patient autonomy, non-maleficience, justice & beneficience, by the way), it might be incredibly hard for a patient/client to be sure that their service has not imposed a diagnosis on them. The system has the power to define the person through diagnosis and as there is no way to opt out of this process the person loses the right to define themselves. Silence, or compliance, or attempts to please this system will not protect you. However, the system might be merciful. It might define you in a way you agree with…or not tell you how it sees you.

The Tweep felt safe and that she was getting a ‘good enough’ service that she valued. That is a good thing. However, the fundamental difference between me and that Tweep is that she was satisfied with mercy. I am only interested in a Mental Health System that relates to the people it serves- which is potentially all of us- with justice.

References

A Prescription for Psychiatry: Why we need a Whole new Approach to Mental Health and Wellbeing by Peter Kinderman

A Straight Talking Introduction to Psychiatric Diagnosis by Lucy Johnstone

Interesting is under-rated

I believe you find life such a problem because you think there are good people and bad people. You’re wrong, of course. There are, always and only, the bad people, but some of them are on opposite sides.

Guards! Guards! by Terry Pratchett

I am always fascinated by the pervasiveness of the concept of good/bad and right/ wrong. It permeates so much of our society, turning up in cultural references from the bible, throughout our great works of literature to popular storylines for Hollywood movies. It saturates our television, our magazines, our conversations about politics and about one another. I have lots of objections to it, mainly that it’s quite boring as it collapses many stories into one easy story that’s told over and over again. Good can feel like an imperative that we see ourselves as simple and static rather than complex and changing.

Good and evil also seem to be very closely related to the idea of ‘might is right’. Historically, conflicts were sorted out by ‘trial by combat…’., ensuring that power stayed with the people who had it already. The concept is so popular because it’s extremely effective at resisting any change.  I think societies’ lack the imagination at any given point in time to see past the powerlessness, confusion and discomfort change brings to a better possible future. When ‘Good’ and ‘Bad’ are so closely related to concepts of power and concepts of violent struggle, what is defined as good gets closely tied to what is counted as familiar and in line with normal expectations. Violence is still considered legitimate if the right people use it- feminism and #black lives matter are testaments to how true this is, as well as how thoroughly the violence of life as normal is disavowed. Normal and neutral are not the same things; normal is loaded with issues of power. The idea of Good and Evil so easily becomes a form of social control.

Good and Bad seem to me to be even more troublesome when we apply them to experiences which are central to human life; love, attachment, loss, change, trauma, growth, pain…. these are experiences that none of us can avoid in our lives and which both form us and transform us. In such situations of extreme intensity and confusion, people struggle against powerful emotional forces to keep an emotional  connection. Finding ways to live with and alongside such pain, staying connected without becoming blaming or punitive, is an act of commitment. It is not possible to try to do it honestly without hurting or being hurt, without at times stepping into another’s expectation that you might harm them, or at times, finding the pain so unbearable that you hurt too much to relate well. Some forms of emotional pain are so raw and bring such an intensity of vulnerability that the matching level of clear-sightedness and integrity does not seem conceivable. For me, the reality is that when people are trying to relate one another around pain and loss it may not always be possible for any of us to know if we are doing harm or not. At such times it does not even seem to be possible to know what your own intentions or motivations are. When people are in the middle of the imploding of meaning which is trauma, when the rescuing force are entwined with the ones that caused the harm, what does good or evil mean? Certainly in some situations it seems inhuman for any of us to keep up the intensity of trustworthiness for the length of time that is needed for healing to happen. 

Around traumatic experiences, it becomes impossible, at any point in time, to tell what is going, on or see clearly, nothing seems to ease the pain and it is not possible to know if the relationship is helping, hindering or harming. In such circumstances, trustworthiness in the relationship can only make sense in terms of carrying on with an expectations of making mistakes and feeling pain when those breaks in the relationship happen in the hope that the breaks can be mended. If we see things in terms of good or bad how can it be possible to carry on making a way through confusion and distortions rather than giving up at each crisis point?

