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A Multifarious Web

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Amodiovalerio Verde. Sourced from Flickr and reproduced under a Creative Commons Attribution-Non Commercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0) licence

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.

References

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.

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Mental Health In Society

Dosage by Marino González. Sourced from Flickr and reproduced under a Creative Commons Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0) licence. 

I have just finished reading ‘Crazy Like Us’ by Ethan Watters, and although published 5 years ago, its critical perspective on the spread of the DSM IV’s definitions of mental health throughout the rest of the world, is critically pertinent to current discourses within mental health.

The book covers four common possible diagnoses found in the DSM IV; Anorexia, PTSD, schizophrenia and depression, and describes how significant environmental and social events were used by proponents of the western diagnosis model to spread DSM IV diagnostic criteria, and treatment interventions. Although initially suspicious of what appeared to be a conspiracy type perspective, I soon became fearfully aware of the truth within Ethan’s arguments. A strong current that flows through most of the book, is the idea that existing mental health symptoms and definitions are characterised largely by culture. So what the wider society considers as being relevant for defining a mental illness, dictates whether a person has, or hasn’t got a mental illness. Emphasised were cultures which did not have pre-determined definitions of disorder, such as PTSD or schizophrenia, until the arrival of western ‘professionals’ who characterised and labelled them according the DSM IV.

Ethan also proposed how physical and emotional symptoms changed, depending on dominant narratives within cultures. He argued that western professionals took advantage of this by creating symptom pools, which given enough media and social credence, often resulted in a mirroring of these behavioral and emotional expressions throughout that society. He gave an example of how anorexia played some part in ‘replacing’ hysteria in the late 19th century, and how the expectations and beliefs of the medical establishment at the time actually played a significant role in changing the physical symptoms of what was then hysteria, to what we now see as anorexia nervosa.

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Do we really listen?

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Listen by KY. Sourced from Flickr and reproduced under a Creative Commons Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0) licence

A common response that I hear from practitioners, is that they cannot engage in therapy with some clients, because their issues stem from problems in the family, school or the wider community, and are still present. I can understand this, and can see how some traditional therapeutic approaches such as CBT may struggle when presented with an overly systemic issue.

However, what I have increasingly become aware of, is that it is hard to find situations where a mental health difficulty and a societal issue are not linked.

Anthropologist Tanya Marie Luhrmann adopts a similar view in her work with Schizophrenia and finds it hard not to draw the conclusion that there is something deeply social at work“, and advocates for an approach that tackles cultural issues as well as the biological. She also goes as far to say that hallucinatory voices themselves are shaped by local culture.

In response to the government’s austerity policies over recent years, psychologists against austerity have highlighted 5 psychological pathways they term ‘austerity ailments’, specifically highlighting the consequences of austerity on mental health: i) Humiliation and shame ii) Fear and mistrust iii) Instability and insecurity iv) Isolation and loneliness and v) Feeling trapped and powerless. The report clarifies how these social stresses can impact on mental health. Within my work with asylum seekers and refugees the above ailments are particularly pertinent.

Working with people from different cultures has given me a unique perspective on mental health, and it is futile if cultural or systemic issues are ignored. Anna Leach picked up on the importance of taking into account culture and how neglecting to do so can result in offense and psychological damage. Similarly, in a BBC podcast Dr Pat Bracken suggests that the first place we need to start, when dealing with mental health problems of people from different cultures, is from their community and what they say are their needs and wants. Pat says that we should not impose our Western definitions and concepts of mental health onto others.

My view is that we need to adopt the same approach with all clients regardless of background. If we don’t truly listen, and don’t approach from a non-judgmental position then we can only impose our own views and diagnosis, and there is the likelihood that we begin to control rather than liberate.

Is there a place then for an attitude in mental health services, which says that a client is ‘untreatable’, because of unmet needs in their environment or society? Perhaps within particular types of therapy yes, but what this does highlight is the need for a different approach.

There are ways that mental health services can work with people who due to social/systemic issues may not fit neatly into prescribed therapies: We can firstly listen to our clients, to understand their needs and wants, rather than looking to define and diagnose in the first instance. We can then work alongside social and community organizations to advocate for our clients and support community interventions to address these wants. We can also be active in politics and active in trying to facilitate positive change at the political level. I admire the The Psychologists Against Austerity campaign which is one such approach. Finally, we need to remain critical of own approach, and continually question our intentions.

Narrative Therapy

Books by Moyran Brenn. Sourced from Flickr and reproduced under a Creative Commons Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0) licence

I attended a level 1 training course last week, run by the Institute of Narrative Therapy, and below I highlight some features of the course which grabbed my attention:

The first thing that struck me was the focus on our sense of self, presented as what motivates us, our passions, what we place value and worth in, and what are our principles and commitments. When I say it struck me, it did, and the relevance of this being hard hitting for me suggests that this is something that I am perhaps distanced from. It wasn’t so much the reference to identity it was what it was seen as. Concepts of identity which referred to constructs such as traits, disorders, aptitudes and needs were frowned upon in favor of less inherent terms. These internal descriptors present a sense of self which is predictable, linear, measurable and fixed and I couldn’t help but wonder if in my professional and personal life I barrier mine and my clients’ existence in this framework. Narrative therapy on the contrary presents self as being more than what can be summarized in questionnaires or squished into test tubes, and presents the person as being one of passion and meaning, unrestricted and uncontainable. I like this definition.

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CAMHS in crisis?

