Stigma

On mental health stigma, and working in a ‘nuthouse’

Quite often, I find myself being quizzed on my job by people I barely know. It’s gratifying that people sometimes find what I do interesting, but, in my experience, it’s often secondary to a problem they have had/someone they know has had. It’s indicative, I think, of the indiscriminate way mental health problems are experienced. There is no protection, really; not money or status or education or any of the things we hope will protect us from the torments of life.

And so it was that I spent a quarter of an hour chatting to some ex-colleagues about my work. Some years ago, I worked in another industry entirely, but I still pop in to the office now and again to say ‘hello’ to my ex-boss. Toward the end of my visit, I got talking to three former colleagues and one person who has joined the firm since I left. ‘What are you doing at the moment?’, one of them asked. ‘Writing m’thesis’, I promptly responded. ‘And what will you be then?’, came the question. ‘A doctor of clinical psychology’, I said. I explained that I was working at a hospital, doing whatever it is that I do and that I am due to qualify in the next few months.  My former colleagues knew that I worked in mental health; the unknown colleague obviously did not. And then came the ‘ooh, how INTERESTING!’ comment, expressed in the worst possible way. ‘What’, she said, ‘is it like working in a nuthouse?’

I am rarely flabbergasted but even I was taken aback. To my shame, when I recovered from the question, I stammered out a deeply ineffectual ‘well it’s hardly a nuthouse’ but I felt like I’d done the people who use mental health services a grave disservice. What I WANTED to say (as I squawked to a friend that evening) was something along the lines of ‘have some bloody respect for people who have experienced untold misery and have demons you can’t even begin to imagine’. Now that’s a bit of a crude statement, because not everyone I see has experienced untold misery and not all have demons (any more than we all have demons, that is). But I was furious at the implication that people who have mental health problems are raving lunatics, locked up for the safety of good upstanding citizens. This is nonsense. People with mental health problems – of whatever persuasion – are not the ‘other’. They’re your parents and friends and bosses and dentists and hairdressers. Notions of Victorian asylums persist, but, when you work in mental health, you get so used to being wrapped up in a woolly world, in which we try to be respectful and aware of vulnerability and the things people have experienced, that it can be rather a shock to encounter a question such as the one I was asked. I don’t think this person had any malign intent; she wasn’t the kind to overtly stigmatise someone with a MH problem, but its not really the overt stigma which is the biggest battle. Yes, it matters that people with MH problems can’t get jobs, for example. But it’s the everyday, insidious stuff which erects the biggest barriers. It’s the casual comments about ‘lazy depressives’ or ‘attention-seeking self-harmers’ or ‘fruitcakes’ , the kind of stuff you hear in the pub, which stops people talking about their own experiences. Interestingly, some of the research indicates that anti-stigma campaigns, which highlight how common MH problems are, actually result in an increase in stigma. Really, it’s the everyday disparagement which needs to be tackled but, if I’m honest, I don’t know you do that. I probably failed, frankly, and I’m still a bit embarrassed by it. If MH professionals can’t pull themselves together long enough to respond effectively to something as relatively minor, perhaps we need to rethink how we tackle something which has a huge impact on the likelihood of people seeking help when they need it. In the UK, we have shockingly high rates of self-harm, suicide and substance use, all of which are often related to unspoken difficulties arising from MH problems. If we could crack the stigma issue, maybe we’d begin to see a shift in these related problems. Sadly, ‘if’ is a big word.

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On learning in learning disability

As part of the requirements of qualification as a clinical psychologist, you have to do a number of clinical placements. In the UK, one of those must be a six-month stint in learning disability.

I came into clinical training through a fairly unusual route, which meant that I had very different experience from that of many of my colleagues. One of those differences was LD – I had never worked in LD services, although I had worked with people who had some cognitive impairment. The criteria for LD are that you have an IQ (a controversial topic in itself) of 70 or less, that there is some difficulty in functioning, be that in academic settings or otherwise, and that the difficulties are not the result of illness or a head injury; i.e. that they have been present from a very early age. (In the US, the term ‘learning disability’ is often taken to mean something like dyslexia or dyspraxia. In the UK we refer to these as ‘learning difficulties’. It is not an easy distinction to remember, and even clinicians get the two muddled from time to time.) I was, it is fair to say, going in with little prior knowledge or experience.

