Mental distress - who has the power?

“Power is essential to how we make sense of the experience of distress and when considering how to be helpful as service providers.” Steven Coles, September 2013

In Powys there is an ongoing debate around who has power about even the simplest things when someone is in contact with services because of mental distress. Freda wrote recently about the issue in her post Smoking and snacking? Saving lives or life-saving?

When I was at the Nottingham conference, Psychiatry beyond the current Paradigm, in September, I went to a really interesting workshop with Clinical Psychologist Steven Coles, who spoke about “Power Dynamics: Marginalised Voices, Strengthened Voices”. Some of the language and concepts were quite challenging to me as a layperson, but I’m going to do my best to describe the workshop with links to Steven’s presentation and hand-outs. (Apologies in advance to Steven for any oversimplifications!) The workshop content was, though, very relevant to the on-going debate about the medicalisation of mental distress, and I really want to share some of the discussion and resources. Steven’s Twitter page header sums up the situation succinctly: “A Questioning Clinical Psychologist. Interested in why dominant ideas in mental health persist, despite sustained criticism”.

What the workshop was about
The blurb said: “This workshop will use theory, examples, exercises and debate to discuss the dynamics of power in mental health services. Power is central to understanding emotional distress and suffering, and the responses of mental health services. Power can restrict and be repressive, though all of us need power to live in the world. Within mental health services some voices dominate and others are quietened. The workshop will consider: what power is; how power is used in services; how some viewpoints marginalise alternative perspectives; and consider case material of how quietened voices could become louder.”

Power in everyday life
Steven encouraged us to talk first about how we experience power in our everyday lives. We considered this in pairs, and almost every area of life was relevant…So, for example, who tells us what to do at work, which newspaper to read, what we wear day-to-day….? Who says where we can or cannot park or what speed we drive our cars… if we drive or ride a bike or walk, when we get up in the mornings and what we eat..? Is it us, or someone else?

Looking at different sorts of power
Psychologist David Smail developed a way of looking at the different powers that operate in a person’s life. Some of these powers can be negative, whilst others can be positive. He separated them out into two areas:

Proximal powers – these are the powers that are close to home and which we are more likely to have control over, such as beliefs, memories, feelings, abilities (part of the person) and family, work, friends, housing (part of our environment and social life).

Distal powers – these are powers that are generally out of our control, such as economics, politics, and media/culture.

Mapping power
The feeling of helplessness or lack of control or power can play a big part in our lives whether we are distressed or not. “The flow of power is central to the experience of distress. Whilst at times services might be limited in their ability to alter this flow, mapping aspects of power can help people to clarify and understand their predicament. Furthermore, it is more likely to highlight realistic areas for change than an inward focus.”

Steven showed us a model for mapping power developed by David Smail and Teresa Hagan in 1997. The chart is split into four areas – material resources, home & family life, personal resources and social life. Each area is split again, and individuals can then chart how much power they feel they have in any specific area. Once this is logged, they could look and see if there is anything that can be done to change the balance of power, if this is felt to be a good thing. So… as an example, under home & family life – spouse/partner… An individual may have an abusive partner… so what could be done to change or move away from this relationship where power is wielded in an abusive way by one of the partners?

Power dynamics in mental health services
Then Steven spoke about the way in which power can work in the relationship between a service provider and someone experiencing mental distress. He shared a case study – and we looked at how an individual who is distressed is diagnosed with schizophrenia by services. The young man does not believe he has an illness, but is told by his psychiatrist he needs to take medication for a minimum of two years and possibly the rest of his life. His relationships with his family, and other professionals, were discussed, and we looked at whose viewpoints and whose voices dominated. It was clear that the services’ view of the man’s situation dominated to an incredible degree, to the extent that the man’s control over how he tried to resolve the distress was almost completely removed. Then we looked at how the man’s marginalised voice could be heard and a more democratic discussion take place amongst the professionals and the family.

Power in numbers
People coming together in groups with a common interest can work much more successfully to overcome powers imposed on them. Steven gave several examples, including the Hearing Voices Network and the Critical Psychiatry Network. Since the workshop a local example has sprung to mind - individual patients have come together at Powys Patients’ Council and can report many breakthroughs, the most recent success being changing the policy around mobile phone use on the ward at Bronllys Hospital.

Read Steven’s presentation for further information about the workshop – including his slides on Ideas Way Forward and “Tricky” Issues.

Some of my feelings at the end of Steven’s session:

• That professionals need to look very hard at the power they wield, and why.
• That the situation can be very complex… for example, a) a nurse may wish to support an individual in his aims (for example, not taking medication but seeking counselling) but feel overpowered by the wishes of the higher-ranking psychiatrist; b) the family members may concur with the psychiatrist that the man has an illness and needs medication in order to “recover” as they find it difficult to deal with his unusual behaviours.
• Individuals currently have very little power… much power instead resides with professionals, pharmaceutical companies and the government who make laws which state how people who behave in certain ways should be treated and/or detained against their will. 
• Individuals do, sometimes, have other options if they can access peer support groups and talk to others going through similar experiences. This increases their power, and subsequently their ability to change their lives going forward.

