Asylum Magazine Interview

The following is an interview between Jonathan Gadsby of the CMHNN and Helen Spandler, part of the editorial collective of Asylum Magazine, an affordable quarterly magazine that is packed with articles about critical mental health. There is simply no other magazine like it in the UK and it feels like it has an increasingly important contribution to critical thinking about mental health. True to the form of the magazine, Helen’s answers contain lots of pointers to other organisations doing interesting work, and links are provided.

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JG: Asylum has just had its 30th anniversary. How did the magazine get started?

HS: Asylum magazine www.asylumonline.net/ was launched in the spring of 1986. It cost 50p and was “Free to Inmates”. The mag was inspired by the anti-psychiatry movement, the psychiatric survivors movement and the Italian democratic psychiatric movement.  A small group of professionals, academics and survivors were galvanised into action by a group of mental health workers who visited the UK as kind of ‘missionaries’ from the Italian movement. Over here, the old asylums were closing down and Community Care was the big thing.  People were looking for inspiration to turn this into an opportunity to do things differently, rather than it being just a Thatcherite cost-cutting exercise. The situation is not that dissimilar to what’s happening now, with austerity and the rise of ‘recovery’ (instead of community care).  The phrase ‘be careful what you wish for’ springs to mind!  But this situation is replete with perils and possibilities. The magazine got started to have a genuine debate about what was happening in mental health and to give a voice to those who aren’t usually heard. This is just as important now, as it was then.

JG: On the front of the magazine it says it is for ‘democratic psychiatry’. What does that mean? 

HS: The term was taken directly from the Italian movement which inspired the magazine. We’ve had many debates over the years about its continuing relevance. Some people, especially those influenced by anti-psychiatry, including the late Thomas Szasz, thought democratic psychiatry was an oxymoron.  I think this is partly true.  I guess we hope for something better – that, whatever we call it, we need an organised system to support those of us in distress. But we believe it needs to be organized more democratically, with people who are most affected at its heart. I see this as aspirational, something that we need to be always working towards.  How this is achieved, and what it might look like, should be open to continual debate.

Personally, I’ve always been inspired by therapeutic communities, but this certainly isn’t shared by everyone involved in the magazine, and they are not without criticism. I’ve also wanted to see Soteria-like developments in the UK http://www.soterianetwork.org.uk/ and more survivor led crisis houses like the one in Leeds http://www.lslcs.org.uk/ I’m quietly optimistic about initiatives like Open Dialogue http://opendialogueapproach.co.uk/ and Peer Support Open Dialogue http://peersopendialogue.com/.  But, again, these are all up for discussion and critique.  There is no panacea.  To borrow a term from the excellent new survivor led anthology http://www.pccs-books.co.uk/products/searching-for-a-rose-garden-1#.WBMfUiTvtAU we’re still searching!  Franco Basaglia used to say that we should avoid creating golden cages and instead transform society to truly include madness.

Oh yes, we had quiz a few years ago about your question. See http://www.asylumonline.net/asylum-quiz/ for various answers!

JG: The last edition contained a short article about ‘mental health stigma’ that I think was the best thing I have ever read about it! Looking back over 30 years, are there any issues or articles that stand out as being especially important? Why? 

HS: That’s a big question!  There have been some very popular special issues over the years. Off the top of my head, our first issue which was devoted to an exclusive interview with Ronnie Laing; the issue edited by the group Women at the Margins on ‘Bullshit Psychiatric Diagnosis’ (BPD); and the special issue on Anti-capitalism and Mental health, inspired by the Occupy movement – all proved very popular.  Our recent 30 year anniversary edition also sold out fast http://www.asylumonline.net/portfolio/23-2-summer-2016/

Over the years we’ve published some important pieces from the early mental patients and survivor movement, such as CAPO (the Campaign Against Psychiatric Oppression) and PROMPT (Protection of the Rights of Mental Patients in Treatment) in the early 1980s; various protests, such as the Kiss It campaign against forced treatment in the 1990’s; and more recent projects like the Survivors History Group and Recovery in the Bin. We’ve also featured whistleblowing stories that other people wouldn’t publish.  I’m often struck by some of the cartoons, comics, stories and poems we’ve published over the years.  These are able communicate experiences in a really powerful way that are hard to convey through the usual clinical, academic or research type formats.

There really are some hidden gems in our back catalogue. We’ve just deposited a full collection in the Wellcome Trust library in London, Euston.  So it’s available for people to consult.  One day I’d like to put together an edited collection featuring some of the best bits of the magazine over the years.  I’d be interested to know what other people think are the highlights.

JG: How did you become involved and what does the magazine mean to you personally?

HS: I came across the magazine many years ago in a radical bookshop (remember them?).  I got involved through the late Alec Jenner and Tim Kendall who helped produce the magazine in the early days (along with Phil Virden and Lin Bigwood who are still involved today). They had just set up a really interesting Masters course which ran briefly in Sheffield in the 1990’s called Psychiatry, Philosophy and Society.  I took along my undergraduate essay on the German Socialist Patients Collective (SPK) to the course interview and, a week later, Alec wrote to me saying they’d like to publish it in the magazine. This meant a lot to me and I’ve always wanted to offer similar opportunities like this to people. When I went to Sheffield I started to get involved in the magazine and I’ve been involved, in one way or another, for about 20 years. I know from personal experience how fraught with tension, contestation and difficulty the mental health field is. That there are no easy answers.  I feel strongly that we need spaces where these can be openly discussed, and where difficult and unpopular views can be aired and thought about.  This is very much an ongoing struggle and an unfinished project for me.

JG: What is next for Asylum?

HS: I’m currently putting together the next issue of the magazine which will be a special themed edition on Mad Studies. I’m really excited about the development of new Mad centred knowledge and practice.  I was hugely inspired by the recent Mad Studies stream at the Lancaster Disability Studies conference and wanted to share some of the new ideas and thinking that were emerging there. We’ve had so many fantastic submissions we’re having to do this over two issues. We also have some superb creative writing and poetry about to be published in the new year. In addition, next June 2017 we are holding an event in Manchester called Action and Reaction that is low cost and free to subscribers. http://www.pccs-books.co.uk/products/ticket/asylum-action-and-reaction#.WBJ_DiTvtAU.   Hopefully this will be an opportunity for Asylum readers and supporters to connect up and re-galvanise.

One of our main struggles at the moment is keeping afloat. I truly believe the magazine is better than ever, but people don’t seem to buy magazines anymore, and we’ve really felt the impact of losing so many radical bookshops.  We also need to get libraries and organisation to subscribe. So if people can get their mental health trusts or University libraries to subscribe it would help us enormously. It’s a great resource for staff, students and service users alike. With the demise of the Mind magazine OPENMIND a few years ago, it really is the magazine for radical mental health.  Please consider contributing, subscribing or helping us distribute the magazine. You can contact us at:  editors@asylumonline.net

JG: Thank you very much. Here’s to the magazine’s next 30 years!

What is going on at the DCP?

This post is a short round-up of some extremely interesting work being done by psychologists in the UK, mostly connected to the Division of Clinical Psychology, taking a critical view of mental health services. It also introduces a brand new document they have produced, as well as two other important recent ones. Mental health nurses won’t be in the least surprised that psychologists do not always agree with psychiatry, and it would be foolish for us to suspend all critical thoughts about psychologists, too: one reason for a previous post from Jonathan Gadsby about the psychologisation of unemployment.

