Beyond Survival

Recently I came across a remarkable article From surviving to thriving: how does that happen. The authors are Mark Bertram and Sarah McDonald, and the piece was published in The Journal of Mental Health Training, Education and Practice, Vol 10, Iss 5, 2015. The work was conducted in the vocational service department of a large mental health center in London, UK.

The authors’ purpose was:

“…to explore what helped seven people in contact with secondary mental health services achieve their vocational goals, such as: employment, education, training and volunteering.”

Here are some quotes, interspersed with my observations and comments.

“It is widely recognised that people in contact with mental health services are one of the most excluded groups in society. The causes of this exclusion are complex, multifaceted and not completely understood, but the facts are stark. Employment rates have hit their highest since records began, yet the majority of service users are unemployed (Office National Statistics, Statistical Bulletin, 2015).”

“Current critiques of the care programme approach (CPA) and the care planning process state that the work of mental health services through CPA is generally not effective – in terms of helping people achieve their goals and enhancing their life experience. There are calls for a fundamental change to the nature of the relationship between service users and professionals – with an emphasis on partnership and collaboration (Rinaldi and Watkeys, 2014).”

In fact, psychiatric care is inherently disempowering. Telling people, falsely, that they have an incurable, disabling brain disease militates against the notion that they can pursue their goals and improve their situation.

“The role of the staff is collaborative – moving from doing to or trying to fix, to helping people find their own way forward by identifying the things people are able to do and encouraging choice and control within a trusting relationship. This has been described as hope inducing and promotes well-being (Rapp and Goscha, 2010).”

“There are continuous calls for new ways of working in mental health services and knowledge from service users to be given its rightful place (Basset, 2008; Beales, 2012; Faulkner and Basset, 2012). What remains less clear in the literature is what service users are actually saying? Specifically, what do service users say are the conditions that help them achieve their goals, increase their well-being and be included?”

. . . . . . . . . . . . . . . .

The authors invited the service users at their center to come forward and be interviewed, with the objective of developing answers to the following questions:

“1. What areas of life were you struggling with prior to engaging in the peer support or vocational service?

2. What mental health services were you using and how was your mental health and well-being?

3. How were you involved in the project, what worked for you and what life changes have occurred as a result of engaging in peer support or vocational services?

Data analysis

The data were transcribed, content analysed and categorised under the key emerging themes.  Validity checks involved giving the participants a copy of their interview with our  interpretations. Some minor adjustments were necessary. Overall, the participants agreed that these records were accurate versions of their interview.

We then combined the qualitative data from all the interviews and through further reflection and content analysis we began to see patterns emerging – similarities between the nature and impact of people’s struggles and the types of conditions that people were saying helped them in a process of change and growth. These were listed on five pages of A4 [letter size paper] and consisted of 50 themes. To try and make the data clearer and more concise, we explored the possibility of creating images to visually represent the themes. We hired a systems designer and she was able to construct initial tree designs. We were then able to embed the themes into roots, trunk, branches and fruits.

We shared these images with staff, peer supporters and service users and the response was enthusiastic and positive. People were saying these images and the themes represented their understanding of the invalidating conditions that cause distress and the validating conditions that facilitate a process of learning, change and growth. Gradually, a model of change – with all its inter-related parts and processes – emerged and this remained faithful to the insights people shared.”

Here are the tree images:

Under the heading Life Struggles, the authors pointed out:

“People were saying their main struggles with their mental health were related to problems with living and these difficult life experiences had created significant distress over a number of years. Consequently, everyone we spoke with had ended up in secondary mental health services for over five years. One person had been in services for 20 years, including 11 annual admissions to hospital. These were bleak, harrowing and painful situations that people arrived with.”

In their Conclusion section, the authors note:

“People were very clear and identified a wide range of life struggles that brought them into contact with services such as: income poverty, unemployment, trauma events, serious physical injuries, bullying, isolation, drug and alcohol problems, family losses, stigma, meaninglessness, hopelessness and a lack of sleep. It was the invalidating effects of these struggles that caused serious damage.”