All in all an extremely thought-provoking session, and  I am keen now to read more on the subject. If you have views about power in relation to mental distress, we would really like to hear from you – please make your comments below or email us at pamhinfo@pavo.org.uk

Steven Coles is a Clinical Psychologist working in Adult Mental Health Services in Nottingham. Clinical psychologists aim to reduce psychological distress and to enhance and promote psychological well-being. Steven is co-editor of “Madness Contested: Power and Practice” and a key contributor to the Division of Clinical Psychology’s* position statement: “Classification of behaviour and experience in relation to functional psychiatric diagnoses: Time for a paradigm shift,” (British Psychological Society, 2013). The statement calls for a paradigm shift away from an outdated disease model, towards one which gives much more weight to service user experience and psychosocial approaches.

*The professional organisation for clinical psychologists in the UK.

Psychiatry beyond the current paradigm

Last week Laura let me out of the office to go to this conference at Nottingham University organised by the Critical Psychiatry Network and Asylum Associates. It was perfect timing, as it meant I had the opportunity to see Jacqui Dillon speak just a week or so before she visits us here in Mid Wales for our own Shaping Services Together event on Thursday 19 September. 

I stayed for two of the three days and found all the speaker and workshop sessions immensely enjoyable. All stimulated some interesting and relevant debate, and I hope to pick up on some of the specific topics in future blog posts (for example, a workshop on an innovative Finnish approach called Open Dialogue, and Clinical Psychologist Steven Coles’ session on the dynamics of power).

Today, though, I just want to give an overview of the conference as a whole to give a flavour – and maybe tempt some local readers to pluck up courage to step outside the county and take part in an event like this – because there are increasing numbers which is great. I say “pluck up courage” because – I went on my own, I didn’t know anyone else before I arrived, and I was a little nervous about how it would be... two days surrounded by strangers at a huge unfamiliar venue (well everywhere outside Mid Wales seems vast)... and people who more than likely knew far more than I did about the subject – even the title of the conference was a bit off-putting! 

But five minutes after arriving at the venue I was deep in conversation with a woman from Wakefield about how difficult it is to find local groups in Yorkshire where people can share experiences about mental distress. And I was telling her about the peer support group based at Ponthafren in Newtown! (It’s a long drive though... better she sets up her own group in Yorkshire...)

The conference was promoted with this blurb: 
“Voices from within psychiatry who are seeking change are beginning to be heard. The Royal College of Psychiatrists’ leading regular publication, The British Journal of Psychiatry, recently carried a paper from the UK Critical Psychiatry Network entitled Beyond the Current Paradigm, which emphasises the importance of services and practitioners working with rather than upon those who seek their help. Perhaps unexpectedly, it received very little criticism from academics and peer psychiatrists.”

The first morning we listened to three keynote speakers, who started to explore this theme. Hugh Middleton (NHS Consultant Psychiatrist and also Associate Professor at the Nottingham University School of Sociology/Social Policy) began. He said that doctors of any sort only have authority to practice if there is clear evidence that it results in good rather than harm, and many now question whether psychiatrists fall into that category. The paper has “disappeared into a cloud of silence,” and Hugh and colleagues interpret that as “assent.” 

Hugh described how psychiatric drugs are trialled, summarising that all evidence to support the use of such drugs is flawed. The evidence around the benefits of psychological therapies is also possibly flawed – it is felt that if there is a positive outcome from such sessions this is down to the success of the supportive/nurturing relationship which is set up with the "client". Hugh said that we have to accept that sometimes something happens to people which profoundly disturbs them and/or the people around them, and that contemporary medicine provides no better solution than the demonisation or incarceration options of the past. He summed up his session by saying, “people want something different to what they get from conventional experiences. What is it? Let’s look for shared solutions.”

Jacqui Dillon followed, responding to the paper from “an activist position.” It is impossible to do justice to her presentation here, but some of the key points raised included:

• Biological (medical model) psychiatry is now trying to incorporate many of the approaches promoted by critical psychiatry groups, such as the impact of trauma on mental wellbeing. “But this is all about outcomes for psychiatrists – what about outcomes for ‘service users’?”
• It is assumed the doctors are the only ones able to do everything – psychological, social, medical – the lot. The message is: “you need us in charge.”
• Vested interests range through pharmaceutical companies, political parties to society in general, families and carers, some ‘service users’ and professionals.
• We locate madness in others – because it makes us feel OK.

