Thursday, March 23, 2023

Comments by JonathanGadsby

Showing 3 of 3 comments.

  • Hi Jay,
    I’m pleased to tell you that a group of trainee Approved Mental Health Practitioners in Birmingham thought this post was absolutely superb today. New ideas to them that seemed to instantly resonate with their feelings of disillusionment and concern. They also liked the work of RITB, too.

  • Hi Alec,
    Thanks for your reply.
    The reasons I feel that demedicalising and deinstitutionalising are not as important as depathologising are something like this (although I want to think more about this).
    1. Demedicalising: Well… taking the bio out of explanations of experience has seemed like a crucial step in emancipating people as more complex, raising them as people who can make sense but also being more vulnerable to others – our multi-storied selves. I think that biomedical explanations of experience are unacceptably reductionist, and they reinforce mind-body dualism (even though weirdly they often claim otherwise), are highly politically contentious, scientifically spurious etc. So, in the main, I am absolutely for the demedicalising of distress in society. Yet two things make this a bit more nuanced for me. Firstly, within the Hearing Voices Network are a number of different ideas about where voices come from and these ideas are in some ways comparable to bio, psycho and social (not that they would be happy with those terms and I understand why). Their ‘bio’ is encapsulated in their story called ‘common human experience’ (it does not necessarily follow that it would be biological, but that is the way they use it). Yet in holding this bio view, they crucially do not pathologise. To have voices as a common human experience is to find solidarity and to be able to make demands upon the state under the guise of equality and non-discrimination. They can see voice-hearing as an ability. I think the HVM has shown me that one can have a constructive and empowering biological explanation (although neither psychiatry nor the HVM have any established grounds scientifically for that view, only that we have bodies and therefore something of our experience is bodily experience, which is weak). It is possible and helpful for some people. It is using biology as a story, ironically, which undermines it as biology, but there you go – wheels within wheels and exactly what psychiatry does anyway. The same is true of psychological and sociological arguments from the HVM. They manage both without making the voice-hearer faulty.

    One further aspect to that is a person I met recently who went on the most extraordinary voyage of personal discovery upon accepting that his voices were ‘medical illness’. He reasoned it this way: If his voices were ‘real’ then he had to follow them (and he quickly got into all kinds of difficult territory with telepathy and self-identity and other things). However, if they were ‘medical’, then they came from him, and if they came from him then their content came from him. If their content came from him this was a key to his self (he called it his ‘sub-conscious’ and his memories) that few people had. Although it was confusing, eventually he was beginning to understand his emotions in a whole new way by thinking about what these voices were trying to tell him and why. He did this without knowing anything about the HVM. For me, this very clever and articulate person challenged the thought that I had that the story ‘medical’ was always necessarily wrong – for him it wad been a great source of liberation (shame about the sedating crap the nurses kept doping him up with and the fact that he had to learn not to tell them about his fascinating thoughts because they just interpreted it as more illness and got the dose increased). So, I concluded that what made him different to so many people who accept their experiences as medical is that he managed to not pathologise his thoughts and voices in the process. He was allowed to think (I mean he gave himself permission) whatever he liked and learn by it. So, although that is the first story I have come across quite like that myself, and I would have to admit that his interpretation of ‘medical’ is rare, I did think it said something interesting to me about pathologisation being key.

    Now that I have written the above I have changed my mind a bit though! It is those points about biology and ‘medical’ being stories which are important. If I am happy with them only as certain kinds of stories rather than as other kinds of stories, then I still want to explode their myths as apparently unstoried natural science, don’t I?! Hmmm. So I still want to de-medicalise.

    2. De-institutionalisation: This one is much simpler. I think if we don’t de-pathologise then we don’t de-intitutionalise. We might close a lot of beds, we might set up community teams etc etc, but if they are still pathologising then the institution of psychiatry is alive and well. I think the NHS has more or less failed to de-intitutionalise (even though that is unfair to some small pockets and some individuals), and I used to be a great believer in my role as a CPN in AO and EI. When I first started in EI in 2008 the buzz words were ‘diagnostic uncertainty’. Now it is ‘earlier and better diagnosis’. Not much to celebrate there. So, once again, the institution of psychiatry (along with much of psychology) is there is maintain the integrity of the story of distress-as-pathology, and we can do that in any location, it seems.

    As for the NMC: I am not an expert about the NMC in general, but in setting up the Critical Mental Health Nurses Network I felt the NMC code of conduct was an ally. There are loads of statements there about our responsibility to evidence, our responsibility to raise concerns, to make our service-users informed and empowered, to escalate concerns about safety etc. I interpret all of that as supportive of the aims of the critical mental health nurse.