This is in marked contrast to the standard psychiatric approach, which is to downplay the significance of these kinds of adverse events and circumstances, and to tell the client that he/she has a brain illness which needs to be treated with chemicals and/or high voltage electric shocks to the brain.

“However, all of the people we interviewed found their own way through and there are several important threads that bound their stories together. How people were perceived and treated was simply everything. It was the human, can do and co-productive approach within the vocational and peer support projects that shone through.”

Under the heading Recommendations:

“The evidence here reveals that the difficulties that bring people into contact with mental health services are multifaceted, but have common themes – problems with living and being invalidated. The challenge for all mental health services is to recognise and address the economic, psychological and social consequences of these life struggles. If these areas are not addressed then the demand on services will continue to increase because the direct causes of distress are not being resolved.” [Emphasis added]

How simple and clear. In my experience, people who are despondent are always able to explain in clear, simple terms why they are feeling despondent. And it always comes down to adverse events and/or abiding adverse circumstances. Psychiatry, however, self-servingly wedded as it is to spurious biological explanations, ignores this entire area, and focuses solely on “making the diagnosis”. So instead of asking open-ended questions and allowing the client to talk, they ask the questions on their inane, simplistic checklists: how often do you feel depressed?; are you less interested in doing things than formerly?; have you lost or gained weight recently?; are you having trouble sleeping?; are you sleeping excessively?; do you feel slow or sluggish?; do you feel worthless or guilty?; do you find it difficult to concentrate?; do you think about death or suicide?, etc.

And if the person answers yes to at least five of these questions, then voila, by the great miracle of psychiatric transformation, the hapless individual now has another serious problem: a life-threatening brain illness called major depressive disorder, which requires the ingestion of dangerous chemicals for life. What an unmitigated travesty!

And what a contrast to the simple, respectful, insightful, and entirely meaningful approach set out by Mark Bertram and Sarah McDonald in this paper.

“The wide range of current standardised approaches and pathology-laden practices in the mental health field need to be reviewed in the light of: the extent to which they invalidate or validate service users lived experiences.”

FINALLY

I cannot, in this short post, do justice to this paper. Besides its obvious merits, it offers a profound contrast to the drug-pushing, people-shriveling practices of psychiatry. Although the paper does not particularly promote anti-psychiatry, it does demonstrate that even people who have been drawn deeply into the disempowering maw of “mental health”, can still articulate their needs, and can still find fulfillment in productive activity and self-direction.

Mark Bertram and Sarah McDonald have demonstrated that when people are weighed down by life’s adversities, what they need is authentic, validating support, not facile pathologizing checklists, and not tranquilizing or stimulant drugs.

I strongly encourage readers to study this paper and pass it along.

  • Rob

    Do events and circumstances cause us to become despondent, or does the way we perceive, interpret, and reject what happens cause us to become disturbed?

  • Sideshow Cledwyn

    The reason why society uses violence against suicidal people is largely because the arts of persuasion are mostly useless against the lucidity of a man who, estimating the worth of his life at its true value, has resolved to dispose of it.

    No good reason has been found to go on living, at the very least for a large percentage of people. Nature certainly doesn’t value us, society, only in some cases, and in the marketplace of persons wherein the business of society is largely transacted, no man’s worth is fixed. As for Nature, she torments and persecutes all our lives, and as we become old we are discarded, like an object that’s outlived its usefulness, but in which a heart throbs and pulses with the same desires and longings ere the advance into dotage and the shadow of death, looming ever-larger on the horizon, swallows up all hope in the gathering gloom, and chases away all trace of youthful illusions, like summer birds that take flight at the approach of winter in search of sunnier climes, leaving us bowed beneath the weight of the days, despair and defeat legible in every feature, awaiting demotion to the vegetable kingdom, to be admitted to an old people’s home and thence to the grave, whither all men are bound, and with them, all their unfulfilled dreams.