So, what can be done? Some of Jacqui’s ideas to whet your appetite for next week:

• Reframe and reclaim ordinary language.
• Take a stand.
• Work in collaboration with people with lived experience.
• Help promote people’s voice.
• Lobby for change.
• Join a group with similar goals.

And what if we phased out psychiatry completely? What would the world look like then? Again, a few of Jacqui’s ideas:

• Develop non-medicated coping strategies.
• Create a range of self-help support (sharing books, setting up groups).
• Survivor-run crisis houses based on the Soteria model.
• Phase out mental health professionals and give basic skills to people – around active listening, being looked after, and sitting with people in distress.

This session was rounded off by Steve Trenchard, Chief Executive of Derbyshire Healthcare NHS Trust. His background is as a mental health nurse, and he said that he wanted to listen and co-produce solutions not yet found. There is “a need to focus on strengths and aspirations.” And he wants to develop ‘listening’ and ‘being with’ skills. 

Again, it’s very difficult to summarise in a short space, and Steve covered a massive range of areas in his talk, but at each point it seemed to me (and others listening as was discussed later) that his approach as a Chief Exec is extremely rare (even perhaps radical) and much needed. He considered new approaches to dementia care, schizophrenia, the use of physical restraint and seclusion rooms (including a pilot to close the latter) and our obsession with risk. He encouraged more self-control for people, which he considered the biggest factor in improving health, and spoke about the Expert by Experience programme – “no decision about me without me.”

Steve took inspiration, in part, from the past. He referred to The Retreat, set up in York in 1813 by a Quaker called William Tuke, a “supportive and healing environment” for people experiencing mental distress, as distinct from the inhumane and squalid asylums of the time. 

In Derbyshire it seems like things could be changing around services as professionals like Steve are listening to and responding to people’s experiences. I really hope that in Powys people who provide or commission mental health services can make that connection so that we see a shift here as well... And on that note, I look forward to continuing this discussion next Thursday at the Shaping Services Together conference at The Pavilion in Llandrindod Wells! See you there!

An update: Jacqui has kindly sent me her presentation and you can now read it here.

R D Laing pops up again

“Madness need not be all breakdown. It may also be break-through. It is potential liberation and renewal as well as enslavement and existential death.”  R D Laing, 1927 - 1989

Yesterday morning I heard the Scottish psychiatrist’s son, Adrian Laing, speaking on BBC Radio 4’s Saturday Live programme (about 30 minutes in if you listen again). He recalled life with his father, a bittersweet combination of experiences also documented recently in The Daily Telegraph, and then outlined his participation in one of Laing’s more unconventional therapies – a “rebirthing”.

The story reminded me of a comment in Laura’s recent post on Thomas Szasz, where a reader made the link between Szasz and Laing. The Anti-Psychiatry page on Wikipedia pulls them both into the same camp, but as Laura pointed out – Szasz was not anti-psychiatry, it was the coercive nature of psychiatry as practised that he opposed. Nevertheless, the two psychiatrists are often lumped together in the political debate over psychiatry, and in pushing the view  “that psychiatric treatments are ultimately more damaging than helpful to patients”.

The debate, which was particularly vocal in the 60s and 70s, is regarded by some to have been “of its time” and no longer relevant. After all, mainstream psychiatry (relying heavily on drugs in its attempts to treat what are regarded as medical problems) seems to rule the roost, certainly in the developed world. However, it appears as if the debate is gaining renewed momentum of late...

I unexpectedly discovered a copy of Laing’s “The Politics of Experience and The Bird of Paradise” on a bookshelf here at home. (It’s not mine – G is also more well-read than me!) Yesterday after listening to Adrian I read the chapter on “The Schizophrenic Experience.” Here are a couple of, what I believe, are relevant quotes:

“It seems to us that without exception the experience and behaviour that gets labelled schizophrenic is a special strategy that a person invents in order to live in an unlivable situation.” (Following research studies made by Laing and two colleagues. His emphasis).

“’Schizophrenia’ is a diagnosis, a label applied by some people to others. This does not prove that the labelled person is subject to an essentially pathological process, of unknown nature and origin, going on in his or her body.”

Dr Joanna Moncrieff, a practising psychiatrist and critic of pharmaceutical drugs, said that “I was reading Thomas Szasz and R.D. Laing when I was at medical school – they were the only ray of interest I could find in the subject area.” With like-minded colleagues she set up the Critical Psychiatry Network which aims to debate issues such as “scepticism towards the evidence base, the biological basis to psychiatry, the efficacy of biological treatments, and an objection to the emphasis on coercion and medicalisation and the issues of social control.”

So... the debate does seem to be very much out there and current. What do you think?

PS: You can watch an intriguing 1989 Channel  4 documentary on R D Laing here. It’s 1.5 hours long (but absolutely worth it), so make sure you are sitting comfortably...