Notes#3(Other)‘From Communism to Schizophrenia and Beyond’

Chapters 11, 12, & 13Chapter 11: ‘Two Psychiatrists Look In’ by Duncan Harding and Frank HollowayNomothetic and Ideographic approaches. Nomothetic is generalised. Evidenced based medicine, rule bound, is nomothetic. Subjective phenomena are ideographic. Mental illness is today understood in personal, narrative terms which enriches literature. Recovery can be understood under both headings. Simple user narratives can be analysed in a sophisticated manner. The increased availability of user narratives can be the basis for a nomothetic body of work and analysis. The recovery paradigm is confusing for some as the perspectives of nomothetism and ideography do not come from the same place, and some do not know the basis of the practice they are engaged with – staff and service users. A third strand is the disability lobby which stresses users’ rights to social inclusion.Psychiatrists are trained to deal in symptoms, diagnosis, illness, disability and impairment. Hope can be lost if mental health professionals do not nurture a person’s optimism. Recovery involves rediscovery of identity and finding meaning in their life. Social exclusion is an almost universal consequence of severe mental illness. Autonomy is lost especially under Section and Recovery means regaining that autonomy. Recovery does not necessarily mean going back to an old life, it means accepting the limitations of illness and going on to get hope. (Romans 5 Ch 5: suffering leads to perseverance; perseverance to character; character to hope.) Medical science is concerned with nomothetic discourse, however an ideographic story can be powerful if it leads to a doctor changing his view. Gordon’s story is a good example. There are reliable tools which enable nomothetic processes. There is however a possibility of

a gap between Recovery talk and Recovery practice. Severe illness can be positively affected by treatment with dignity and respect. This is the principle on which hospital closure, deinstitutionalisation, was based. The patient is the ‘expert by experience.’ Everyone is influenced by those around them – a social construct. There is evidence that it is better to work with psychotic symptoms rather than trying to prove them false. With autonomy comes responsibility and choices including for their own Recovery. There is the notion that symptoms are illness, and a move towards the notion that these are shared human experiences. Recovery can have its origins in the ‘moral’ movements of the 19th Century about social welfare of inmates – cf Henry Hawkins. Gordon’s experience and that for Recovery is based on narrative and service users’ experience.

Chapter 12The right to contribute: Employment and recovery

By Rachel Perkins

Rachel’s Quaker upbringing gave her a belief in the dignity of labour, and that work inevitably defines us in our society. Manic depression is a serious conversation stopper. Rachel has been aware that she gets ill, but is fearful of the statistical downsides of mental illness; prejudice, discrimination, exclusion. She crosses the divide from sane to mad. She gets fearful that she will lose everything: friends, home, sports car, job. There was the ‘Clothier two year rule’ that said you can’t be employed for that time in the NHS after a breakdown. Her grandmother said that if you fall off a bike, get straight back on. There was advice given to Rachel that work as a clinical psychologist will be ‘too stressful’, maybe she should do something with less pressure – tell me about it. The right to work is denied in mental health. Normal: 74% employed. Disabled in general: 47%. Mental health: 21%. Incapacity benefit due MH = 30%/1999 to 48%/2008. Thatcher years: move from UB to IB. Now move to reverse this (2010). This means still no job, and less money. Choice to work or not is only real if there is actually the choice of available jobs. This means support and adjustments. Much to learn from social model of disability. ??She says no-one with MH is intrinsically unemployable (Michael W? Margaret B?). This may mean intermittent work only or with high level of support (Instructors in IT units?). SU permitted earnings – this is exploitation if not properly paid. Greek philosopher Galen said work was ‘nature’s best physician.’ Szasz agrees: ‘closest thing to a panacea.’ Supported employment is an aid to recovery better than meds or talking therapies (Drake 2008) – sounds like an IT unit. To have no job is not to rest, and a vacant mind is a distressed one (AGREE) (William

Cowper). Unemployment can mean premature death. MH means 10 years less life expectancy. Unemployment means worsening of MH condition and greater risk of suicide. Unemployment does not lead to social and leisure pursuits, it leads to isolation. Any class of people – including MH excluded from labour market is devalued, marginalised, and excluded from everyday life. It can lead to loss of identity except that of mental patient. Recovery is a challenge to live beyond what has happened – there is no way back to how it was before – you need to believe a decent life is possible. Patricia Deegan: In mental illness, hope can be a matter of life and death. This can be difficult if no-one believes you will amount to anything. Options for MH: unpredictable and dangerous OR incompetent and unfit to join in society. Professional literature : full of risk, deficit and dysfunction; this reinforces social constructs about madness, and unlikeliness of ability to work. For most people, they want jobs, homes and friends. Always being on handouts is demoralising...the empowerment of becoming a tax payer and help from employment specialist. ‘It was great to be back on the Tube in the rush hour.’ Voluntary work in MH as an SU with no pensions, sick pay and other benefits – this is inadequate and what the service providers themselves get. Yet it shows how user involvement and other activities are engaged in, a willingness to contribute and to work. Some SU’s are told they will never work again. Employers avoid recruiting MH, and this itself reinforces social constructs that SU’s cannot work. There is dignity and risk in recovery. Media images are of welfare scroungers with the threat of loss of benefits. It’s better to remain in the security of poverty on benefits than to risk seeking work. This is reinforced by psychiatric emphasis on deficits, disorder and dysfunction. Number of randomised control trials that show 60% of people with MH can find and keep work. Model in UK: treat symptoms and then put into sheltered employment. This is

