Sometimes the only way to protect the therapeutic relationship is temporarily to behave as though you have no concern whatsoever for the other person’s point of view. This seems counter-intuitive and it most certainly doesn’t ‘feel’ good but how we feel is often far less important than what we do.
It’s important not to allow anyone to use our emotions against us in order to influence our therapeutic decision-making. That’s a form of emotional blackmail. It’s also a very common behaviour strategy that people use because it often works.
You probably won’t be able to stop someone using this sort of underhand strategy with others but you certainly can stop them using it on you. The trick is to show them that it won’t work and then invite them to bring something better to your therapeutic relationship instead.
Regular followers of my stuff might be forgiven for thinking that I’m opposed to psychiatry and the biological model. After all I regularly complain about the standard medical approach with its reliance upon medication to treat mental disorder – especially relating to antipsychotics for people diagnosed with disorders like schizophrenia and bipolar disorder. But that doesn’t mean I’m ‘antipsychiatry’ – just that I’m cautious. This is especially true where medications are concerned.
The list of side effects (otherwise known as undesirable consequences) that accompany psychotropic drugs can be a major problem but the same is (and has always been) true of all medications from AZT to aspirin. If a particular person suffers side effects from a particular drug then there’s a case for trying a different drug or even a different dose but that, in itself, isn’t really a case for scrapping all antipsychotic medication. All we can really say is that we need to be cautious about medication and avoid the ‘hammer to crack a nut’ approaches of the past.
Medications are biological tools. They are chemical preparations designed to make chemical changes in the physical body. This is because of an assumption that mental disorders are caused by physical (specifically chemical) problems. But is this always true?
Combat veterans are known to develop psychotic disorders as a result of their experiences spending time in active service. It seems ridiculous to assume that all these men and women (who had passed psychological evaluation before entering the battlefield) suffer from organic brain disorders. Yet their symptoms are similar, if not identical to those experienced by many of their civilian counterparts who are diagnosed with major psychotic disorders and treated with chemicals.
Combat veterans suffer a form of psychosis that is caused not by biology but by stress.
For these people I think that there is an excellent case for using medication to treat their distress and to provide a degree of respite from their symptoms but that’s not the same as cure. That’s one thing I do disagree with traditional psychiatry about. I believe that recovery is attainable for many more people than the drug companies would have us believe. Happily though, so do many modern psychiatrists. People like me who advocate recovery aren’t so much joining the mainstream as the mainstream is catching up. That’s a nice feeling.
There are, of course many people who argue vehemently that psychiatry is flawed and that medication should never be ‘used on’ mentally ill people. However, sincere though I’m sure these people are, they may well fall into the same trap as the overly zealous arguments in favour of using too much medication. They may be too general.
Just as not all cases of psychosis seem likely to be chemical, so not all cases need necessarily be purely stress related. Whether the argument is in favour of medication or against it there is a real problem with polarisation and over-generalisation in mental health care. The disadvantage of these ‘black or white’ arguments is that they assume that everyone is the same and that everyone needs the same sort of intervention.
This sort of one-sidedness can feel easy and comfortable for those doing the arguing but there’s a price to be paid for superficial reasoning. The price is poor treatment because of flawed assumptions that compare chalk and cheese and assume that they are the same thing.
And that price is not generally paid by the individuals doing the arguing. It’s paid by the mental health service-user whose options for recovery are limited not by lack of knowledge but by stubborn refusal on both sides of the argument to look beyond their own, pet theories.
If I seem a little hard-nosed about this it’s for good reason. I was trained in the traditional way where medication and unquestioning acceptance of the biological hypothesis were everything. I was at the extreme ‘medical’ end of the continuum.
Then I was lucky enough to be selected by the NHS for further training at the Post Graduate level. I spent two years part time being exposed to the other side of the argument and, like many of my peers, became just as rabid in my defence of social and psychological perspectives instead. I was for a while the typical antipsychiatrist (or more accurately ‘antipsychiatric nurse’). And that felt good.
Today I’ve moved on a little from either of those two positions. Now I am able to see past the partisan posturing of either side and I try to walk the middle line. It seems to me that balance is everything. Isn’t that usually the case in the real world?
I no longer see much of a place for extremism in mental health care – especially when those who pay the price are not the ones making the arguments.
Please don’t misunderstand me though. I am far from an apologist for the biomedical status quo. I believe that medicine may well have something very positive to offer in relation to symptom management but in most cases that’s about all. I think that true recovery is generally achievable in other ways. But that’s for a later video.
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Caring for people with psychosis can be both stressful and mystifying. People who hear voices and respond to visions that the carer can neither hear nor see present particular problems and frustrations. It’s distressing for the individual voice-hearer and, for different reasons it’s distressing for their relatives and other carers as well.
“It’s real for them” is a common expression intended to promote empathy and understanding but there are very real drawbacks if that’s as far as it goes. We all know it’s real for them – that’s why they’re distressed, but if we simply accept that without question we give up a vital part of the recovery process.
In this video we explore the positive benefits that can come from refusing to accept that ‘it’s real for them’ whilst still accepting the other person’s experience. We look at the power of attribution in psychosis, especially in relation to hallucinations and consider the benefits of helping people to change their view about their hallucinations. It isn’t trivialising the problem to see it for what it is. A voice has no power unless the voice-hearer gives it some. However distressing and disturbing voices are they’re still only voices.
By helping people to reframe their interpretation of voices they hear we can reduce the power, the distress and the disruption of those voices.
