Early Intervention

On clinical psychology as part of the problem

It feels a bit trite writing this now.

Last week, (and believe me, I have never said these words before) I wanted to go to Birmingham. There was a conference I fancied going to, on the topic of ‘Power, Interest and Psychology’. The conference sprang from the ideas of David Smail, a deeply influential psychologist who died last year. I never met him but he wrote prolifically on ideas related to the causes of distress – not faulty genes or a lack of moral fibre, but a society in which power is distributed unfairly and in which humans suffer as a consequence. I love that stuff – the chance to think about the unequal structures we have created and the ways in which they can be dismantled; the chance to be (legitimately) angry; the chance to thrash the ideas out with friends and colleagues who are sympathetic to them. I didn’t make it because it was priced well out of my reach which, if anything, shows at least that the organisers, my professional body, retain some sense of irony. But I was going to write a blog, regardless. Then Paris happened and my thoughts were consumed with that. I have toyed with writing something on that – on being Muslim in Europe; on having spent my entire adult life being part of a group widely feared as potential terrorists; on the fact I am now more acutely aware of my Muslimness than ever before – but I don’t know what the point is. I wrote things after the London bombings and after Lee Rigby and after Charlie Hebdo and I don’t know what more there is to say aside from the fact that I am weary of it and I am increasingly feeling less safe as a Muslim woman and that I see no sign of any improvement.

So, in that context, you will see why it feels trite to write this now. But life does not stop because of atrocities and I am still a psychologist and I still think there is much to be done in the world of psychology. Those who know something of me will know that I struggle enormously with my profession. I think it is worthwhile, which is why I do it, and  I often enjoy it, but it is far from perfect and  I would be lying if I said we always got things right. I suppose my attempts to do things slightly differently – to organise conferences looking at social context and to be part of a group which contributed evidence for a DWP report on Workplace Capability Assessments – stem from this; from some sense that there is so much more to be done than spending the next forty years tackling only the resulting distress, rather than the root causes. I don’t believe in cure without some attention to the causes and I certainly don’t see myself as some kind of healer. I think there is value in the work I do with people but to be perfectly frank by the time I see them there is often so much damage that has been done that it cannot be undone. I may be many things but I am not a magician. I can do nothing about the fact some of my patients were brutalised by their parents; about the fact many were raped; about the children they have had removed; about the violence they have endured; about the bullying they have experienced. I can do nothing about the fact that they have grown up in a deeply unequal society in which being gay or black or poor or an immigrant is often stigmatised. I know that experiences such as these lead to distress – I mean, I have data to back it up, because apparently we can’t just think in terms of common sense anymore – but I see virtually no efforts to do anything about it. Instead, we only see people when their own resources have been entirely used up and they are in desperate pain and we might try to help but the blunt truth is that our systems can brutalize and damage people further. It’s an unpleasant thing to think and to write but it is sometimes true.

A simple example is children who are sexually abused. We know that these children are much more likely to: develop an eating disorder, self-harm, drop out of school, use alcohol and drugs, have violent relationships, end up in the psychiatric system and get a diagnosis of borderline personality disorder, which, until fairly recently, was seen as ‘untreatable’. Now, if you get a BPD diagnosis, you might get some form of help, though the cuts are wreaking havoc, frankly. But the thing is, for some people BPD is a really bloody awful diagnosis to have – think of it, a label slapped on you which tells you your very personality is deficient. I can’t say I’d be thrilled. But if you are a person who has been sexually abused and who has had lots of bad things happen to them as a result because your attachments are ruptured and you find relationships hard and you feel ashamed and guilty and worthless and you take drugs to numb those very painful feelings, you may well not get the help you need, no matter how much you ask for it, because, unless you have a BPD label, you might not be seen as ‘ill’ enough. So what’s the message mental health professionals give people? ‘Get worse, if you want any help. Show us how desperate you are for help.’

Our system, dear reader, is flawed.