When we say things are good, we mean lots of things but often implicit in it is the idea of normal, familiar, safe. Safety in the context of the difficulties of life and relationships feels to me like a stale dead-end.  People seem to like to categorise roles around trauma and loss as worker, carer, patient or service user. I like learner, doer, teacher as it disrupts the easy stories and easy assumptions we can make. Wherever I have placed myself in the ways people can relate to each other around trauma I have found,

  • if staying where you are feels too difficult and dangerous
  • if doing something different feels unbearably controversial
  • if developing in one direction or another feels overwhelmingly painful
  • if others feedback can do nothing to help because the horizons of your inner world growing or shrinking cannot be measured by other people
  • if most things feel difficult, or frightening, or bad;

the concepts of good or bad are spinning compasses not a guide. It is not possible to make a good decision, because life itself is so painful and uncertain. There is no way to go forward or stay the same that is less painful or without risk. A bad decision remains possible, of course, but making a bad decisions delibarately makes no sense either.

In such spaces I have found thinking about what is interesting useful. Interesting:

  • seems to offer hope-  why give up if things are interesting?
  • seems to offer choice and power- you can learn to notice where your attention is going, what you find interesting and make some choices around that.
  • help with a sense of progress and direction- questions like what is interesting right now? How come? How has it changed? reveal how you are going somewhere, even if it is not where you thought you would go.

Interesting means that it is possible that something new might happen, though perhaps this is why I also like the idea of sensible…

I have found that being interested in the problem feels less painful than anything else. Of course, interesting doesn’t mean safe and it doesn’t mean there will be a resolution. There are no guarantees and life is a daring leap towards the future, or it’s nothing at all. 

 

 

 

It’s not why we trained

It was so much easier to blame it on Them. It was bleakly depressing to think that They were Us. If it was Them, then nothing was anyone’s fault. If it was us, what did that make Me? After all, I’m one of Us. I must be. I’ve certainly never thought of myself as one of Them. No- one ever thinks of themselves as one of Them. We’re always one of Us. It’s Them that do the bad things.

Jingo by Terry Pratchett

There are lots of ways of thinking about organisational culture and organisational change. One I like is called ‘Appreciative Enquiry’. Like all ideas it is useful in some ways and limited in others, so I am not going to go into too much detail here.

Briefly Appreciative enquiry sees organisations as a shapeless organism in a constant state of development. The system constantly shapes and adapts itself to its environment. The people form the system, and influence the nature of the organisation particularly through their behaviour and through the language they use. This means that the culture of an organisation or a profession becomes something that is constructed by the people who are part of that organisation in the course of their conversation.

One idea from this school of thought is if the system or culture of an organisation or a profession exists, then something is working and something is giving, preserving, nurturing and encouraging the life of the system. This seems to me to be a healthy way to look at developing human systems.

However, on Twitter anyway, I don’t really get those stories about mental health. Mostly because a lot of people feel a lot of things are not working well. This means that conversations most usually go:

A valid criticism of mental health practice, is followed by:

“It’s not why we trained” or “Think of it from my point of view” from someone working in the system, which is then followed by:

  • A list of out of ‘out of our power’ organisational constraints that might make the professional behave that way, or
  • A list of the ways that the professional might be thinking that makes them behave that way

This moves us towards a way of thinking called Constraint Analysis. In this way of thinking, it is possible to ask questions to work out which set of limitations are causing constraints, which mean that the system is not as able to deliver the things it might want to. This can also be a useful way of looking at organisations.

It might be quite interesting for me to play around with these questions on Twitter and see what happens to Mental Health Professionals when they get asked organisational system level questions!