Please feel free to comment either here on the blog or by using the contact form below and let me know how helpful or otherwise this video has been for you. Please also let me know if you’d like me to cover any other issues facing carers and relatives. I can’t promise to cover everything but I’ll do my best to help if I can.
Those of us who work in mental health services, be that for the NHS or in social care settings receive both payment and training for our efforts. However, there’s an army of unpaid, informal mental health carers who receive neither, despite the fact that without their contributions the whole system would collapse.
It’s estimated that informal carers save the NHS more than it actually spends each year and that situation doesn’t look like it’s going to get better any time soon.
The ‘Carers in mind’ project is my attempt to help redress the balance by providing information and training in practical ways for carers struggling everyday to hold their families together, often in truly desperate circumstances.
If you’re a carer involved in mental health please feel free to comment and let me know what you’d like me to cover. I can’t promise to fulfil every request but I’ll do my best.
Please leave a comment to let me know what you’d like me to cover as this series progresses or use the contact form below to get in touch privately.
Back in 1963, researcher David L. Rosenhan masterminded an elaborate hoax. It was a scam designed to study the effects of labelling upon clinical practice and to determine whether psychiatric diagnosis is based upon professional skill or simple expectation and prejudice. It was a bold experiment with profound implications for clinical practice even now almost half a century later.
The idea was simple enough. Rosenhan persuaded a group of confederates to approach state hospitals in America and request a consultation. Each told the psychiatrist who assessed them that they had begun to hear a voice which said “Empty”, “Hollow” or “Thud”. That was enough to secure them a bed in the local psychiatric hospital. But that wasn’t all, bad though that low threshold for admission might be, in itself.
Once admitted on to the ward Rosenhan’s confederates ceased any pretence of voice-hearing. They behaved perfectly normally and showed no symptoms of mental disorder at all. At this point we might expect the staff running the ward to smell a rat but that’s not what happened. Whilst the fellow patients could tell very quickly that their fellow patients weren’t actually ill, the staff apparently could not.
Even perfectly ordinary activities such as writing was seen as pathological. Pacing up and down through boredom in this secure, low-stimulus environment was interpreted as a sign of illness. It seems that once the label of ‘mentally ill patient’ was applied everything the confederate did was interpreted by those lights.
The staff saw precisely what they expected to see.
This mirrors an earlier study by Rosenhan and his colleague, Jacobson who examined teachers’ attitudes to students who had arbitrarily been tagged either as ‘bright’ or ‘not bright’ by the researchers. The school, known as ‘Oak school’ to protect the identities of all concerned, also lived up to expectations of labelling theory. Not only did teachers interact with children in accordance with the labels they had been assigned, but the children also began to live up or down to the expectations of the teachers – even though their actual test scores had been ignored when they were randomly assigned ‘bright’ or ‘not bright’ status. Each child took on the behaviours and traits of the label, regardless of their actual abilities and achievements.
This is why it is so important that we understand labelling in our work with people who have mental disorders. Whatever we believe and expect is likely to come true.
If you want the people you work with to recover you need to start believing that they can, and you need to act upon that belief. Remember that recovery is built upon lots of little steps in the right direction and we can encourage that simply and effectively by doing relatively simple things, things like offering praise, acknowledgement, recognition and practical help, repeatedly and well.
That’s hardly rocket science, is it?
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Personality disorder is a controversial diagnosis. There are no blood tests or physical criteria confirming personality disorder. In fact there’s no real evidence to suggest that personality disorder is a medical condition at all. So why do psychiatrists diagnose personality disorder? More importantly… should they?
Here we consider the roots of personality disorder diagnoses from the Moral defective of a century ago to the 3 personality disorder clusters of today. We look at the way personality disorder is diagnosed through behaviours, emotions and enduring patterns of response to society and we consider the advantages of understanding a person’s personality traits. Knowledge is power.
The more we know the more likely we are to be able to help. But we must be careful. Too often the diagnosis of personality disorder is used as an excuse to write a person off as incurable, hopeless or even undeserving. That’s the legacy we’ve been left by our Edwardian and Victorian predecessors.
If we are to do right by the personality disordered patients of today and in the future we need to embrace the understanding this diagnosis can bring but reject the pejorative notions of undeservingness, incurability and hopelesness that all too often come along with it.
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“Don’t blame people with mental disorders for behaving like people with mental disorders”
Too often mental health workers expect far more from their service-users than they are currently able to give. Then they blame them for having the very problems that brought them into mental health services in the first place. This is a fundamental misunderstanding of mental illness, of the process of recovery and of the role of mental health workers themselves.
It’s true that people are just people and there really is no ‘us and them’. But when people are struggling it’s not fair to expect them to perform at their best. Instead we should practice ‘therapeutic optimism’… Accept the person’s current difficulties but continue to expect them to overcome those difficulties with a succession of little steps.
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I often get to take student mental health nurses around in my day to day practice. It’s part of their training to spend time ‘in the field’ so to speak and learn their craft. We don’t just drag them around and let them watch what we do though. We try to help them understand what seems at first to be a very complicated world of diagnoses and disorders, mindsets and medications.
This short video is intended to reassure new students and others that mental disorders don’t need to be complicated. It’s true that we can (and often do) make the world of mental health as complex and convoluted as we like. But there are still some basic principles that can help guide us all through the maze.
This is how I explain the basics of diagnosis and disorder to those students unfortunate enough to cross my path. We should always begin with simple principles and then build upon those foundations. That way, when things start to get complicated there’s something straightforward to rely upon as we go.
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