Angel With A Shotgun

I want to start by acknowledging the emotive and controversial nature of some of my recent postings, both here and via Facebook/Twitter.  I have attracted some criticism and resistance, which I fully expect as it goes hand in hand with having strong and somewhat less-than-conventional views & opinions.  It is true that I sometimes speak in extremes, present things as more black & white than they really are, and make bold statements.  This is because I so strongly feel there are things that need to change radically, and this won’t happen if the status quo isn’t challenged fervently and compellingly.  This is why I write in an emotive and zealous style: my aim is to inspire positive change and innovation, or at least persuade people to think a little differently about certain things. 

The result recently has been what might best be described as an attack on psychiatry in my writing, elements of which may come across as vindictive (or indeed false) to some readers.  I accept this fully, but have no real qualms in light of what I’ve just explained.  I will listen to anyone who has something to say on the matters I write about, which is why I’m always so keen to invite comments on my posts!  I know there are many different perspectives on the things I discuss, and that it would be possible to present more balanced accounts than the ones I offer.  This is not least because the very issues I am passionate about are particularly complex and sensitive ones. 

Most poignantly, I have recently experienced criticism for making the bold claim that, essentially, there is no such thing as mental illness.  I realise now it was unwise to make such a statement in isolation as there is a hell of a lot behind it and it sounds incredibly insensitive (This said, all it takes is a look at a text such as The Myth of Mental Illness by Thomas Szasz or Cracked: Why Psychiatry is Doing More Harm Than Good by James Davies to see where this point comes from).  The post in question was a Tweet reading: “So... If #mentalillness was actually a thing, it wouldn't be called 'mental illness'.  It would just be called 'illness'... #foodforthought”.  The abruptness of this claim was mainly because of Twitter’s less-than-generous character limit for Tweets, but also partially because I indeed intended to make a bit of an unconventional statement to get people thinking. 

What I have to stress, first and foremost, is that this does not mean I don’t see mental health as important, or believe that people in mental distress are in desperate need of help, or that their difficulties aren’t genuine; in fact, these things could not be more opposite from the truth.  I simply see mental health in a different light to the conventional medical one, which unfortunately results in a bit of alienation from my field of work, since the accepted approach is largely medical.  I advocate non-medical approaches, which are seen as dangerous and unsupported by evidence by some of my colleagues.

I have to say that I absolutely, whole-heartedly support the notion of evidence based practice.  Who wouldn’t?  To base care on knowledge of what does and does not work is the obvious way forward.  However, inasmuch as one might criticise ignorance of elements of the evidence base, it is equally negligent to take such evidence at face value.  We should be especially concerned with the presence of ‘publication bias’, which is more prominent in some fields than others, psychiatry and pharmacology included.  Publication bias occurs when those who review a research paper for publication may be keen for a positive result to make the journal more readable, or prefer papers that match their own views & findings, and so on.  It also occurs when researches manipulate their data or change their original research protocol retrospectively to make their hypothesis supported, when their original tests did not achieve this.  

 

There is considerable evidence for the existence of publication bias and this has been shown, for instance, to inflate the efficacy of psychiatric drugs and diminish  their harmful effects.  It has also led to evidence of completely non-medical and very successful approaches to psychosis being hidden.  In case you’re interested, I am taking my facts here from peer-reviewed sources!

If we couple this with the incredibly unscientific basis upon which the diagnostic criteria for mental illness are put together, we have two of the key reasons I largely reject the biomedical model of mental illness.  This post isn’t the place to go into detail about diagnosis (see my post Freedom, and more to come in the future), but I’ll say this small piece for context:  Whereas physical illnesses are discovered by the presence of some sort of physical marker, for the vast, vast majority of mental illnesses, such physical markers are absent and the diagnostic criteria declared by psychiatrists, albeit based on well-founded patterns observed in behaviour, etc. 