    It is quite a fate to which all men are foredoomed, one whose conclusion delivers a resounding verdict on the utter worthlessness of human life.

    Jean Amery found aging so horrendous, he preferred the Holocaust!

  • Sideshow Cledwyn

    That should be “torments and persecutes us…”

  • Cledwyn Antinatalist extremist

    Suicide prevention, that is, the particular forms of force and violence baptized thus, come in for disproportionately small scrutiny in the writings of anti-psychiatrists.

    This, I would surmise, is because most people are actually or potentially complicit in this atrocity, and agree that force must be used to stop people from topping themselves, disagreement centering only, for the most part, on the precise means to be employed in attaining this end.

    Nothing is more inimical to the cause of justice in human society than widespread complicity in evil, actual or potential. Only to the extent that we are not personally implicated in injustice are we usually opposed to it. Justice, it would seem, is merely a stick to beat other people over the heads with, almost never ourselves.

  • Cledwyn In Search of Lost Pus

    There’s nothing more stubbornly wrong-headed than the belief that the masses are sane, but as I’ve said before, the diagnostic net of psychiatry catches only the small fishes; a leviathan such as the mob just swims straight through it.

    Were the mob arraigned before a tribunal convened to determine its sanity, sufficiently impartial and reasonable to pass judgment, then surely it would be in vain that it would try to clear itself.

    Alas, those who judge the mob are generally not so Rhadamantine in their judgments.

    When men, united under the centripetal pull of a shared madness, come together to form hordes of madmen, they acquire a reputation as “sane”, and as such are they baptized by their rulers, ever the courtiers to the mob. Sam Harris was right when he said that, in human society, there is sanity in numbers.

    The case that could be brought against the mob is pretty damning, notwithstanding the reputation it has obtained through the counterfeit currency of normalcy, the mindless reverence for which; the tendency to refer all to the authority of the common example; to cede control of our minds to this, not to mention other authorities, are but a symptom of the widespread abdication of reason.

    Human society is a kind of farce in which each man labors lifelong to delude himself about himself so that he may not be crushed under the weight of self-consciousness, for which possibility nature has made many provisions, such as by making the world without – and not within – the vision’s natural point of orientation, and corresponding to the focal imbalance arising thence, there results a like unevenness in our understanding of self and others, wherefore it comes to pass that for this, and not to mention other, reasons, men exhibit a marked tendency to bray and pour scorn on each other in a manner akin to the monkey in Krylov’s fable, who attacks its own image in the mirror. Is not this madness?

    Self-knowledge is perhaps the sine qua non of sanity, yet even man in isolation possesses little of it, and all the more so man in the mass, who everywhere conspires to keep the depressing, indigestible truths about the human condition and himself safely beneath the threshold of consciousness, shunning, ridiculing, and labeling as mad those who conjure them out into the open to this end, not to mention sundry other lines of defense along which people repel attacks on their grandiose delusions of self-worth, which is at the root of so many of man’s worst crimes.

    And what depths of delusion man plumbs in his retreat from the reality of his own insignificance! What airs this jumped-up ape gives himself in his madness!

    One regularly hears sports stars claiming that god is responsible for their successes! Suffering humanity, on the other hand, supplicates the heavens in vain. Obviously we don’t come within the purview of the providential government! It would seem to be the case that god, like mass-produced man, has trouble putting things into their proper perspective, magnifying out of all proportion the most trivial shite, and distributing his providential dispensations accordingly.

    No wonder there’s so much suffering in the world; god’s too busy watching sports, the old reprobate, too busy no doubt, boozing it up and debauching himself in celestial orgies.

    And look at the greed and acquisitiveness of the masses. How can such an avaricious, prehensile creature possibly be considered sane? The more we’ve got, the more we want, and no matter how much we’ve got, we want more.