But of course it’s more fundamental than that. As psychologists, my colleagues and I are highly trained. Many of us have three degrees; some four or five. We are trained researchers and clinicians. We understand health but we could probably hold our own in some areas of sociology as well. I lecture trainee clinical psychologists on the topics of social context and race and class and sexuality. We are highly skilled people, often with vast amounts of knowledge at our fingertips. We know the causes of inequality and emotional distress; we know that intervening early is more useful than doing so later on and we tend to have the networks and the credibility to use that knowledge for social good.

Unfortunately, for most of the past 100 years, we haven’t. It wasn’t psychology which campaigned for the civil rights movement; it wasn’t psychology which rioted at Stonewall. On the contrary; we were too busy being involved in the eugenics movement and ‘treating’ people for being gay, which was classified as a mental disorder. More recently, we have had the dishonour of being complicit in torture. My profession does not have a good record when it comes to fighting for the rights of the oppressed, the marginalised and the dispossessed. And even now, knowing the crimes that were committed by our predecessors, many of us are content to sit in our consulting rooms and our ivory towers, working with the tiny proportion of people who come through our doors. I don’t know if you have ever tried to access NHS psychology but it is not easy. There are too many people in pain and too few of us to be able to provide them with what they need. I have the luxury of being able to see people for six months at a time if they need it; maybe more. Many people I know have nothing like that flexibility because their resources are so stretched but ultimately it’s our patients who draw the short straw.

My job is full of ethical dilemmas. Do I see the lonely old person because seeing me is the only social contact they have and because it lifts their mood slightly? Or do I discharge them because I am not ‘doing psychology’ with them? I’m not sure what ‘doing psychology’ is, really – as far as I’m concerned, most of my job is simply talking to people and trying to understand their situation and how they came to be in it and trying to fathom a way we can help them change it. Sometimes we can’t change it but that doesn’t mean there is no value to my input. I can’t just discharge someone sad and lonely without any follow-up but other agencies are drowning in referrals and their waiting lists would make your toes curl. But I can’t see people unless I can justify my involvement and sometimes it is hard to do that when you are the only psychologist covering a massive borough and sometimes I have to, with regret, discharge them and hope I have done enough.

But there are the bigger dilemmas. Make no mistake – I earn my living because other people are in emotional distress; because life has battered them and they cannot cope. You may say that I am doing a ‘good thing’ by doing what I do and that I must be a ‘good person’ but, believe me, there is very little about me that is noble. I care about my work and about my patients but the fact is that the day we manage to eradicate inequality, oppression and societal violence is that day many of us will be out of a job. Of course, given our current policies, that day isn’t coming anytime soon, but that in itself is a concern.

I see my job in the way I see a charity. It exists to fill a gap. If a charity is effective, at some point it should cease to be necessary because the gap has been filled by advances in policy and practice and it should close down. If I and my fellow psychologists were doing what we should be doing – focusing on preventing sexual violence, war, substance use problems, torture, racial and gender inequality, homophobia – we would, hopefully, run ourselves out of jobs at some point. That would be a good outcome, societally. A world in which you don’t need mental health professionals is a world I would like to live in. But we don’t do it. We don’t fight the causes; we firefight the dreadful consequences. And the effects on us are terrible. Health professionals are prone to all sorts of mental health problems. And why wouldn’t we be? Imagine spending forty hours a week hearing of others’ pain and distress. Imagine doing that for forty years. Imagine what that does to your view of humanity. Imagine what that does to your relationships. Make no mistake: our jobs can destroy us.

So, in fact, our lack of action when it comes to dealing with the root causes of emotional distress serves no one. It doesn’t serve those who continue to be marginalised, oppressed and victimized. It doesn’t serve the people around them. It doesn’t serve us as professionals. It doesn’t serve society. It simply perpetuates the damage and the despair; it keeps rotten systems alive and it maintains a steady flow of people through our doors for decades to come.

It is an outrage and we should be ashamed.

On advertising for Jinn in mental health services

Despite having worked in mental health for some years, I know very few people outside work who earn their living in quite the same way I do. Since going back into academia (a fancy way of saying ‘trying to qualify’) three or four years ago that has changed slightly, but it’s only since I began to use Twitter for work purposes that I’ve started to build networks in psychology outside of the region in which I live and work. On the whole, my interactions are with people at a roughly similar stage of their careers, but the great thing about Twitter is that there are no restrictions on who you talk to or what you say.