Four months in, I think I’m starting to get a handle on working with this group of people. I am in a team which works with those with a learning disability and mental health problems. Not until I began to work in this area did I fully start to appreciate how marginalised some of the people I see are. I have long known that being perceived as having mental health problems can result in stigma and barriers and social isolation and I knew that having an LD was likely to do the same, but the interface of the two can sometimes vastly magnify the difficulties. This isn’t because of the LD itself, nor as a result of the mental health problem – it is purely the result of the way society treats those who are different and of the way that some vulnerable people are exploited. I use the term ‘vulnerable’ carefully – not everyone with an LD or an MH problem is vulnerable and many people with neither of those labels are vulnerable. But in the Venn diagram of such things, there is bound to be some overlap.

One of the things I like about my profession is that, despite having spent a good few years working across a range of services, I regularly get angry. Not with the people I see professionally, but with the people around them. The fact I can get angry about the accommodation in which someone lives or the staff with whom they have to deal or the neighbours who make their lives difficult means I still care as much as I did when I chose this as my career and that I still believe that change is possible. To my mind, it’s when you stop getting angry that you should re-think the way you earn your living, because that anger signifies a passion for your work. I think most people come into this kind of work wanting to change things (whatever those things may be). The focus might shift over time, in the way that most revolutionary aims change over the course of years, but as long as the will and the belief is there, you can make a positive impact on the lives of the people who come and see you. Virtually everyone who I have met who works in LD still has a desire to change things for the better. Sometimes that’s change which is recognised: those esteemed colleagues who write reports for the Department of Health and inform policy; more often, it’s the people who do their jobs, day in, day out, trying to help people in distress make their lives better. It can probably feel like you’re constantly pushing for the small victories, but as anyone in mental health will tell you, the small victories are necessary if you’re ever to snatch the big ones.

So what have I taken from this, aside from a better understanding of the impact that disability can have? Well, I’ve learned that even in an environment where NHS services are becoming more protocol-driven, there is still room for flexibility in service provision; indeed, you cannot run an LD service which is not flexible. I have learned that it is possible to get away from the language of psychology and psychiatry (a language I have always avoided, given that, like most specialist languages, it is designed to exclude those who don’t understand it) and make our ideas accessible to everyone. I have learned that writing reports is made far more fun when you use 100 words and fifteen pictures. I have learned that working in LD requires a particular skill set, but that like all skill sets, it can be learned.

And I have been reminded of something too. I have always said that my job is one of great privilege. Strangers come into my consulting room and they tell me about their pain and their distress and their fears. They show me their vulnerability, a vulnerability that is sometimes so raw that you marvel at their resources. I have often been amazed at the strength and grit of the people that I see; speechless at the difficulties that have encountered and which have threatened to overcome them, but which they have not allowed to do so. Factor in the added stress of physical disability and cognitive impairment, as well as the adverse experiences that can result, and I have been reminded of the strength of human spirit, the resilience that many of us have (but which we perhaps don’t know we have). And again, I marvel. And I think that with enough time and will, perhaps we will see the day when those with disabilities, of whichever variety, will cease to be marginalised and will be seen in the way the rest of us like to be seen: as human, with our foibles and neuroses, but with more binding us together than setting us apart.

This post is also due to appear at joereddington.com

In which I am furious at the Sun for promoting stigma against those with mental health problems and I shout at the Government

I have been meaning to blog for ages. I recently went to a very interesting conference in Copenhagen and spent three days discussing personality disorder, which is one of my primary clinical and research interests. Unfortunately, I’ve been incredibly busy and it’s had to fall to the bottom half of the to-do list. I thought I would make an extra effort today, however, since it is World Mental Health Day.