However, it is gratifying that there are a number of psychologists who are very critical about all ‘psy-diciplines’, and as such, their efforts are a really important part of what makes up an increasingly articulate, urgent and influential critical mental health scene in the UK. Anne Cooke’s collaborative piece, Understanding Schizophrenia and Psychosis is another significant contribution – and the CMHNN thoroughly recommends it as a plain-English introductory guide – imagine the impact of this document were it to be read on every mental health ward and CMHT in the UK!

Steven Coles is a clinical psychologist in Nottingham and one of the editors of a 2013 book called ‘Madness Contested, Power and Practice’, published by PCCS books. It is a very interesting collection of critical mental health writing and certainly one of the best of its kind in the past few years, and £20 that no mental health professional wanting to understand some of the controversies of their work could regret spending. In this post he writes about the steps which led to the Beyond Diagnosis Committee, of which he is chair, and particularly focuses on a document about the use of language by mental health professionals, which makes suggestions for terms which are less pathologising and do not rely on diagnoses.

It is this committee which has now produced a new information leaflet about diagnosis. The link to the leaflet in PDF form is here. We would greatly value mental health nurses and service-user feedback about this new leaflet. Specifically, nurses, this has been designed to be something you might give to a service user. Is that something you are going to do? If yes, why, if no, why not? And, if you are a user/recipient of mental health services, what do you think about this? Helpful? Or not? Please feel very free to comment below – and, as ever, Steven will see them and be able to respond.

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Steven Coles: The topic of psychiatric diagnosis appears to cause significant emotional reactions for people and be a continuing source of debate – with a variety of opinions expressed within and between: professionals, people who are labelled, people who avoid being labelled, family members and the wider public. In 2011 the Division of Clinical Psychology started to work on a position statement on diagnosis (partially influenced by a statement by an East Midlands DCP subsystem statement on diagnosis) [link here].  This led eventually to a short statement that called for a movement beyond diagnosis and was released in May 2013 on the day of release of the new Diagnostic and Statistical Manual (DSM-5). This statement was not formed easily but came from much discussion, debate, consultation and eventually the formation of a shared position. The build up to and release of DSM 5 was controversial with many people and groups highlighting concerns about diagnostic practice, including psychiatrists and mainstream organisations, such as the director of the National Institute of Mental Health, who described that DSM’s  “weakness is its lack of validity” – essentially it was scientifically meaningless. This statement from a mainstream organisation is astounding given the claims made of psychiatric diagnosis as being scientific and the vast amount of money that has gone into research.

Why is this important? For me, it is significant as psychiatric diagnosis shapes how we make sense of our lives. Finding and creating meaning out of our lives and our experiences is crucial for us as individuals and as communities. Currently within mental health services (spread to wider society) distress, unusual behaviour and experiences are classified based upon a medical framework which is more usually used to categorize problems with legs, lungs and livers. Usually medical diagnoses give an indication of the cause of a medical illness, its outcome and treatment, however, psychiatric diagnosis is unable to do this. However, we are still led to believe that the cause of our problems is some biological dysfunction, due to psychiatric diagnosis association with physical medicine. By focussing on the biological we marginalise the importance of abuse, poverty, poor employment conditions, housing, social inequality and so forth in making sense of our lives and it ultimately shapes how we respond to people who have been harmed by the world. This is not to say biology has no role to play, biology enables everything we do, including typing this paragraph, but biology is not necessarily the cause of what we do or what I write.

As a starting point, I believe we simply need to honest about psychiatric diagnosis and be transparent with people who enter mental health services and the wider public that it is a contested practice. It really does not seem ethical to me to give people a diagnosis as if it is a simple unproblematic fact, given that a wide range of people are critical of the practice. To support clinical psychologists to work in a manner that is consistent with the DCP position to move beyond diagnosis, brief guidelines (not a diktat!) were written in 2015 [link here], the key aspect to these guidelines were encouraging psychologists to describe behaviour and experience within its “personal, interpersonal, social and cultural context”. The basic principles are:

  • Principle 1: Where possible, avoid the use of diagnostic language in relation to the functional psychiatric presentations
  • Principle 2: Replace terms that assume a diagnostic or narrow biomedical perspective with psychological or ordinary language equivalents.
  • Principle 3: In situations where the use of diagnostic and related terminology is difficult or impossible to avoid, indicate awareness of its problematic and contested nature.

Moving away from diagnosis is a long road as it is embedded within many of the organisations and systems people turn to for help, however, I believe it is important we step out on this journey. This journey is not just important for the people who enter mental health services, but important for all of us in improving how we understand our lives. If we don’t see the importance of the real causes of pain in society, how are we to build a better life for us all?

Steven Coles

Clinical Psychologist (Assertive Outreach / CMHT), Rushcliffe CMHT (2nd Floor), George Road Medical Practice, 93 Musters Road, West Bradford, Nottingham, NG2 7PG

The Surviving Work Survey

Hello everyone.

The following post is from Elizabeth Cotton, and provides background information about the ‘Surviving Work Survey’. It is an important project that we feel will interest mental health nurses (it is for other professionals too).

Please forward the link to your colleagues, too.

Yours,

The CMHNN team.

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If you’re working in mental health it’s time to talk about money. Whether you’re a mental health nurse, psychologist or a counsellor, trainee or occupational therapist, or community mental health team the growing reality is that you’re probably concerned about earning enough to sustain yourself in the current mental health job market.

The lack of understanding about employment relations in the sector exposes a range of problems faced by mental health workers, including the growth of contract and agency labour, the use of unwaged labour, the insecurity of ‘permanent’ staff in the NHS.

Because of the growing insecurity of work in mental health and the fear of blacklisting of individuals who raise their concerns, people are often unwilling to speak up at work. As a result not much is known about what is happening to wages, working conditions and clinical practice in our sector.

In our society there is a growing split between the established and the disestablished.  We see it every day in our mental health services – we now need to allow ourselves to see it in our profession.

After four years of talking to mental health workers and now carrying out The Surviving Work Survey mapping jobs and working conditions into our sector www.survivingwork.org/surviving-work-survey,  I think it’s fair to say that we are experiencing a rise in what Sally Weintrobe calls Noah’s-arkism. This is the phenomena where those people who still have decent jobs –  or who are safely established on pensions or private practice, leadership positions in our professional and training bodies –  are protecting what they have while turning a blind eye to those of us who are very-soon-to-be-disestablished.

This second tier of workers includes the declining number of mental health nurses, the Psychological Wellbeing Practitioners who provide the main bulk of IAPT services, the hundreds of honoraries working for free in the NHS, the people manning the mental health call centres, the clinicians carrying out disability welfare assessments and the ones working in social care and support services who were forced to leave their clinical jobs.

The debate about precarious work is a defining one in the field of employment relations. It links research between nationally set cuts and targets, privatisation of health and social care services and growth of labour outside core-public sector, the shift and confusion over commissioning powers, the use of command and control management, work intensification and bullying cultures.