The above is why I suggest ‘mental illness is not really a thing’.  As soon as a clear-cut biological cause is discovered for a mental illness, it becomes a physical illness.  In other cases, the ‘illness’ gest removed from the repertoire of psychiatry (homosexuality as a prime example).  Hence, there is no need for the distinction.  Mental distress is a different thing to illness.  It is caused by a combination of many things, such as trauma, environment, socio-economic factors, and perhaps elements of biology.  But the lack of distinct biological markers makes mental illness clearly separate from physical illness. 

For these reasons, I feel psychiatry has gone too far in its medicalisation of mental distress, which is why I am fighting hard for a move towards less medical approaches.  I do not see it as any less important to support and help people with mental health difficulties than any of my colleagues do.  In fact, it couldn’t be more important to me.  Allow me to use some lyrics to illustrate:

They say before you start a war

You’d better know what you’re fighting for

…

I’m an angel with a shotgun

Fighting till the war’s won

I don’t care if Heaven won’t take me back

…

Sometimes to win

You’ve got to sin

Don’t mean I’m not a believer

My motives and intentions are good and pure; I know what I’m fighting for and I know it’s right.  Why would I open myself to criticism, even the possibility of resentment, from people I admire, like and respect if this weren’t the case?  It’s tough, even heart-breaking, to experience this, but I cannot be acquiescent; I absolutely have to do all I can to make things better.  This means perhaps sinning against my own profession, but I do this in the knowledge that what I’m doing is good… a bit like an angel with a shotgun! (Except I’m not big-headed enough to describe myself as an angel!)

It is difficult to explain all this in a way that’s concise and means people will get where I’m coming from, but I hope I’ve gone some way to making my position and the motives behind my actions clear.  I would love to hear from you whether you agree with my outlook or not, and look forward to lots of productive work, debates and discussions with colleagues, friends and new acquaintances in the coming months and years.

What is Recovery?

Recovery in the context of mental health is one of my biggest passions.  I noted in a previous post (link below) how pleased I was that the NHS Trust I work for is increasingly implementing recovery-focussed approaches into practice.  Whilst this is a step in the right direction, it is my contention, particularly in light of recent reading, that it is not enough.  The crux of what leads me to believe this lies with a simple question: what is recovery?  The extent to which services, interventions, etc. are deemed to be conducive to recovery will inevitably vary depending on how you answer this question, and I posit that the generally accepted definition of recovery is somewhat different to the one I subscribe to.  As a result, in some cases, ‘recovery’ interventions may be damaging in certain ways, if helpful in others.  I’ll explain why…

I have been fortunate in recent months to come into contact with a lovely lady by the name Marion Aslan, founder and director of charity Elemental Wellbeing, who has become a great source of influence and inspiration for me.  In The Art of Thriving: Beyond Recovery, Marion addresses the issues of defining and implementing recovery in great depth.  Here, I will synthesise some important points made in the book with my own judgements and observations, in order to illustrate my concerns over the credibility and efficacy of recovery approaches within mental health services.

Many readers are likely to disagree with and even be offended by some of the things I say here, and many will probably see some of my views as quite cynical.  I will start on a positive note, which is that I believe everyone has the propensity to recover from what society calls mental illness.  I use that phrase because I personally prefer the term distress and have recently learnt a lot about what my friend Marion terms “the politics of madness and the psychiatric deception”.  I have touched on this in previous posts and will do more of the same later, but in a nutshell - and I know this is a very bold statement - knowing the facts leads me to view mental illness essentially as something that is defined, constructed, created and perpetuated by psychiatry.  With this in mind, here is a quote from Marion’s book:

“[Psychiatry] contains madness by seeing symptoms of illness rather than consequences of distress and ‘treating’ these so-called symptoms in a superficial way.  Instead of working with distress and allowing the individual to flourish, they are often maintained.  If this were not true why do so many people remain in the system for years, the same problems that brought them to psychiatry continuing to hinder their growth and independence?  Workers…talk about ‘revolving door clients’ as if it were the fault of the individual…rather than any inherent failing within the system.”