This seems an apt time to consider some of the issues which persist in mental health. There is the very concept of ‘mental illness’ of course, the battles between the pro- and anti-diagnosis camps, the bickering over effective treatments; all stuff that often goes on in the ivory towers that some of us inhabit. I have always believed that there are two main issues which really affect people with mental health problems and their families: stigma and funding.

i think we’re often quite proud of the way we have come to acknowledge mental health issues in this country, and, to some degree, rightly so. But often success is only lauded because it comes in a sea of perceived failure. So when MPs talk about their mental health problems in Parliament I am pleased, but the very fact that it is such a big deal suggests we still have a long way to go before we truly have an open discussion about the prevalence and impact of mental health problems.

On Monday, the Sun ran this front page:

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‘1200 killed by mental patients’. Now the term ‘mental’ went out of use many years ago amongst those us who have some compassion and humanity. News International publications are not, if you will indulge me, known for either their compassion or their humanity. Despite the story admitting that most people who have committed serious violence in the context of a mental illness, the headline will do nothing to eradicate the image of the knife-wielding patient (an image that persists, as we recently saw of the Hallowe’en costumes being sold by Asda and Tesco).

So what are the real figures, the contextual ones? Well, here are a few:

– 1.2 million people in the UK use adult mental health services

– 95% of all murders are committed by people who have NO mental health problem (remember Harold Shipman, who killed hundreds of people?)

– Half of all violent crimes are committed by people under the influence of alcohol

– Around a fifth are committed by those who are under the influence of drugs

– People with severe mental health problems are 10x as likely to be the victims of violence as they are to be the perpetrators

– They are also more likely to harm themselves than anyone else: 90% of people who kill themselves have mental health problems

Given that 15 million people in the UK will have a mental health problem at some point in their lives, and that substances are implicated in the vast majority of all violent crime, this witch-hunt against those who are often very unwell is appalling. But let’s take a look at some more stats:

– Mental health services in the UK have had funding cut by £150m since the Coalition government came to power

– 2000 psychiatric beds have been cut in the last two years. No one, not even the Sun, got angry about that. But I know psychiatrists, good psychiatrists, who openly admit that they are discharging people from hospital when they are still unwell just because of pressure on beds. I have worked on wards where there are three people to a bed and you just hope to God that no one has a relapse whilst they’re on leave, because the chances of finding a bed anywhere in three boroughs is so slim.

– Mental health NHS trusts (which are distinct from physical health, as a general rule) have lost up to 20% of their staff since the cuts came into force. These cuts affect everything from secretarial support to the number of social workers and psychologists available to see those who need such intervention.

– Some of the areas most significantly cut: crisis resolution, early intervention, home treatment teams. In short, the very people who take care of those in crisis; the very people who can intervene if they see that risk is escalating. But they can’t, can they; not when they have caseloads of 60 or 80 people. As someone who works in community mental health services, I tell you this: it is impossible to look after that many people who present a moderate risk to themselves or others and to do it well. As the cuts take hold, services have increased their thresholds and increasingly, only take those deemed to be at high risk. 80 high-risk people cannot be managed by fewer than 2 professionals, and even then they will need intervention from other members of the team.

The fact is this: mental health services are buckling under the strain. Staff are overworked and under-resourced; many are simply burning out. It doesn’t take much intuition to realise that in a job which requires you to deal with people who often have complex needs, this is unsustainable. Newspapers could do a terrific job, if they could be bothered, of putting mental health on the agenda in a positive way. They could get angry about those people who are being denied services they need, not because we don’t want to provide them, but because we simply haven’t the resources to do so. They could make services better for the one in four of us who will have mental health problems – your brother, you best friend, your partner, your mum, your neighbour, your child. They could, if they wanted to. But, like so many others, they simply add fuel to this ghastly fire which means that those with mental illness are further stigmatised, further dehumanised and increasingly seen as the ‘other’.