Over the last 5 years there has been a 50 per cent increase in services provided by non-NHS providers with expenditure rising from £6.6 billion to £10 billion. There are an estimated 53,000 private contracts in the NHS with 15,000 within 211 CCGs in community health services and secondary care. An estimated 12.7 per cent of the CCG budget is spent on specialist mental health services – and the primary problems relate to poor contract management and very low penalties for poor delivery. What we do know is that in 2014 half of the private mental health providers commissioned by NHS England to provide specialist care were not fully compliant with NHS standards.

Commissioning Support Units were set up to administer the NHS contracting process and raise any concerns about the governance and monitoring those services provided by private providers. From April 2016, these Units will be privatised. You read that correctly; the administrators in charge of managing third-party contracts will themselves be working for third parties.

Although it’s possible that the third parties currently may offer a good-enough service, if the experience of every other sector is anything to go by, within a two-year period the contracts will be downgraded to compete with ever-stringent budgets. Within 5 years the clinicians and managers in these private companies that came from the public sector will have retired or moved, leaving a new generation of workers without any living memory of good clinical practice or decent work without even the slightest fuss over patient safety.

Our professional bodies are in crisis – torn between defending the sector and their organisation which increasingly cannot happen at the same time. Our unions are literally asleep at the wheel with a growing gap between the rhetoric of collectivisation and the reality of it. This dis-connect creates a professional culture in psychological therapies much like a 17th Century French Court – a preoccupation with the minutia of court procedures rather than the blood and guts of economic crisis and finding therapeutic modalities that can respond to it. There is a growing possibility that we are within a decade of our profession dying out as we become de-professionalised, downgraded and demoralised and our experienced leadership retire.

This is what we know about as people working in mental health; that all we have is each other, right now, listening and talking long enough to see and understand reality for what it is. A relational model of solidarity where we make the best of the people around us and the bad lot we have been left with in mental health.

If you work as a mental health nurse help us build up a picture of the facts of work by taking our anonymous Surviving Work Survey here.

The aims of the Surviving Work Survey are to help us build a map of the trends in working conditions for mental health workers in the UK. Through the questionnaire and anonymous case studies we want to create a map which measures:

  • trends in wages and earnings in the sector
  • what jobs people are doing in mental health
  • the scale of unwaged and honorary work, principally by trainees
  • growth of private contractors and private employment agencies providing clinical services
  • impact on clinical supervision and professional practice
  • impact on our states of mind and our relationships with each other

The online survey can be accessed here www.survivingwork.org/surviving-work-survey

As we build a picture of our sector, we will produce infographics and an online map to raise awareness and encourage debate about the future of work in mental health.

Jobs

The following blog post has been contributed by Jonathan Gadsby.

This week in the Guardian newspaper published an opinion piece by columnist George Monbiot on the subject of neoliberalism. Those interested in critical ideas about mental health will have noticed that it is a word which gets mentioned increasingly. Before Monbiot’s piece, I would have recommended David Harvey’s introductory book (see below), but Monbiot hits the major themes in just a few thousand words.

Monbiot’s claim is that our collective lack of understanding of that word is like imagining that the people of the Soviet Union had never heard of Communism. So asking where does the rubber of neoliberalism hit the road of mental health practice? turns out to be a complex question: other people have frameworks and ideologies, but we see the world as it is… our own assumptions are always more difficult to spot than those of others. Yet neoliberalism arguably finds expressions from service commissioning to the most intimate of our conversations.

In this post, instead of trying to capture that wide-angle view, I just want to focus on one element. This surrounds the way that employment and mental health are becoming viewed as the same thing. Here is Anna Kirkland, editor of a fabulous 2010 book about health and morality:

My thought about this began with a beautiful idea of the geographer David Harvey. Harvey writes fabulously polemical books about how globalization affects people’s visceral lives. In Spaces of Hope, Harvey writes that under capitalism sickness is defined as the inability to work. When I first read that thought, I could not breathe in the face of its profound truth (Kirkland, 2010, p28).

Here, the words are globalisation and capitalism; neoliberalism is a term which overlaps with both, a particular ideology of free-market self-regulating capitalism, with a particular kind of selfhood.

Essentially what is being said here is that (without denying that what people do with their time has an important effect on their mental health) there is something about our current culture which has made paid work – of any quality – a primary measure of health. It has become common to think that if a person is working then they are not unwell or not unwell anymore. It isn’t long before nursing becomes hijacked with the idea that getting someone back to paid work, or ensuring they do not lose it, is our primary purpose, or at least one of them. Recovery means working, working means recovered. On a related note, can anyone remember when it was that we mental health nurses routinely started to use the word ‘functioning’? I’m sure we used to think people had ‘activities of daily living’, didn’t we?

Some nurses may not feel that this is a problem. Don’t we all know that, deep down, our self-esteem is very much attached to what we do? Why shouldn’t we try hard to find similar meaningful roles for our service-users? There is so much that could be said. We could talk about what exactly these meaningful roles are. I was recently CPN to a young woman who felt she had failed in employment because of her poor performance at the one job she had tried (helped into by her previous care-coordinator): full-time cold-calling telephone sales. There was a big screen displaying the ranking of each worker in terms of sales; she was always at the bottom and was sacked after a month. I have worked in one or two difficult work environments, but I cannot imagine I would survive that job for long (or be able to guarantee the safety of the screen, either). But questions such as these aside (they are very important questions about the changing nature of work under neoliberalism), it is important to note that we nurses are not quite on the sharpest end of this idea. We might support our service-users with employers or employment, we might come up with various suggestions, but actually we are not the people who they mostly have to talk to about these things.

And that is why what is going on in Job Centres right now is very important. There are several strands to this. The first is simply that in linking mental health and employment, those in distress in society, even those experiencing the extreme mental states we mental health nurses care for, are viewed, first and foremost, as being in desperate need of a job. Is this what the fine ideals behind ‘the Recovery Movement’ and ‘social inclusion’ have become? Last month, a letter by the Mental Wealth Foundation took issue with this simplistic idea, putting it in a way I doubt many mental health nurses could disagree with:

Current DWP policy intended to reduce the socio-economic causes of mental illness to the one simple fact of unemployment is clinically and intellectually ridiculous.

I recommend reading the letter in full, partly because it is a good letter, and partly because the Critical Mental Health Nurses’ Network chose to sign it, along with a plethora of activist groups. The letter is written in response to a statement by the British Association of Counselling and Psychotherapy about government plans to include psychology input in Job Centres. It might seem strange to pick up this thread in the middle of correspondence like this, but (a) I think the letter holds many of the main points and (b) this is not just an internal affair within psychology. In fact, part of what has prompted this post are discussions I have witnessed between mental health nurses considering taking up positions in Job Centres – and some already have.

The letter also describes concern over the very idea of merging DWP activity (such as Job Centres) with health activity. This is the second strand of concern, about the combination of mental health promotion/psychology and unemployment services. In response to this idea, Friedli and Stearn wrote:

Increasingly, [activities required to receive benefits] include interventions intended to modify attitudes, beliefs and personality, notably through the imposition of positive affect. Labour on the self in order to achieve characteristics said to increase employability is now widely promoted. This work and the discourse on it are central to the experience of many claimants and contribute to the view that unemployment is evidence of both personal failure and psychological deficit. The use of psychology in the delivery of workfare functions to erase the experience and effects of social and economic inequalities, to construct a psychological ideal that links unemployment to psychological deficit, and so to authorise the extension of state—and state-contracted—surveillance to psychological characteristics (Friedli and Stearn, 2015, p40).