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Black cracks and blue by Geir Tønnessen. Sourced from Flickr and reproduced under a Creative Commons Attribution 2.0 Generic (CC BY 2.0) licence

The UK rarely fails to find a scapegoat, and within the media a spectacle is developing where children’s mental health services across the country are being shepherded towards the city gates, as reports make reference to services being fragmented and in need of complete overhaul (CYPN 2014, The Independent 2014). Large waiting lists and a shortage of beds are used to shine a blamelight, and there is nervous anticipation regarding Norma Lambs’ report scheduled for spring 2015. (The Guardian 2014, 2015)

Sarah Brennan says that cuts to preventative services underpin these apparent difficulties in CAMHS, and she is right, but the large weight of responsibility that is placed on CAMHS by the media suggests some level of societal misunderstanding surrounding how to maintain good mental health, and how to treat it when it becomes problematic. (Community Care 2014)

Sloping responsibility to CAMHS suggests that mental health difficulties can only be tackled by experts who have professional knowledge and also alludes that it is beyond the skillset that currently exists within other agencies. Continue reading

A quick reflection

reflections

I graduated with a psychology degree in 2005, but at the time felt a little disillusioned, believing that psychology was too diagnosis orientated and somewhat oppressive. Although I was interested in mental health, psychology wasn’t right for me at the time and I focussed my attention towards youth and community work, completing an MA in Youth and Community Work in 2010. I felt at home with the empowering and liberating ethos of the profession, but my passion for mental health never dissipated. In fact, it flourished through youth work, and through maintaining a critically reflective approach have become quite excited at the inseparability of community and mental health approaches.

As a result in 2014 I quit what was a fantastic job within the Local Authority as a professional youth worker, to take on two part time roles: a Community Mental Health Worker within CAMHS, and a Community Mental Health Support Worker within an asylum seeker and refugee mental health team. It was a bit of a risky move for a few reasons, and I still have a slight niggle of trepidation about it at times.

However the more I read and network, I am continually encouraged by an overwhelming appreciation for the social nature of our selves, Continue reading

Lets make a metalogue

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I attended an interesting presentation recently by Clinical Psychologist Dr Alexandra Lagaisse, who was introducing some of Gregory Bateson’s work on metalogues. A metalogue was defined as ‘a conversation about some problematic subject. This conversation should be such that not only do the participants discuss the problem but the structure of the conversation as a whole is also relevant to the same subject.’

Alexandra highlighted how Psychology traditionally was a study of the soul, and the impression given was that we seemed to have lost this. This led onto a discussion of the very concept of mental health and our views seemed inclined towards a person centered and social/systemic viewpoint. Alexandra asked why have we distanced ourselves from this and highlighted that rather than add to the problem narrative by focusing only on the mental health problem, we need to question the very cause of it in the first place.

At the end it was opened to questions, and I asked how we hold these discussions with those in power and those who provide the funding. I said how in my experience the palate is for a very medical and individual model, and that this easily boxed, accountable and measurable approach is what allures the funders. There were two aspects to her answer which I found important… one, that we have identified that the system currently isn’t working, something is wrong. In itself I guess this is a prelude to a metalogue. Secondly, we need to engage with people on a personal level. When she said this I couldn’t help but be reminded of how the IPAT program originated from a conversation from 2 people at a party. Continue reading

The Value of Youth Services towards Child and Adolescent Mental Health

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Below is an article I wrote for Youth & Policy last year, whilst employed by the youth service: http://www.youthandpolicy.org/youth-and-policy-112/

There are small snippets of research showing some benefits, an example being Mahoney and Stattin (2002), who show the value of after school activities on depressed unattached youth, and Fite et al (2011), who link attending youth programmes as a buffer against depressive symptoms in young people developing in deprived areas.

Coulston (2010) appreciated the affinity between youth work and promoting mental health, and published a report, detailing some of the ways in which Youth Work can help prevent young people from developing mental health problems. They identify how youth clubs can help to develop and strengthen young people’s resilience, reduce young people from adversely negative social-demographic factors, and also help prevent young people with ‘low level’ mental health problems from developing a more severe mental health problem. They also indicate that youth clubs can help promote mental health awareness and also assist in young people getting access to more specialised mental health services.
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Working with Young People

I had the following printed in the Careers section of the Psychologist in Dec 2013: (http://thepsychologist.bps.org.uk/volume-26/edition-12/careers)

I am currently a Youth Worker within Plymouth City Council, and have been a youth worker for the last 7 years. Since completing my Psychology Degree in 2005, and having worked in some diverse youth work environments, the impressions that mental health can leave in the various contexts of a young person’s life has always captured my attention.

I began my paid employment within Devon Youth Service, which involved staffing generic drop in sessions for young people aged between 13-18 in Tavistock Devon, and then went onto work in a similar generic youth drop in setting for Plymouth City Council. Within the context of an open access and generic session, young people just turned up, and would engage with youth workers in social settings, perhaps playing pool, cooking, fashioning art work or other similar activities. My interactions with young people recurrently included discussions around their social, familial and educational relationships. I would also respond first hand to conflicts and tensions arising from young people’s relationships or due to young people’s emotional and behaviour difficulties. It was within this generic youth work environment, underpinned by some of Youth Work’s core values such as; starting where young people are at; being young people led; voluntary and focussing on empowerment, that I realised the contribution that Youth Work accomplished towards reinforcing Social and Emotional competencies in Young People.
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