It’s just that there are other ways of thinking about the language used and the effects that that language has in a social context. If we think about mental health systems as being strongly bound to systems of power and oppression, both historically and right now, then thinking that came out of civil rights movements is relevant and interesting too. It is important here that anyone who’s used these linguistic moves takes a step back, and gets ready to think about the impact of the discursive moves they make and where they learnt it. It is never easy to look at your place in a system that may not use power wisely and even harder to look at your place in a system that indeed may not be even designed to use the power it has to support and help the people it claims to support and help. I guess “thinking into” the system and your role in it is particularly hard if you are a professional that really wants to help and believes in that role wholeheartedly. So, if you are reading this my request is that you try and disconnect things you say from repeated patterns of interaction over time and across different people. After all, it is likely that your professional culture taught you to say and see things that way.

The above examples could be seen as a tactic of misdirection that deflects attention away from complaints about the abuse and wrongdoing of those in power and towards a different topic that does not challenge those interests. This is called derailment.

There is a pretty good argument that when mental health professionals use this when they are talking to people who are criticising the system in which they have a position of (relative) privilege they are doing this to unconsciously uphold practices of institutionalised power and oppression. Perhaps discussions of why things aren’t working well are not about you if you are a mental health professional, perhaps people are commenting on or talking about a set of power relations. Personally, I find the “Think of it from my point of view” response particularly unpleasant, as it inverts the power dynamic of care. People who are looking for help after all may not feel that they have the right to be looked after well, or may feel (or have been told) that they are not good at caring for others or taking others perspectives. It’s quite an attack on the person as well as making unsubstantiated judgements on the rationality of their argument.

So perhaps if, when I am tweeting. I mention that ‘It’s not why we trained’ or ‘Think of it from my point of view‘ is very often a derailment, professionals might want to stop and think, especially if that makes them feel defensive. And don’t be surprised if my response is to put it back on you, by saying, “If you aren’t doing what you trained for, what steps are you taking to change that?”. If you are not happy with your working conditions and are not able to do your job, it’s your role to get involved in activism or your trade union to change that. After all, I am not a mental health professional, you are paid to solve those problems, so it’s your problem to sort out, not mine.

By the way, there are professionals on Twitter who I really rate. To be clear they never use those phrases. They acknowledge the problems, call out the problems, clearly state how they try and avoid being part of the problem, take on feedback about what the problem is and take clear steps to not be part of the problem. Alternatively, they just say what they are doing about the problems.

In addition this is a useful website about derailment, if anyone wants to know more.

http://www.meta-activism.org/2015/09/derailment-handbook/

An Enormity of Unbelief

First thoughts are the everyday thoughts. Everyone has those. Second thoughts are the thoughts you think about the way you think. People who enjoy thinking have those. Third thoughts are thoughts that watch the world and think all by themselves. They’re rare and often troublesome. Listening to them is part of witchcraft.

A Hat Full of Sky by Terry Pratchett

One of the problems I have with thinking about my parent being sectioned is that I remember what I remember, but nobody from my family who was involved remembers the same thing. Actually we don’t seem to remember any of the same events at all. Some people don’t seem to remember any of it, but fragments seep to the surface anyway and then float away. This means that the whole story doesn’t make sense. This is trauma, the outgoing circles of pain that disrupt memory, disrupt meaning making and make it impossible to see the harm for what it is. People struggle even to have First Thoughts about these sort of events.

There is one bit that we are all agreed on. The hospital he was detained in was called by all of us “that horrible place”. Various people I know have been physically ill and they were in hospital at times. I guess none of us thought those hospitals were nice, but the general feeling of horror about the psychiatric unit is not the same. It wasn’t only that people who are not in touch with consensus reality, or are very confused or very frightened are worrying and distressing. This is entirely about how the staff talked about people and how they treated them. It’s about the things we saw the staff do but don’t always remember and don’t talk about. It’s about questions I asked and asked, that got no satisfactory answers. It’s about the attitude that someone who is not experiencing the world the way we do, or not experiencing themselves in the same terms as our culture allows them to, does not have human rights and if they have no human rights they have no meaningful feelings. It about witnessing abuse, but not being able to do anything about it.  It’s about being silenced to the extent that you cannot even articulate what it is you disagree with. It’s about all that being state enabled and state sanctioned terror. You can’t argue with people implementing the law. Though in this parrallel reality there is no court, no judicial oversight, no jury of peers. The process going on here is a social one not a medical one. It is one of judging someone as less than human. It’s just history and habit.