Just how serious is this problem? Haven’t we all had to do ‘labour on the self in order to achieve characteristics said to increase employability’? Perhaps, although employability is not simply about personal characteristics, is it? And what begins with ‘positive psychology’ (not psychology’s most well-evidenced idea) to be more employable can startlingly quickly become a new way to fail and be sanctioned, perhaps even ending up with a new quasi-psychiatric label: ’employment resistant personality’. This delightful term has been coined by Adam Perkins of the Institute of Psychiatry at Kings in London, author of ‘The Welfare Trait’ And yes, Adam Perkins is a eugenicist. Sounds a little bit extreme? Then try this article by him, in which he claims that welfare dependancy can be bred out.

The idea that people deserve their position in society, either intrinsically because of their genetic inheritance, or else because of their attitudes and characteristics, is one simple and easy way for people to account for all the inequality, as Owen Jones, author of The Establishment: And how they get away with it, said on Ian Hislop’s recent BBC documentary. It seems that this idea (essentially ‘meritocracy’), post banking-bailouts and Panama Papers, is wearing more than a little thin. Positive psychology for the unemployed is part of a political attempt to make the unemployed wholly responsible for their unemployment, the distressed responsible for their distress. Once the ‘psychological defect’ of unemployment becomes a new kind of ‘personality disorder’, Perkins’ style of genetic posturing (it is not genetic science) may not be far behind.

One unusual aspect about this issue is that it has the potential to unite nurses who don’t agree about the causes of mental health problems. It really doesn’t matter if you think that distress is caused by broken genes, broken brains, broken thoughts, broken families or broken Britain – supported with whatever ‘evidence’ you enjoy most – you can still probably agree that your service-user is not going to be miraculously ‘fixed’ by a call-centre job. You may feel comfortable describing all this as an illness-related ‘disability rights’ issue, or perhaps you are at the other extreme, seeing it as a further oppression of the State in addition to the oppression of diagnosis following the oppression of discrimination and inequality; whatever your views, this merging of Job Centre and health service compromises your role and greatly over-emphasises the idea that paid work – of any quality – is the cure for distress. To then reinforce that view with the very real threat of actual destitution is just plain scary. Even if you are a nurse who has been fully recruited into the neoliberal philosophy that distress is a failure to take responsibility for oneself, you would probably feel aggrieved if an untrained and inexperienced Job Centre employee, perhaps subcontracted by G4S (yes, that was included in the letter, too), started telling you what your service-user needs (or, more likely, not telling you at all).

What can I do about all this?

There are many things that can be done. Here are two. Feel free to add more:

  1. If Monbiot is right and our collective knowledge about neoliberalism is so limited that it would be like people of the Soviet Republic not having heard of Communism, then we are at a stage when raising awareness is a primary concern. We need to be reading books like the three listed below to learn how health is being used to promote certain values that we may not agree with, or at very least have not had adequate chance to think through. If we do not reflect on these issues, we mental health nurses are destined to reproduce them instead. 
  2. Many nurses would agree that it is important for us to dissent from the parts of our roles which are not about health but are about other people’s political agendas. With mental health nursing, that has always been a very hard thing to decide upon – some are going to feel that most of what we do is unproblematically health related, others are going to feel that we are pawns of the State the moment we so much as pick up a biro. But this issue – this dangerous combination of workfare + psychological input + sanctions is something that even the most trusting of us should be concerned about. Dissent comes in many forms. I have been inspired by the group Psychologists Against Austerity. I am indebted to Recovery in the Bin collective. I think Jay Watts has hit the nail on the head. It is a moment to seek out allies of all kinds and have some dialogue. But, above all, to come back to our best instinct: when in doubt, be kind. The Job Centre is not a kind place right now.

 

References:

Friedli, L., Stearn, R., 2015. Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes. Med Humanities 41, 40–47. doi:10.1136/medhum-2014-010622

Harvey, D., 2007. A brief History of Neoliberalism. OUP Oxford.

Jones, O., 2015. The Establishment: And how they get away with it. Penguin.
Kirkland, A., 2010. Against Health: How health became the new morality. New York University Press.

Two Open Letters

This brief post is inform followers of this network that the CMHNN have asked to be included as signatories to an open letter, written to the BBC by clinical psychologist Peter Kinderman.

The Story so far…

The BBC has been running as series of programmes about mental health in recent weeks. These have included a programme about suicide, about psychosis and childbirth, and a high-profile outing for Stephen Fry, in The Not So Secret Life of the Manic Depressive 10 years onThis programme prompted long-term critic of psychiatry Professor Richard Bentall to write a friendly but firm open letter to Fry, suggesting reasons he might wish to present a more balanced view to the public.

Read that letter here.

It is a good letter – of that there is no doubt – and a moving one. The Critical Mental Health Nurses’ Network was particularly pleased that it placed some emphasis on service-user/survivor knowledge (through citing the Hearing Voices Movement and Eleanor Longden) and on societal factors of poverty, urbanisation, poor environment, poor working opportunities and conditions and inequality more generally. So far, mental heath nurses are invisible in this debate.

The Story continues…

Peter Kinderman is another professor of psychology, and also works at Liverpool University. He has been a significant part of some seismic shifts in the British Psychological Society in recent years. He has written a parallel open letter, which, instead of being directed at Fry, is addressed to the BBC. The letter revisits similar material (we were pleased to see the specific inclusion of migration). This letter is demanding programming of a more balanced nature and Kinderman is looking for signatories from individuals and organisations. It is our opinion that this is uncontroversially a good request to support, and would encourage interested nurses to email Kinderman, as he suggests (see letter for details), to add their names to the growing list.

Read this parallel open letter to the BBC here.

Further to these letters, if anyone wishes to read more about this BBC season on mental health, we suggest Gary Sidley’s half-time analysis.

Luddite Health Promotion

Happy New Year from the Critical Mental Health Nurses’ Network!
As we begin to plan our year ahead, we are delighted to present a new piece by Ed Lord which asks what it would mean to be Luddite Health Promoters. We hoped that this blog would help us pull together the strands of a critical mental health nursing, and it seems clear that for authors such as Ed, Karen Taylor, Kris Deering and others, there is something about records, measurement, coding, categorisation and technology – technology in a broad sense – which troubles us greatly. 
 
According M. Crawford (2001), when Henry Ford first started to employ workers to his new assembly line, he was recruiting people who had experience in building whole cars. They were craftsmen, mechanics and engineers. But he wanted them to just tighten a bolt… and pass it on down the assembly line. He had to employ approximately 1000 workers to keep 100. The other 900 left, disgusted, demeaned, humiliated. Within a few years they were all in other work anyway, with the efficiency of Fordism eventually reducing the 800 or so automobile manufacturers in the United States down to just three. By that time, Ford could find plenty of workers who had no experience at all at building cars and would not know how to begin – the expertise had been lost. The rise of personal debt kept them at their work-stations, something which new nurses will need to increasingly contend with as we lose our education bursary. When Ed asks whether psychiatric nursing is part of a ‘Fordist factory’ he is asking us whether we also feel demeaned and humiliated. We may or not feel that the knowledge that was forgotten across Ford’s employees was important. But what are we losing? And what is lost for the people we work with?
Crawford, M.B., 2011. The case for working with your hands, or, Why office work is bad for us and fixing things feels good. Penguin, London.
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division of labour has outsourced your mind  (Marmaduke Dando, If This Is Civilisation, 2010)

The Luddites, those groups 200 years ago who donned masks and stormed mills to smash the machinery within, fascinate me. The reason for this is partly that they are most widely remembered as a term of insult. To take actions against technology is seen as laughable and is rarely given any serious analysis. In this post I want to make a case for a “Luddite nursing” and suggest this as a health promotion activity.