    The general belief of people that they are sane is itself a symptom of their madness. We are often told from the mouths of people whose thoughts originate in their bowels and not in their brains, that such and such a person is delusional, detached from reality, which here carries with it the supposition that there exists an elect group of individuals who by grace of the god of reason are free from such madness, among whose distinguished company the speaker numbers himself. Which is not say we are incapable of understanding reality, but not to the extent that we could be said to be attached to reality, which implies an accurate grasp of all its particulars.

    A feature of the mass-mind is its total lack of scepticism, its inability to doubt its own conclusions. Everywhere you find people, held captive by their enthusiasm, convinced their “truth” is the only truth, squabbling endlessly with each other, advancing their opinions, almost always wrong, with the same depressing certainty, only one day to switch allegiance, and to further their new “truth” with a like conviction. What a farce.
    .

  • Hypatia

    Circumstances and events 100%.

  • Rob

    We often blame life for our problems. In reality, we disturb ourselves and create depression, anger, and anxiety. All chronic emotional disturbances are rooted in our thinking. I encourage you, the next time you get very angry, to explore the thoughts that are fueling your anger. It’s fascinating to discover where these emotions come from.

  • Hypatia

    We had this conversation before. I emphatically disagreed then, and that has not changed. That our surrounding social reality imposes on us all (economic, political, social, psycho-social, etc injustice, structural violence, illness, accidents, personal tragedies), and its often in a conflict with our interest to secure the objective conditions of subsistence, nay wellbeing, is an undeniable reality for the vast majority of people. People die of starvation, wars, are subjected to apartheid conditions, denied rights, denied basic income, kept in constant insecurity.

    The individualization of the social, the economical, the political, the blindness to see how in relation to the individual, society is encountered as an objective reality with overwhelming power and coercive force, that in relation to the individual`s existence society is an a priori entity, a vessel into which he arrives, is one of the major ideological roadblocks not only in genuinely understanding personal distress and identifying its causes, but also in the unwillingness of many to change society for the better. Blaming the individual makes sociological, structural issues invisible, trivializes the suffering of people who are subjected to those circumstances and absolves society of all responsibility in creating artificial inequalities, injustices. Its ideologically convenient for a system to keep its own power-structure`s legitimacy, to justify the status quo via blaming the negative consequences of its modes of operation on individual deficiencies, atomizing the individual, robbing him of his very ability to recognize, conceptualize its own predicament and ability to organize with others and fight back.

    The material basis of distress can not be so glibly denied. On the coin of the human condition, suffering is just the corresponding subjective side of objective harm. Suffering is a subjective response to objectively harmful conditions. The level of suffering/distress a given harm produces may differ from person to person, but the very existence of the harm-causing agent can not be entirely subsumed, eliminated from the equation and the whole burden of the cause of suffering put on the individual`s shoulders alone. I would argue that there are certain forms of harm, which eliminate all subjective differences in perception and degree between individuals. Its certainly true, that cutting a finger will elicit different levels of distress in different people, but serious pain due to serious illness is so bad for all who have to experience it, that toying with slight differences of perception at this point is not only meaningless, but cruel. And an illness, lets say cancer, is an objectively harmful circumstance, a malicious feature of what life can become and it does not have anything to do with how we think.

    In my view the primary root cause of distress lies in how the objective reality around us facilitates our wellbeing: things like being exploited, oppressed, enslaved, marginalized, being in poverty-cycle, losing a job, losing a family member, losing a friend, being subjected to prejudice, contracting a serious illness, etc, etc are all objective circumstances, which can trigger various different forms of psychological distress as their primary cause. The experience of being laid off work because big capitalist CEO`s favor Chinese slave labor for increased profits is an objective circumstance you are subjected to. The experience of being spat on for having a certain un-status in society or just because you have a different skin color is an objective circumstance which is imposed on you. The experience of being victimized by objectively bad circumstances out of your own control can not be justifiably invalidated. It makes no sense if we accept that we are born into already made social, physical, economical circumstance, if we are not professing a world-view of subjective solipsism which is demonstrably delusional.