I remember a lot of adults turning up after things had got very difficult at home. I remember finding the officials very aggressive and violent. I didn’t think much of them as I felt I had been handling things better than they were able to. Before they arrived everyone was safe and my parents had stopped hurting one another. I was sure that if I could handle things without force then the adults should be able to. Of course, this was because I saw the situation differently to them. I saw it as a misunderstanding where one parent had become aggressive because the one who was struggling was behaving in ways they found hard to make sense of, and so the situation had escalated. The adults saw it as the parent who was struggling being the aggressor. The officials had an easy story to get hold of and once they had, they were out to impose it on everyone. I felt my Third Thoughts were more use and gave us a way forward.  I looked at the adults and thought they couldn’t even manage to have Second Thoughts. I wasn’t really sure that they were people who liked thinking about their own thinking though. They might, I guess, see something about themselves they didn’t like. I do know that up until that night I had wanted some sensible adults to turn up and deal with the things I could not. After they turned up, I was pretty clear that I didn’t need more frightened adults in my life, as they only made things worse.

I am sure I remember my parents being asked questions by lots of adults I had never met. I remember this even though I think it would have been highly unlikely that any adult would have allowed a child to be hanging around that sort of conversation. However, I have a pretty good idea that I would have found a way to listen in if at all possible as it was always best to know what the adults were up to. Meetings like that never boded well and it was better to get your information from the horses mouth than try and work out what adults really meant when they told you the version of events they could cope with afterwards.  I remember that I was frightened that the adults would listen to the pleas of one of my parents not to take the other away and that would mean that the problems at home would be ongoing. I didn’t know what might happen if that was the case, things seemed threatening enough already. I remember that I was quite relieved when it became clear that these objections would be over-ruled because I didn’t think things could go on the way they were. I was also pleased at first that the parent who was going to be detained would be going to hospital, not to jail. That seemed right as things were certainly not going well with them. I thought hospital would be kind and approach things like I did, with people listening and trying to make sense of things with my parents. I thought they would be more skilled than me and more able to cope. I thought they would be more able to keep going over time. I didn’t know that the hospital was going to be pretty much a jail.

I was very upset though that they didn’t think to listen to what I remember happening. It seemed easier for them to believe that the parent that was clearly struggling, the one who dipped in and out of sharing the same reality the rest of us did and was finding the world hard to make sense of had hurt the other one because they were ‘mentally ill’. I rather remember that the aggression had been the other way around, before it escalated and got out of control.  It wasn’t the parent they were detaining that I was frightened of, but no-one was interested in that part of the story. I felt that adults had their easy story, the one they wanted to believe. There’s no point in having Third Thoughts if you are the only one having them.

The professionals who came later to tell me about decisions that they had made tried to explain ‘mental illness’ to me and ‘diagnosis’. I listened. I listened to them explain their confusion about what the diagnosis might be and how the situation was complex and how they would give my parent medicine which might make them better. I asked them what tests they were going to do to find out which problem it was as they weren’t sure yet. They said, ‘There aren’t any tests as such…’. I heard them out of course, as I was taught to be polite. I did have a view, when they had stopped talking. However, it takes time for the habits of mind that come from trust to fade- I had an idea that adults weren’t telling me the truth because they tend to patronise children to protect them. ‘I know I’m only 12, but its OK, you can just tell me you don’t know, can’t find out and don’t really know what to do so you just have to guess’. I know now that the adults had managed to kid themselves and all of society into a lie so grand that it is only just beginning to unravel. A lie that seems to be based on so little evidence that I cannot believe that we ever engaged with it as a society. It is also a lie that starts to unravel as soon as you ask whether there is a test for the diagnosis. I listen to my Third Thoughts, they seem to get to centre of the problem. I don’t know what you call the thoughts that lead to a lie like that. Wrong?