In a previous post on this blog I described a research project that I recently completed exploring mental distress, modernity and geography. Here I am expanding on this in a more personal and reflective way as a means to chart a possible direction for a radical critical mental health nursing. The often conflicted meeting point of my activist leanings as an anarchist and my professional identity as a nurse brings me to search for such a radical path that could inform a more ‘sane’ existence.

As a mental health nurse I find myself at a certain nexus of regimes of knowledge, institutional practices and subjective experiences of mental distress. These forces shape who we are in our working lives and how we approach people experiencing mental distress. The things we focus on, the preoccupations of our practices and the techniques we employ are extremely contentious, as can be seen from numerous posts by others on this blog. The core of our practice, however, remains untouched by the many criticisms levelled at it (eg, Fanon, Laing, Cooper, Basaglia, Szasz, ‘Bifo’, Bentall, Moncrieff, etc, etc). The reason for this is that we are blinded to the necessary systemic critique by technocratic structures within which we are embedded. As numerous philosophers have suggested, we are operating within an iron cage (Weber) in a disenchanted culture in which our lifeworld has become colonised (Habermas) and technology has ‘enframed’ (Heidegger) the normal, the reasonable and the possible.

Thus as bio-medical psychiatry has come to the fore, under the cover of a narrow definition of “Evidence Based Practice”, we find that we are stuck delivering standardised interventions to people reduced to numeric codes from diagnostic manuals. Distress in a particular person, in a particular culture, in a particular time and in a particular place is reduced to a problem of individual mental hygiene abstracted from its context. Care in the modern world has been characterised as moving from “the sanctuary to the laboratory” (Peacock and Nolan 2000), and this is what we see in mental distress that is no longer an aesthetic and existential crisis, but a technical problem of neuro-chemistry and genes.

This is not only a problem for those using mental health services, it also means an alienating working life (Marx’s alienated labour) for nurses and our colleagues. We take pride in giving of ourselves to help others (the therapeutic relationship), and this is the appeal of the profession to many at the outset. The entanglements of the medico-legal bureaucratic machinery of paperwork, protocols, shift patterns, clock-in machines, et al, soon ensnare us however and it becomes almost impossible to give anything genuine, immanent and satisfying. This brings us back to the Luddite rebellions, which were at a basic level a reaction to alienating working lives wrought by the introduction of new mechanised processes. Their expression of rage was a significant threat over a number of years (leading to the allocation of more troops than were sent to fight Napoleon) and targeted machines that were fundamentally changing daily lived experience and relationships for the worse. What could it mean, I wonder, for a nurse to radically face up to the machinery of alienation?

This focus upon the machinery as more than just ‘neutral tools’ is key to an understanding of how technologies come to redefine human existence (David Kidner’s work is excellent on this subject). Deleuze and Guattari suggest that our desires become part of the current infrastructure and are not ahistorical universal ‘human nature.’ Thus when problems arise with these technological approaches it is not the logics of such a system that come in for criticism or analysis, but the individual technological device in isolation. Following this logic technological solutions come to be seen as the only way to solve technological problems: a process akin to digging a new hole to fill in the previous problematic hole. This applies directly to mental health nursing with the constraints of techniques such as the Mental Health Act, record keeping and medication protocols, but the constraints are also wider than our professional domain. Jacques Ellul describes the modern western world as a “Technological Society” in which a narrow rationality comes to enforce its logic across all activities. This systemic analysis allows us to see that a totalising rationality of this type is the genesis of much mental distress as well as being the apparatus that then captures this distress in technocratic definitions, institutions and treatments.

So to conclude, what could be the implications for a critical mental health nursing? Firstly it must be acknowledged that the systems we are enmeshed within demand a narrow division of labour in the same fashion as a ‘Fordist’ factory. The task of nursing is just such a specialisation. To function in such a discipline, according to the anthropologist Tim Ingold (2000), the person is drawn from the centre to the periphery of the activity. The technology then takes the place in the centre, with the nurse simply operating the device from the periphery with no meaningful agency in the task at hand. The nurse in such a system is simply a bored operative putting in a shift in the psych-factory.

To reclaim some autonomy, satisfaction, meaning and helping efficacy I suggest the radical critical mental health nurse can take on the Luddite mantle. Are we going to join in the frantic digging of new holes to fill in the problematic old holes, or are we going to don masks in the dead of night, feel the rage and sabotage the digging machinery?

Can we challenge the paranoid technics of metric reductionist interventions/outcomes and forge an imminent art and craft of care that is responsive to a holistic promotion of mental health?

human life needs reframing, redrafting, reweaving: a surrogate, virtual, second life, sacrificed on the altar of the technological gods, is no substitute for a life of immersion in rich, storied objects and relationships. (Dark Mountain book 8, Introduction, 2015)

 

References:

Ingold, T. (2000). The Perception of the Environment: Essays in livelihood, dwelling and skill. (London; Routledge).

Peacock, J W and Nolan, P W. (2000). “Care under threat in the modern world”, Journal of Advance Nursing. 2000, 32:5, 1066-1070.

 

12 Questions about Record-Keeping

Kris Deering is a lecturer in mental health nursing at the University of the West of England in Bristol. He has 15 years experience working in practice over various sectors, including as a senior practitioner within an intensive team and specialising in care for adolescents experiencing psychosis in an Early Intervention team. A key area of interest is the various effects of neoliberalism on mental health services, in particular how it’s philosophical underpinnings are becoming symbiotic within recovery-based approaches. He is currently exploring how co-production may assist creating positive risk taking tools with service users. He is always happy to have chat with others who subscribe to CHMNN, so please do email him kris3.deering@uwe.ac.uk
Kris has written the following piece for the network about record-keeping. In it he raises and discusses a number of questions which we hope the network will find useful to open further conversations about something which nurses frequently talk about but is hitherto not addressed on this website. As ever, please feel free to comment or ask questions, which Kris will read.

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When Bulwer-Lytton wrote that the pen is mightier than the sword, he could not have predicted that one day many nurses would gladly apply a sword to electronic record devices! In contemporary mental health care communication does not exist without it being objectified through inscription – as the judicial adage goes – an event has not occurred unless it is written. How did such necessity occur? And what if the act of writing, in particular following instructions to fill the blank spaces of electronic records, is itself becoming the performance of our daily professional actions? We need to ask,

Question 1: Has record keeping about our nursing work replaced our nursing work?