really not common sense. Research shows that treatment and employment support must go in parallel, and support must be flexible and available for as long as needed. Very few people get this effective support. There may be more fundamental difficulties with this approach of treatment, cure and care. A: The social model of disability shows that it is the asymmetry of the world that is at fault, not the person (so why try to cure the person?). B: Even if a person’s symptoms can be got rid of, there is still stigma and discrimination to cope with. The right to treatment and cure is not enough – you need full citizenship with the real choice to work. We need to negotiate the social world, as opposed to the physical. (Social construct.) Some people may need a buddy all the time.

Chapter 13Recovery for practitioners : Stories to live by

Glenn Roberts

This Chapter is very strong on narrative and creativity

The power of stories and the concept of the wounded healer. Quotes ‘Chronicity arises in part from telling dead or static stories’ – this is a bad thing: cf my evolving narratives at MHFA etc. Alive-stories, they define, inform, and guide us. How to keep your story alive. After 100 years of research, the origin of severe mental illness remains unexplained. Understanding comes through stories and can contribute to collective origins. Quotes ‘We are born into stories; they nurture and guide us through life.’ Re-authoring of our lives can apply to practitioners as well as those in recovery. We are all ‘people first’ and debate around the medical model can discomfort psychiatrists. The medical model can be characterised by broken brains in need of drugs to correct chemical imbalances. This can add to stigmatisation – Glenn thinks this is wrong. Writing by professionals has become progressively depersonalised. Chiron was half man half horse in Greek society, who was the wounded healer, a member of the ‘second oldest professional.’ Panacea was a female in Greek mythology. Early medics were illegitimate, despised, rejected, and raised by strangers. Narratives are similar, as transitioning from victim to victor. There are stories of survival and overcoming. Through telling our stories we can get a sense of belonging. Glenn himself has had periods of extreme depression. He emerged from a difficult childhood, and from his earliest encounters with mental hospitals he felt at home with residents. He has worked in rehabilitation and also has had to deal with the Mental Health Act. Much of his adult life has been spent struggling with depression.

This results in low mood plus diminished energy, hope, attention, concentration, capacity for life and relationships. He can wake with a sense of dread. He once considered for three days and nights whether to hang himself. Even kindness does not move him. His first marriage failed, he refers to suits worn to work as ‘body armour’. He has hitched around Europe. He began to hear stories of recovery and heard of people taking responsibility for themselves. Recovery seemed to pull together several strands of practice. Glenn writes of supporting staff in their recovery journeys. In a survey, 43% of staff respondents said they had personal experience of mental illness, and 63% cared for someone close with MH.

Chapter 14Conclusions:

One man’s journey of recovery, is everyone’s journey?By Gordon McManus and Jerome Carson

Ch7: Jerome states that Recovery is a relatively new concept, including from Patricia Deegan as recently as the 1980’s. Recovery requires a great commitment. Peter Chadwick: with right attitude you can put it all behind you and move on – a journey to who you really are, for Peter mixing with the mind-healing folk, not the mind-wrecking. Peter endorses JAM of Rachel (Perkins). Both Peter and Gordon have written themselves better. At Jerome’s behest, Peter states the number of people benefitting from a psychotic experience as about 8%, who can then be an inspiration to others. Harding and Holloway state that professionals need a profound interest in personal histories and the personal context. Rachel states that it is not illness that stops people working, it is low expectations and inadequate support. Gordon points out that his journey is ongoing, and a major turning point was when Gordon had CBT arranged for him. Gordon and Jerome developed a multi-stage model of Recovery, with the fifth and last stage being a return to a normal life, something he is only nearing and has not as yet obtained. Previously psychosis had taken him away from the dream of being a communist revolutionary. The McManus/Carson model of Recovery showed Gordon he wanted that goal of a normal life. Jerome helped Gordon by giving him articles on Recovery. You have to ‘keep it up’ with the Recovery journey. Gordon had to confront his life when he wrote his chapters (cf me and Margaret Moss writing my stories initially.) Gordon has found other SU’s experiences to be invaluable, providing a light for his journey. There needs to be a dialectic between the Recovery and medical models, with a paradigm shift

which Gordon hopes to write about. Gordon’s goal of a full recovery and normal life will be a place on his ‘long march’.

which Gordon hopes to write about. Gordon’s goal of a full recovery and normal life will be a place on his ‘long march’.