In other words, rather than helping people to become better, services are often perpetuating problems by taking a closed-minded, reductionist medical approach.  As such, the introduction of recovery approaches – in my experience, largely in the form of peer support workers and recovery education – is refreshing and encouraging.  The question is, are these approaches really facilitating recovery?  To continue addressing this question, let me go back to the topic of defining recovery.

The NHS confederation notes three key principles in recovery, as highlighted by mental health service users.  These are:

• the continuing presence of hope that it is possible to pursue one’s personal goals and ambitions
• the need to maintain a sense of control over one’s life and one’s symptoms
• the importance of having the opportunity to build a life beyond illness

This all sounds good to me, but unfortunately, in practice, it’s not really happening like that.  Somewhat paradoxically, the very same web page the above was taken from also defines recovery as “ the process through which people find ways of living meaningful lives with or without ongoing symptoms of their condition”.  The problem, to me, lies in the concept of living with symptoms of an ongoing condition, although I am encouraged by the addition of the term ‘or without’.   


It seems to me, from experience, that the assumption by most is that recovery is about managing a condition, maintaining a certain level of functioning, avoiding crisis, but continuing to suffer symptoms of some chronic condition.  Since such ‘symptoms’ are simply elements of human experience (that cause varying degrees of distress) that have been medicalised and categorised into illnesses by psychiatry, this is quite frustrating. 



Onto a positive note: people can and do recover from mental ‘illness’.  By this I do not just mean people function in society without crisis and manage their symptoms effectively; I

mean they become completely free from the illness, the diagnosis, the mental health system.  They thrive.  How do they do this?  According to Marion, recovery comes when “support challenges the long-term ways of working found in traditional services.  Warmth of welcome, sharing of knowledge and common ground…offers a fertile place for people to put their distress into context, find acceptance of their coping strategies and behaviours which some in psychiatry deem maladaptive…organisations [that provide this type of support, give] the individual a sense of purpose, responsibility and self-worth.  This is the thriving which my colleagues and I firmly believe in.”



As I write this, I am reminded of a talk given by Rachel Perkins at a recovery conference I attended last year.  Rachel notes the importance of recognising the difference between clinical and non-clinical recovery.  Clinical recovery is about reduction in symptoms, maintenance of a decent level of functioning, usually by taking medication long-term.  Non-clinical recovery is about building a meaningful life and reaching a state of wellbeing and functioning that is quite possibly beyond where the person was before becoming distressed or ‘unwell’.  



This way of working challenges the status quo and the lucrative medical model embraced by psychiatry and mental health services; therefore, it can be incredibly difficult to secure funding and support for such endeavours.  Meanwhile, available resources are generally allocated to those ‘recovery’ approaches that may be serving to perpetuate the illness-medication model, thus contributing to the problem of ‘revolving door patients’ referred to previously.  This is actually the opposite of recovery, so it is somewhat a paradox!  “If the medication works as well as it is purported to, why are people still in the system – often with their original problems unresolved?”.  More on this in a later post.  



As much as each person is different, so is each person’s experience of mental distress and their recovery journey.  Medicalisation detracts from this, not only causing harm in many cases but culturally reducing our ability to deal with distress autonomously.  I was inspired by the aforementioned talk by Rachel Perkins, who spoke of the notion that each one of us should be experts in our own recovery and wellbeing and that of those around us.  As such the very notion of a recovery ‘model’ is almost futile.   


Unfortunately the notion of individualisation is not really present in many mental health services at the moment; it seems that the notion of recovery has been watered down and moulded to fit the already existing modes of treatment: as Marion notes, the implementation of recovery principles such as service user involvement are “manipulated to fit into the organisational box...[they embrace] what suits and fits into the still predominantly biochemical system”.  I have witnessed this myself in peer support workshops I have co-facilitated in my workplace, where alongside endeavouring to teach people valuable skills to manage their distress, there is still seemingly relentless reference to the notion that one has a severe and enduring illness and must learn to live with this, helped by medication.  And so I find myself greeting these sessions with an odd mixture of admiration and disdain.  