Record-keeping has been around for millennia, famous texts such as the Domesday Day book saw records intrinsically related to the fiscal, in this case tax losses of William the Conqueror. Such practices assisted later with medieval feudalism (Mutch, 2006), whereby for military service, a person gained land that was divided and distributed to assist localised governing. The Bayeux Tapestry which depicted William’s triumphs strengthened the trend to capture history, and perhaps to not allow the truth to get in the way of a good story. ‘Truth’ becomes dependent on which writings survive. As Walter Benjamin said, ‘History is written by the Victors’, suggesting the investigation of what is excluded is as important as what is read. We need to ask,

Question 2: As nursing records become increasingly framed through the boxes of computer databases, what is excluded and why?

What if ‘how’ history is written becomes more important? Critique of Westernised positioning on using specific knowledges to make sense of the world may have a bearing. The theory ‘Coloniality of Power’ originates from the work by Anibal Quijano (Quijano, 2000). Quijano argues that the dominance of westernised colonisation is still being felt today, especially as knowledge is constructed within hierarchies to enact power over others (Alcoff, 2007). Partly this originated from plantation owners need to categorise and ultimately dehumanise slaves to maximise profit. Slaves were not asked how they constructed themselves individually or culturally, but were observed and placed into categories that aided highest yield of crops (Quijano, 2007). Thus age, height and proficiencies were important, not slave’s personal identities. We need to ask,

Question 3: Could record keeping ever be a politically neutral exercise?

Coloniality of Power also proposes that while colonisation increased so did the importance of impartial observation in health research – limiting knowledge to experts who have a supposed proficiency in being impartial (e.g. education at university), rather than those experiencing health concerns (Alcoff, 2007) – an explosion of empiricism. Less was noted on interpretation and more on objectifying experiences into tangible realities (Quijano, 2007). Understandably this was driven by suspicions about how human bias may affect health findings, hence the eventual work of Karl Popper and seeking information going against the hypothesis (Bolton, 2008).

Florence Nightingale proposed that nursing documentation assisted care by noting personal needs and was also a way to communicate the orders of doctors (Darmer et al. 2006), whilst Virginia Henderson, a prominent US nursing theorist in the 1930’s, suggested documentation assists planning care (Darmer et al. 2006). It seems that not until regulation increased from the 1970s onwards that documentation become more important. There are many reasons to why this occurred, such as taking on the judicial view that experiences become realities once documented, or the need to professionalise nursing and have status with other disciplines. Many of these themes of empiricism, status and shaping objective realities can be seen in the rise of evidence based practice; demonstrating a written process of reasoning on what helps a person, potentially demonstrating influence from higher education, for example Project 2000 in the UK (Brunt, 2000).

It appears that there has always been an influence of hierarchy in record keeping, yet justified as a way of helping a person, as Nightingale alluded – to assist the consistency of care. Also how knowledge is constructed to determine truth has a bearing on documentation, perhaps relating to the arguments of Coloniality of Power that in health care, there is emphasis on the objective of the categorising of people (Quijano, 2007). We therefore need to ask,

Question 4: Does increasing record-keeping increase hierarchy?

You will be forgiven for the assumption that I am staunchly against electronic records, however, their initial premise was one with great intentions, a record that is accessible by all regardless of time and place to help service users’ holistic needs. The tool has the possibility of binding disconnected services of various disciplines and promoting innovation, and yet, this is not the apparent experiences of nurses using this tool. There are cries of ‘death by documentation’; less time is spent with service users than documenting what occurred, to the detriment of care. It seems this is happening by the convergences of different systems (noted below) unwittingly battling each other for supremacy, though as proposed by Coloniality of Power the winners are those within hierarchies who determine how knowledge is constructed. We need to ask,

Question 5: Is record-keeping increasing divides between disciplines and fuelling the categorisation of persons ?

Question 6: Is record-keeping delivering what it promised?

Health organisations drive towards uniformity to demonstrate homogeneous good practice to those who commission services. These rely on data envelope analysis, which are evaluating or auditing processes of tools used to govern organisational mechanics, such as policies and managers. The Griffin report (Department of Health, 1983) instigated senior managerial positions detached from ‘shop-floors’ to enable more effective cost making decisions. Record keeping in this context becomes the evidence that managerial processes use to assess care and quell nursing dissent by using reprimands in the form of performance management. However, as shown by numerous historic events – e.g. Stalinism in Russia – there can be no uniformity which does not also contain oppression.

It could be suggested that the above contributes to surveillance emphasising the ‘management’ of health departments, whilst senior managerial detachment from actually experiencing or observing care increases the need for other methods of monitoring. Knowledge becomes constructed that eases the operations of an organisation from a hierarchal perspective perhaps superseding other types, for example interpretive experiences from service users. It is understandably within such a context that documentation becomes the focal point of monitoring care rather than actual care itself.

Electronic records ask questions in specific ways easing answers seeking causality, clear examples are risk assessments and need to document specific histories that increase risk, such as previous self-harm; this has been transposed to digital care plans which offer specific needs/problems alongside interventions. Indeed interventions may be evidence-based, but may generalise and reduce choices, or at least influence that there are limitations possibly reducing enquiry on the service users’ personal needs.  We need to ask,

Question 7: As records are required to become increasingly uniform, is the service increasingly oppressive?

Question 8: Do management and records exist mainly for their mutual self-perpetuation?

Question 9: Is it enough to claim that the information collected by records is ‘evidenced-based’?

Arguably ‘Performativity of Economics’ may be relevant to the above –  the theory suggests all performances regard some economics (Callon, 2006) – for example limiting care options guides nurses to what interventions are available while the format of electronic records instructs how nurses use their time (Bar‐Lev, 2015; Halford et al. 2010). Perhaps similarly to the arguments of Coloniality of Power, service users are becoming merely assets that require processing through electronic records, comparable to the ledgers used by plantation owners to measure and influence crop yield.  Equally how and what data is collected for electronic records perhaps involves mostly the views of those in hierarchical positions, rather than views of those accessing and providing care.

Question 10: How do records extend the reach of market ideologies into nursing work? 

Which leads us to two inescapable further questions:

Question 11: Have records, which began as part of a therapeutic process to assist quality and consistency of care, now become a ‘manual’ for nurses to follow? 

Question 12: Who gains most through nurses keeping records?

 

References

Alcoff, L.M. (2007) Mignolo’s Epistemology of Coloniality, CR: The New Centennial Review, 7(3), pp. 79-101.

Bar‐Lev, S. (2015) The politics of healthcare informatics: knowledge management using an electronic medical record system, Sociology of health and illness, 37(3), pp. 404-421.

Bolton, D. (2008) The Epistemology of Randomized, Controlled Trials and Application in Psychiatry”, Philosophy, Psychiatry, and Psychology, 15(2), pp. 159-165.

Brunt, B.A. (2000) Lessons learned: developing education for a system-wide documentation project, The Journal of Continuing Education in Nursing, 31(6), pp. 280 – 283.

Callon, M. (2006) What does it mean to say that economics is performative? [Online] available from: https://halshs.archives-ouvertes.fr/halshs-00091596/document [accessed 10 July 2015].

Darmer, M.R., Ankersen, L., Nielsen, B.G., Landberger, G., Lippert, E. and Egerod, I. (2006) Nursing documentation audit – the effect of a VIPS implementation programme in Denmark, Journal of Clinical Nursing, 15(5), pp. 525-534.

Department of Health. (1983) The Griffiths Report. NHS. Management Inquiry. London: Stationary Office.