    We are not windowless monads, we are in a constant input-output relationship with a world around us, which is not of our own creation and which may be in opposition to, limiting of the objective criteria of flourishing.
    Anger can be justified by injustice, thats why revolutions happened in history, when people got their basic needs unattainable.

    Explore the history of the civil rights movements, read about worker exploitation, read about the inherent flaws of capitalism and how it effects simple working class people, etc. You will see, that emotions are reactions to circumstances, you will see that the life they have access to can be really cruel to some people who lacking realistic, actual, material solutions (often only remediable through social change, common effort) to right their circumstances, people who are abused by the system, have no problems in their thinking, quite the opposite, they are in bad a situation they can rationally ascertain and realize how bad it is, and if they have no means to change those circumstances, if they are helplessly victimized, then they are basically shoehorned into a corner where emotional distress is the only way they can maintain an internal mental homeostasis in the face of overbearing adversity. Have some compassion!

  • Sideshow Cledwyn

    So much of the difficulties faced by “mental patients” likely stem from the fact that, in being human, we are likely foredoomed to live our lives ever at the mercy of cruel hordes of fallen apes, who in their descent from the chimpanzee have plumbed such terrifying depths of iniquity.

    Man is an ape sui generis, one who has the distinction of being the only creature among his simian brethren to torment his own purely for the pleasure of it.

    Only man could have invented Hell, by which some men console themselves for the mortality of their enemies with the thought of an eternity of suffering commensurate with their infinite cruelty.

  • Aussie farmer

    We make choices we can choose to be controlled by circumstance or we can control the circumstance by our choice. The power is within the individual.

  • Anonymous

    Hello Dr. Hickey,

    I am writing because I guess I am very confused about the way people will take away the message from your articles and they are not very easy to read for a person like myself. I am starting to understanding by reading multiple articles that you want to see an alternative to psychiatric treatment, but it comes off very confusing.

    I really had to dig deep in for a few hours to understand, and I guess I’m just concerned that the messages people will take away from this article is that the old way of berating people until the behavior is changed is the correct medical solution.

    Specifically talking about learning issues, when trying to learn a new thing many have said you’re not trying hard enough, and that they can do it, and the they expect that that person should be able to figure it out themselves because of the person telling them that has been able to figure it out themselves and get frustrated at the other person and trying to shame them until they figure it out.

    I guess I’m just concerned people will read these articles to justify that line of thinking because of their interpretation of your article and want to change the psychiatry industry to go back to the old way of not offering solutions but continuing to try and offer their version of encouragement until that person changes, or then completely dismantle their self esteem.

    While I’m not fond of putting random chemicals in your body I can’t say that the old way of ignoring the problem and hoping it will go away through shame has worked much better.

    I am also concerned that many religious fundamentalists will read these articles to confirm their suspicions about mental illness but also confirm that the problem is a lack of faith in god and push for that to be the current standard again. Many have pushed for ending psychiatry but replacing it with theology. Again that might be where you stand on this issue but I am not quite sure.

    It just seems that people are reading these articles and coming up with so many different interpretations, and that people could use these articles to fuel their confirmation bias and instead of coming up with new solutions could advocate towards archaic solutions, that could cause just as much damage as the psychiatric medication, since people can interpret so many different ways.

    I am just concerned since many schools are coming up with new ways to help slow kids learn that don’t require drugs and I would not like to see things go back to the old way where we just discard slow children if they don’t learn fast enough and it becomes survival of the fittest.Or when someone cannot express themselves properly they are shamed with being sinful and not given any constructive solutions.

    Again this might be what you advocate for, but I am having a hard time understanding. Apologies for my poor wording skills, and have a great weekend!