Below I reflect on the need to consider the bigger picture when working with psychological distress.
At times it felt gritty and often was very stressful, demanding and unpredictable, but recollecting on my past experiences within youth and community work leaves me feeling silently despondent that something fundamental is missing from my practice now.
It was the multifarious web of interwoven relational circumstances within youth work, which fuelled my interest in the ever-present role that mental health played, and I still struggle to draw the line between what we can identify as the individual, and what is more socially related.
What did seem consistent was that an individual’s mental health always seemed to be emblematic to their circumstances, and although individual factors were clearly relevant, social and cultural influences seemed crucial. An individual’s mental health was clearly part of a cyclical system interwoven throughout multi-systemic areas of people’s lives, and it was difficult to really grasp specific causal factors, or come to neat formulations of emotional distress. Being so enmeshed within these systems as a professional, I saw that to better understand emotional distress I had to really move beyond biology and physiology to the real life of people’s families, streets, neighbourhoods, schools, council policies etc. The systemic threads were interwoven and complex*, and to deny the existence of the elaborate multiplicity of events that make up a life, in a sense devalues the person.
However, on moving into more specific mental health job roles, the disparity in appreciation of this within treatment interventions initially attributed to a momentary lack of confidence in my understanding of mental health, and I felt a little disillusioned regarding the relevancy of my past experience. The biopsychosocial model is frequently referred to as the additional model alongside medical psychiatric interventions, yet as highlighted by Cornish (2004), it doesn’t seem to go far enough in appreciating the relationships and roles of the 3 systems, in particular the role of the social.
Cecil (2007) makes it clear that the very definition of mental health is not clear cut and describes how culture defines abnormality and illness. Watters (2011) discussed how culture can go so far as to influence clinical presentations and distribution of mental health. There is a strong argument to suggest that within the UK we are witnessing a governmental attempt to define mental illness, through IAPT counselling services being placed within jobcentres, and the consideration of benefits being sanctioned if counselling is refused. (Jackson 2015).
When we consider evidence for more systemic approaches, (although difficult to fit within a restrictive template for what is deemed as legitimate therapy by ‘Evidenced Based Practice’ (Johnstone & Dallos 2003)), systemic approaches work (Dallos 2003).
Within more community type interventions, there is lots of evidence and voice about early intervention in the community being preventative (Early Intervention 2015), however as important as awareness of this is, community type interventions are not just preventative, but also should be seen as a form of intervention. It would be futile to treat a patient for a broken leg for example, without ever attempting to deal with the giant sink hole outside their front door!
For me this is perhaps one of the biggest pitfalls within evidenced based practices. Working within mental health services in Northern Ireland, Bosqui (2015) discusses how the common models of intervention assumed that trauma was in the past, leaving her with a feeling of helplessness when working with clients in the context of present traumas. She described how she then went onto work in the psychosocial department of the Palestine Red Crescent Society, and found that similarly her usual reliance on trauma focussed CBT was inadequate for the unstable environment her people were in. The reality for her was that there needed to be a different approach, which led her to reflect on the Inter-Agency Standing Committee’s multi-layered model (Bosqui 2014), where intervention was approached via 4 tiers; of Basic services and security, community and family support, focused non-specialised support, and specialised services.
Within statutory therapy services in the UK I don’t perceive that the influence of current stressors, such as those highlighted by psychologists against austerity (2015), is really taken into account. I also question whether any of the randomised controlled trials that justify IAPT services and interventions really consider current stressors within their research methods.
To summarise, emotional and psychological presentations of emotional distress are more representative than many of our clinical models give credit to. My opinion is that it is all very cyclical, and that although biological and chemical accompaniments are part of this cycle, in most situations the environment and society is a large and majority part, and it is futile to consider the biological without the societal.
* Rug metaphor kind of originated from ‘The Tapestry Poem’, quoted by Corrie Ten Boom, author of poem unknown.
Bosqui, T.J. (2014). Clinical psychology without borders: Psychosocial interventions in the occupied Palestinian territories. Clinical Psychology Forum. 258: 4-7
Bosqui, T.J. (2015). The role of clinical psychology in global public psychosocial and mental health. Clinical Psychology Forum. 268:5-6.
Bronfenbrenner, U. (1979). The ecology of human development: experiments by nature and design. London: Harvard University Press
Cornish, Flora (2004) Making ‘context’ concrete: a dialogical approach to the society-health relation. Journal of health psychology. 9 (2):281-294
Coulston, K. (2010) Somewhere to talk, somewhere to listen. The role of youth clubs in supporting the mental health and Emotional Wellbeing of young people. London: Clubs for Young People.
Dallos, R. (2003). Working Systemically with Families: Formulation, Intervention and Evaluation. Karnac books: London.
Early Intervention (2015) https://twitter.com/Time4Recovery Last accessed 16th Aug 2015.
Jackson, C (2015). Should counsellors work with workfare? Therapy Today, 26 (9). pp 8-11.
Psychologists against austerity. Mobilising psychology for social change. https://psychagainstausterity.wordpress.com/ Last accessed 16th Aug 2015.
Watters, Ethan (2011). Crazy like us: The globalization of the western mind. Robinson: New York.