Halford, S., Obstfelder, A. and Lotherington, A. (2010) Changing the record: the inter‐professional, subjective and embodied effects of electronic patient records, New Technology, Work and Employment, 25(3), pp. 210-222.

Mutch, A. (2006) The institutional shaping of management: in the tracks of English individualism Management & organizational history, 1(3), pp. 251-271.

Quijano, A. (2000) Coloniality of Power, Eurocentrism, and Latin America [online] Available from: https://www.unc.edu/~aescobar/wan/wanquijano.pdf [Accessed 11 November 2015]

Quijano, A. (2007) Coloniality and Modernity/Rationality, Cultural Studies, 21(2), pp. 168-178.

Changing Mental Health Policy and Practice for Changing Times, by Peter Beresford

This post is one we are particularly delighted to share. We have said right from the start of the Network that ‘the critical is political’ and this is a highly political piece. It is a talk given by Professor Peter Beresford at the Mersey Care conference in Liverpool last Friday. The conference was called Service User’s Voice, Change, Rights and Advocacy: What is the reality?

Peter Beresford, OBE, is Emeritus Professor of Social Policy at Brunel University London. He is Co-Chair of Shaping Our Lives, the national user controlled organisation and network of service users and disabled people. He has a background as a long-term user of mental health services and has had a longstanding involvement in issues of participation as activist, writer, researcher and educator. He is author of A Straight Talking Guide To Being A Mental Health Service User, (PCCS Books) and his next book: All Our Welfare: Towards participatory social policy is to be published by Policy Press early next year.

Peter’s talk struck a strong chord with the approximately 200 delegates. You may know him from his writing for The Guardian, from his books or if you have heard of Mad Studies, introduced in this talk and a movement with which we hope to engage further as a network. So, in introducing Peter Beresford we hope to bring more topics into our conversations and also to further the links between our network and survivor expertise, with whom so many critical mental health nurses find such resonance and – finally – the kinds of partnerships we were looking for when many of us first began. 

Peter’s talk also included two examples of people who have found themselves in impossible discriminatory hardship due to cuts to welfare. We have mutually decided to edit these out to protect their anonymity. It is Peter’s view that they are not exceptional as examples, but share an increasingly common experience.

Please feel free to comment or ask questions below, which Peter will read.

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Changing Mental Health Policy and Practice for Changing Times

Hello. It is really good to be here again. Although in one sense things could hardly be said to be getting better since I was present at the last of these terrific conferences. Exteriorly they can only be seen to be getting worse. But since I was last here with you many terrible things have been happening and here I’ll just list a few;

  • The worsening situation for so many people in Syria and elsewhere leading to massive flight and seeking of asylum
  • The failure of the west to respond to this in an effective and humanistic way
  • The election of another far right government in the UK
  • The increasing bad mouthing of disempowered groups here, from refugees and poor people, to young people, lone parents and others
  • Continuing determined efforts to unravel and destroy the welfare state

Nonetheless, we can also see at the same time new conversations emerging. Things that were not being said, permissions to say such things that were denied through a frightening political consensus are being challenged – at last. So:

  • We have the election to the labour leadership of Jeremy Corbyn who says things that before all major political parties insisted must not be said; that austerity is a lie and a confidence trick; that all our problems aren’t the fault of people needing benefits and refugees
  • We hear Alan Bennett the respected writer supporting Jeremy Corbyn and rejecting this government as totalitarian in intent
  • We have actors Benedict Cumberbatch and Samantha Morton speaking truth to power about the situation of refugees and this government’s cruel response to them
  • We have the determined response and opposition of the house of lords to the planned cuts to tax credits

The neoliberal parade is beginning to look as it would have looked to the small child in the crowd when the emperor processed by naked.

And I think when we consider mental health policy and practice, we must be honest about the extremes that our politics and policy have been reduced to. But equally we must be open to and fully aware and in a position to respond to the new discussions that are beginning to take place.

So I don’t doubt that there are local managers, practitioners, service users and carers here as elsewhere committed to maintaining positive services, making savings where they can as best they can, introducing and developing new ideas, taking seriously ideas of user involvement and co-production. These determined, hard fought efforts must be applauded, they must be reinforced. They must never be devalued, talked down, belittled or denied. But at the same time we must be honest with ourselves. We must not deny the truth. These are fightbacks. These are rearguard actions, they are emergency operations. They are taking place in a politics of destruction, committed to the ending of those values which our grandparents fought for before, during and after the Second World War, that found their expression in the welfare state, social security, public housing and the National Health Service.

This government and its broader fellow travellers will only be happy when these achievements are cut, privatised, outsourced out of existence. They are in some senses even honest about this. Remember the extreme comments and the madness of the recent Conservative Party Conference. Through mouthpieces like the Daily Mail, Katie Hopkins  and the Sun, they recast us all as a scrounging detritus who want to live off hard working people, when the reality is that they and their fellow members of the one percent club are sponging off the labour, voluntary, waged, and mutual of all of us.

This is a government that seeks constantly to divide and rule us; to make one group hate another; to set us at each other’s throats. This is a government which majors on what it calls competition, making us fight each other for ever diminishing pots of money, while making the wealth we create available for the profit-making of big corporations. This is a government which seeks to destabilise us by increasing our uncertainty, fear and anxiety, whether it is about the threats they identify to security, from different generations – the young versus the baby boomers, from different faiths and cultures, from us as strivers from those it damns as skivers. This is a government that let alone supporting social justice, has undermined the prospects of justice in our society, slashing legal aid, even charging people for pleading not guilty. This is a government that seems determined to encourage hate crime by attacking with its media allies disabled people, mental health service users, people with learning difficulties as self socialised into dependence. This is a government that wants to make us deny who we are, not see ourselves as the people it puts upon, but instead for us to be aspirational; to fantasise that we are someone else; on a par with the tiny band of super rich that alone they help prosper. We have a government committed to denying who we are and wanting us to deny ourselves too. That is its justification for reducing policies to help people when they need help which any of us might need at any time.

I believe therefore that this is a government committed to the generation of mental ill health, to mental distress. This is a government whose welfare reform policy has undoubtedly driven many people to contemplate killing themselves and some to do so –only the numbers are not clear.

So we can hardly look to this as a politics that will take seriously mental health policy and practice, when it is a politics that is essentially distressing and maddening, except for its top dogs and fat cats. A politics that seeks to make you deny who you are and hate everyone else by othering them, is I would argue a politics of madness. Its appalling record on and dismantling of mental health policy is of course just a part of this bigger denial.

What has it done, this government, like its predecessor, is instead of supporting good policy and practice for mental health is to sell rhetorical positives while whittling away at and destroying the actual infrastructure of help and support and understanding. It is using policy to oppress people. So it talks up recovery and mindfulness, while it makes them the handmaidens of policy to try and force people off benefits into jobs, however inappropriate they may be, whatever difficulties people are facing; whatever barriers there are in the way of such jobs for them.

We have to accept that we cannot expect to see understanding, sympathy or a grasp of good mental health policy from this government. The problems it poses because of the nature of its politics and ideology are much more profound. One simple expression of this is its approach to welfare reform as it calls it and the implications this has for people’s mental health and for mental health service users.