Medication puts a sticking plaster on distress without addressing the issues behind it

As I write I am struck by thoughts of research into depression, which I have been investigating elements of for an upcoming university assignment.  Such research sometimes talks of recovery from depression, often measured by a reduction in symptoms based on a generic measurement tool.  Whilst I can see why such tools are useful, I strongly feel we need to move away from this limited view and to give people enough respect and credit to believe that they can truly recover and thrive, and to embed this into the way we work with people in distress.  Medication may help reduce symptoms, but it does nothing to deal with whatever issues and traumas caused the distress in the first place. 



This reminds me of my previous post about interpretations of suffering.  If we take suffering not as a sign of illness but as a part of human experience, we can then see it as something that can be worked through and learnt from.  To quote Marion again, “we have to take responsibility for our own recovery and not rely on others to do it for us!  Recovery is hard work!”  This is likely another key contributing factor to a lack of real recovery in services: quick fix approaches are (arguably), at the point of delivery, quicker and more efficient; there is enormous pressure on beds in mental health services and medication is seen as the quickest way to get someone out of hospital.  I maintain that in the long run this is less effective and far more likely to end up with further crises and hospital admissions, where true recovery approaches would not have led to this.  


What’s to blame for services not living up to promises to recovery recovery-focussed care?  Pressure on staff time and unnecessary bureaucracy are factors, but the unrelenting medical approach and the culture is creates is probably most to blame.  The Art of Thriving talks of service users becoming disillusioned with services because staff see the patient in terms of illness and not wellness or sanity, interpret coping strategies as ‘symptoms’, focus on medication and fail to recognise the relationship between life events and mental distress.



And so arises the need to go beyond recovery and embrace The Art of Thriving.  This will be different for each individual, but crucially, facilitating recovery and thriving in a meaningful way cannot happen without there being a shift in the culture of mental health services.  Related to this is the question as to whether hospital is even the right environment for the majority of people experiencing mental distress.  I honestly don’t believe it is.  If things are to improve and true recovery is to be achieved by more than just the odd few individuals who break free from the psychiatric system, I feel what is needed is a wholesale review of the way we support people in distress.  I won’t say anything further on this other than that I take a great interest in Loren Mosher’s Soteria House project, which you can learn about in this video:
 

 

In the context of our current cultural perspective of mental illness, my views are controversial, and as I stated earlier I know my view will be challenged by a lot of people.  I realise I have made some bold statements and not all of these are completely backed up in this piece; there is only a certain amount I can say in just one post and will return to some of the key issues later.  But please know my sole aim is to help people overcome distress and live meaningful lives.  It is unfortunate that these values are so heavily contradicted by the current psychiatric system and that I must so radically criticise the work currently being done in the field.  However, I hope you can find some agreement with my approach based on what I’ve said here. 



So, to return to our original question; what is recovery?  I have demonstrated here how my view of it contrasts with psychiatry's, and would be interested to know others' take on this.  It is your choice whether to believe in recovery, whether to believe in thriving, whether to believe in the biomedical approach to mental health, whether to believe in individuals’ ability to master their own wellbeing.  I hope that whatever you choose to believe is based on sound knowledge of the truths behind it.  I believe there are a hell of a lot of people out there who simply want to do the best for others, as I do, and hope that more and more of us will start challenging the current system and channelling our efforts towards true recovery.


NOTE: for copies of The Art of Thriving (£6 + P&P) and other books by Marion Aslan, please contact marionaslan@aol.com



Links:




Previous post mentioned in introduction: http://laurenscloud.blogspot.co.uk/2013/10/all-we-do-is-aim-for-better-things.html


NHS Confederation – Recovery: http://www.nhsconfed.org/Publications/briefings/Pages/Supportingrecoveryinmentalhealth.aspx



Elemental Wellbeing: http://elementalwellbeing.org/