    Finally, I am really interested in your thoughts about peer-reviewed journals and academic orthodoxy etc. I want to open conversations about the undemocratic nature of journals (it’s scandalous) and I wonder what may be said about that. I am at the beginning of that game and I don’t know if I want to play, basically. I’ve just done a PhD which would have been quite impossible without some extremely creative re-interpretation of copy-right law, shall we say, and, well, theft. Couldn’t have done it otherwise and I know I am far from the only one. Now I am stepping over into a paid researcher role, I would rather be honest about the broken and corrupt system than pretend it gives me what I need. And, as you imply, I have doubts about how much I can respect the peer process anyway.

    Cheers, Jonathan

  • I’ve been really enjoying this post and comments.

    Firstly, yes, I always hoped the CMHNN website would develop a set of pages for and about nurse education. I’m hoping to think some more about the Willis Shape of Caring review and how we might piggyback a lot more critical ideas into the course because of it. Certainly there is a remit there to demedicalise and deinstitutionalise nursing, and an intriguing possibility about special training for community roles – perhaps that maybe a chance to shoehorn in more ideas about what community actually is and what shapes it? But I have also been reflecting recently that demedicalising and deinstitutionalising are not as important as depathologising. As usual, it is survivor networks I have to thank for that point of view.

    In regards to this comment thread, all I can say is that I have taught critical ideas to six cohorts of mh nurses over the last three years. I have been bolted on to their course at the end for just a few hours and, although I have been very grateful for that opportunity, I think it is very unfair on the nurses that it should be so, and frustrating for me to try to ‘do’ critical mental health in about 4 hours. To me it is clear that if it is worth the attempt of getting nurses to see what the world looks like outside of their very particular and peculiar ’emplotment’, then it needs to start much much earlier. I need to do what I have been doing more slowly, more gently and right from the first year.

    It has been interesting to see how the classes have responded. I have felt torn in the very rationed time available about whether to devote time to thinking about the problems of validity of psychiatry, or instead try to take a bigger view of the range of ideas and the politics of distress in society. I have gone for the latter, because I don’t want to give the impression that the problems of psychiatry are mainly down to not quite getting the science right yet… although students are stunned when I tell them a very few things about, say, the validity of the ‘chemical imbalance’ trope. I also feel that without this broader political viewing, then there is nothing there of critical psychology, and I feel some of the most important critical thinking applies to both and is better understood that way. As a community mental health nurse I felt that psychology was the antidote to the excesses of psychiatry, and I think many nurses a drawn to that idea.

    How do they respond to this repoliticisation? Mostly, they seem to find it good, but it really takes them a lot of effort to see their subject as something that has anything to do with politics. I usually shy away from saying more overt things about psychiatry’s connections with the far right, because I don’t want them to think I am some kind of dismissible extremist, and in any case, they never seem to have heard the word ‘eugenics’ before. It became apparent yesterday that the class was not really familiar with the idea of ‘left’ and ‘right’ in politics anyway. Politics is separate to nursing in their view…. so we have to cover a lot of ground. It is my aim for each class to be able to understand something of the phrase ‘the personal is political’ by the end of the time we have together – both the interpersonal and the intrapersonal.

    I find it very very irritating when students tell me that really, things have changed now, and they are more holistic, less medical. I really relate to the part of the article above in which Alec says that there is an idea that really, there is already all this critical thinking going on, and really, psychiatry is not all medical, and really, I am making a strawman out of psychiatry. If that were true, then there is simply no way – no way at all – that the students could be so astonishingly ignorant of the world outside of their ghetto. And, like Alec, I don’t think they can be blamed all that much – not yet, anyway – because they see themselves at the bottom of a big hierarchy and are just hoping to get good enough, learn the right words, to get a job, to become qualified. YWaves, I admire the time and space that you seem to have developed with students. At present I have to fly in like a kind of aerial bomber and zoom off again – the worst way of effecting real change; the killer lecture. The good news is that this is going to change for me, I am being employed by the university and I hope to be able to get into different parts of the course, actually get to know the students a bit more, etc.

    Finally, it has been interesting to me to teach similar material with student social workers, qualified psychiatrists and (soon) AMHP’s. Social workers are also nothing like as switched on politically as I would like, but they do seem to get it faster – but then they have less to lose. The medics were hard to draw into conversation, and I suppose they can’t have enjoyed my ‘portrait of a psychiatrist’ section, adapted from Bonnie Burstow, in which I suggest that psychiatrists use future evidence for current practice (among other things).

    It seems we have an awful lot to do. I look forward to continuing these conversations.