I listened to the adults tell me that because my parent was ill they didn’t have responsibility. I thought sometimes they did, sometimes they didn’t. However, when I talked to them, even when they very confused they seemed to be making moral decisions. I thought that this idea made no sense in general. Up till then they had being making perfectly good choices not to hurt me or anyone else- in spite of everything. Both parents had had choices and neither of them had made good ones. Society had made a choice not to provide services until things were at crisis point. Mental Health services had made choices not to talk to my parent about the things that were bothering them, but to see some experiences as something that should not be talked about or engaged with, increasing fear and isolation. Lots of decisions, none of them seemed very good to me. Third Thoughts again.

When I visited my parent in hospital, I was pretty clear that ‘the horrible place’, wasn’t what I imagined a hospital would be like, which was pretty much the last piece of trust in adults I had left after that night.

So if you work in mental health I will probably give you a hard time, though mostly I don’t say anything unless I am trying to get you to think. I am trying to get you to have some Second Thoughts, I do think you should be able to manage that. Whether or not you personally use violence, you are part of a system that often enough uses coersion and force in ways that destroys a fundamental trust. You are also pretty arrogant.  You think that trust can be rebuilt whatever harm you do. You think that trust isn’t something that is earnt. You think that it is a quality you ‘are’ because of your role.  If you are a psychiatrist, mental health nurse or AMPH, you think that in spite of your role and the purpose of your job, you are a special case. I am here to tell you that none of those things are true. You are a special case if you can see the abuse and violence of the system  and understand that although the officials say it is necessary, is much less necessary than they want it to be. You are a special case if you can see that, name it and then do something about it. You are a special case if you don’t respond to my point of view by assuming that I am against detention. I think it is necessary at times. You are a special case if you don’t assume I’m against medication because I disagree with the system as it is running at the moment. As far as I can tell it is overused, but helpful for some people at times. You’re a special case if you understand that I am not against psychiatry, but against the abuse of psychiatry.

I once told someone that I didn’t hate the officials and professionals who use violence and deliberately and repeatedly hurt my parent, and unthinkingly harmed me and my siblings as yet more worthless collateral damage. That is true. What I did do was reject them and reject all authority, falling back on my own resources. I listened to my Third Thoughts and came to the conclusion they were much more important than the official’s easy stories. I decided I was not going to be tricked into doing things I thought were wrong. If I thought it was wrong, I was going to resist doing it in all the ways I could. Power and authority could do a lot but they couldn’t make me agree. The interesting thing about that is I never became oppositional or unco-operative. I got on well with the adults in my life, though not in the least because I had learnt what might happen if you are not easy to understand, or challenge their need for order and conformity. I had learnt that our society rests on an unseen bedrock of coersion and threats, some overt, some subtle. We don’t live in the society we are taught we live in. However, although I remained a child that every teacher would be happy to have in their class, every university wanted, every parent was happy to have as their child’s friend, I never did anything ever again just because an adult asked me. I always had Second Thoughts or Third Thoughts about what people in positions of authority might be about- Are they lying to me? What do they want from me? What needs of theirs am I meeting? What things are they avoiding that they can’t cope with which might hurt me or others? Not least I learnt to separate out people ‘doing being nice’ from the function of their role. I learnt that social structures ask people to deliver an outcome and that someone seeming to be nice was no measure of the function that they were there to fulfil. I became oppositional to social structures and the function of social roles. I became angry at people who were not clear about what their social role asked of them and didn’t question any conflict between their personal sense of integrity and what they were asked to do. I became intolerant of people’s repeated willingness to believe easy stories and outright lies; their decisions to not see, not hear and not recognise abuse. 

Mental Health professionals taught me that there is good reason to have an enormity of unbelief. That lesson is a lifelong ache.