Over the weekend, I came across this, and it provoked a little debate:

Jinn

For the unmitigated, a Jinn is essentially a spirit. They are a common concept amongst people from Africa, Asia and the Middle East, but most cultures have equivalents. Jinn can possess you and they are generally seen as bad. The only way to rid yourself of the spirit is to go to some kind of religious or spiritual healer and I believe that such folk do a creditable trade, even in the secular metropolis that is London. My colleagues on Twitter were rather uncomfortable with it. I confess I took a rather different view. I should state that I have not verified its authenticity but that I have no reason to doubt it. My colleagues thought that the flyer was deceptive, because it suggested that if you made contact you would be provided with a spiritual approach when, in fact, the service would give you Western medicine. I disagree in several ways. I see the flyer and its careful choice of language more as a ‘hook’ with which you can encourage people to approach services when they would otherwise be reluctant to do so. Services are generally set up so that you have to see your GP and request a referral. This does not work well for all groups and we are well aware that there are an awful lot of people, often from groups which are already marginalised, who do not access services simply because of the rigmarole required to do so. Being of Asian origin myself, I have a fairly good understanding of the fear that surrounds statutory services and the avoidance that can result.

But there remains the issue of the help that will be offered. We do not, routinely, offer spirit healing in the NHS. There is no reason that MH services cannot be culturally sensitive, however. I know lots of clinicians who are sympathetic to non-medical approaches to what is commonly-labelled ‘mental illness’. The region that this flyer refers to, South & West Yorkshire, includes areas such as Bradford, well-known for its South Asian population. I would imagine that clinicians would be trained to work with people from a range of backgrounds and with a range of beliefs and that they could help those in distress without dismissing their beliefs. Additionally, this flyer relates to an Early Intervention Team. Such teams typically work with young people who have recently noticed unusual experiences. They try to work with the young person and their family for a couple of years (family work is a precious commodity and one that is rarely available in adult services), helping the person to either rid themselves of the things which are distressing them, or, if not, aiding them to live full lives despite them. They try to help the person to get better and remain well .EITs try to get people put of mental health services, not stay in them, but they can’t do that unless the person comes to them in the first place.

Is it still deceptive? I don’t think so. On the contrary, I actually think that attributing unusual beliefs and perceptions to Jinn could be quite useful clinically. One approach that psychologists use is called narrative therapy. This simply allows the person to tell their narrative; their story. It encourages them to name the thing that is causing them difficulty and externalise it. This enables a person who is experiencing low mood to call their experience ‘depression’, for example, and see it as separate from themselves. Thus, they are not staying in bed all day because they are lazy or feeble; it is ‘depression’ which makes it hard for them to do the things they want to. Again, this is a subtle difference: narrative work allows the person to recognise that they have strengths and the motivation to change but that there is something powerful which they find it difficult to overcome. In narrative therapy, the person is not the problem, the problem is the problem and we help the person become stronger than the problem by building on their skills and increasing their confidence in their own ability. If someone already attributes their unusual experiences to a Jinn, they have externalised the problem of their own accord and an approach such as narrative therapy could well be appropriate. It is also an approach based on the person’s view of the problem and has the potential to be very culturally-sensitive. It can be combined with family work and there is good evidence of its effectiveness when applied in this way.

So, all in all, I don’t share my colleagues’ scepticism of the flyer. It may be a stab in the dark, certainly, but, really, what does it cost to print a few flyers and stick them up? It’s hardly a drain on resources. But it indicates that, finally, we are trying to adapt our ways to encourage people to seek help. If it works, terrific. If not, we’ll have to think again. Crucially, though, we’re finally thinking about it and trying to make ourselves more accessible and less frightening. All statutory services need to do that and for too long, we’ve failed to do so adequately. This may not be the start of a wholesale revolution, but it’s a start, and as far as I’m concerned, it could well be the beginning of something rather interesting.