Service users like me have highlighted the importance of policy and practice giving equal value to experiential knowledge, the knowledge that comes from lived experience, service users’ realities, as well as traditional expert knowledge, generated by research, by professionals, by experiment. Governments like this however have made clear that they devalue and ignore both expert and experiential knowledge. That is why I argue that they are themselves irrational and themselves advancing and responsible for a form of madness.

Last year when I also had the privilege to contribute to this wonderful event, I talked about Mad Studies, a new international development. I referred to a new Canadian book that had really helped this take off. This is Mad Matters. I said that this book was living proof that people with direct experience, supportive professionals, academics, educators and researchers can together take forward something better, different that offers hope. This is mad studies and mad action. And here we can see the value, the strength and the possibilities of such a new direction building on such alliances. Suddenly it feels like a struggle that can be won. Since then much has happened here in England and the UK to take forward this alternative way of coming at our mental and emotional distress, with more events, publications, social networking and social media spreading the word.

Lucy Costa, the Canadian survivor/worker/activist’s has offered a helpful definition of mad studies on the Mad Studies Network Website. She says it is:

…an area of education, scholarship, and analysis about the experiences, history, culture, political organising, narratives, writings and most importantly, the PEOPLE who identify as: Mad; psychiatric survivors; consumers; service users; mentally ill; patients, neuro-diverse; inmates; disabled – to name a few of the “identity labels” our community may choose to use. …Mad Studies, right here, right now is breaking new ground. Together, we can cultivate our own theories/ models/ concepts/ principles/ hypotheses and values about how we understand ourselves, or our experiences in relationship to mental health system(s), research and politics. No one person, or school, or group owns Mad Studies or defines its borders.

As explained in the book, Mad Matters, Mad Studies is a, “project of inquiry, knowledge production and political action”. Presently…we need more action. She makes clear that she sees Mad Studies as a cooperative venture, but one led by the experience, ideas and knowledges of ‘mad-identified’ people. I believe that this is a wonderful hopeful new development. And I think it is particularly timely.

I believe that this is our golden time, a time when the supposed certainties of neoliberal dogma are being to be questioned; beginning to come unstuck. This makes it the time to develop our ideas, our plans, our proposals, our initiatives to start building them and to challenge right wing received wisdom – specifically in relation to mental health policy and practice, and also more generally from our standpoints as service users, workers and carers. We now have a powerful new narrative to tell and to share and spread. A counter to the over medicalised, over drugging psychiatric model in daily operation. Now is not the time just to try and respond and just make the most of the cracks this government leaves, but to prepare for the time that is afterwards and which increasingly clearly and strongly beckons. This government wants to take us back to a poor law past where people were driven mad by the deprivation and disadvantage that was made routine and left unsupported by the absence of any real system of support. We must have the courage and confidence of our convictions and fight for a very different holistic, social and humanistic model of help which involves us all as service users, workers, family and friends.

Thank you.

Best wishes from the CMHNN to the 7th World Hearing Voices Congress

Dear 7th Hearing Voices World Congress,

Warmest greetings from the Critical Mental Health Nurses’ Network as you embark on the 7th World Hearing Voices Congress in Madrid. The 6th Congress in Thessaloniki produced a declaration which we hold in the highest regard and re-publish below. We eagerly anticipate all that you may teach us about your experiences as we work to see the demands made in your declaration come to full realisation.

The Critical Mental Health Nurses’ Network

DECLARATION

“It was worth existing, so that we could meet” G. Ritsos

We met in Thessaloniki because our lives have value. Our voices have value and acquire meaning when they encounter other voices. We demand and we create safe spaces for our dignity and our quality of life together with others and not against others. We consider ourselves a part of a living movement of solidarity and mutual respect, which comes as a response to the one-sidedness of biological approaches. We are, thus, a political and a multi-cultural movement. The experience of voices is not a personal, but a collective matter: it concerns family, friends, professionals, the whole society.

We live in a continuously changing world, with precariousness spreading to all aspects of our lives. Particularly in Greece, at a time of complete collapse of the public health services, the empowerment and participation of persons with psychiatric experience at all levels of human rights advocacy, influencing policies and decision making is of outmost importance.

We demand

  • Safeguarding human rights in the field of mental health

  • Adopting approaches which focus on experiences and their meaning

  • Abolishing stigmatizing and un-scientific terms, such as schizophrenia

  • Developing a simple and experiential discourse, that can describe our experiences without labels and diagnoses

  • Undoing the myth of the omnipotence of psychotropic medication

  • Information on alternative ways of managing our experiences

  • Possibility of choice of the care, support and treatment we might need

  • Connecting up with other social movements

Our struggle is a struggle for the self-determination of our lives.

We walk together in crisis, we seek common paths of recovery in an Odyssey where the personal becomes collective and the collective becomes personal.

Critical Perspectives in Mental Health Nurse Education

This is the 3rd of the workshop reports from our recent conference. Here, Jim Chapman and Anne Felton summarise and reflect on the discussions that they facilitated in a workshop designed to help people think about MH nurse education. There were other parts of the day in which people considered education too, and as the previous post about the UnRecovery Star shows, other members of the network are considering ways to bring more critical ideas into mental health nursing education. One of the suggestions from the floor discussed on the day was about whether this website can develop a section specifically to resource university tutors and student nurses. In a sense, this is the aim of the website anyway, but it may be that members would like to develop a set of references and resources which may be of particular use to tutors and students, and if this is something which interests you, and if you have experience teaching or learning critical mental health nursing at university and would like to share that, then please make yourself known to us.

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The workshop used a world café approach to pose some key questions for mental health nursing education:

  • Does the Shape of Caring Review support or hinder the development of critical perspectives on mental health in nurse education?
  • What is the difference between critical perspectives and critical analysis – can we teach both? 
  • How do we support nursing students who adopt critical perspectives to avoid becoming isolated and disillusioned? 

There was a mix of perspectives over whether the Shape of Caring Review is a good thing for mental health nursing. Some people felt that mental health nursing was already seen as second-rate in relation to other fields of nursing, and that the proposed 2+1+1 model would amplify this inequality. Others saw opportunities within the new proposals – firstly, here would be a chance to give non-mental health nurses the essential skills to care for those in distress, whatever the care environment; secondly, the extra year devoted to preceptorship could help qualified nurses to pend good quality time role-modelling excellence in mental health nursing.

Some people felt that giving 2 years over to a core curriculum is a step too far, in that it would hinder the creation of the professional identity of the mental health nurse, as well as the passion for the job.

Most people agreed that this could once again give us the chance to challenge the content of an undergraduate nursing curriculum, that it should be based as much on values as competencies and that we need to increase subjects such as sociological explanations of health. It was pointed out, however, that the existing NMC standards for pre-registration nurse education are open to wide interpretation from higher education institutions and that the curriculum they design is often driven by the prevailing belief systems of academic nursing staff responsible for the programme.

The discussion around whether critical analysis and critical perspectives were the same thing was summed up neatly by one participant, who wrote:

A critical perspective is a ‘way of being’ that can develop in a person – the desire to question, deconstruct, unpick. Critical analysis is a skill, but may not be based in a broader critical perspective.

Other comments reflected this view. One person commented that critical perspectives may not always have a strong ‘evidence base’ whereas critical analysis needs to be driven by good evidence. This, of course, opens up the debate about what we mean by evidence and good evidence.

There was an interesting thread of conversation in that maybe our critical discussion should start with our own professional identity, in that we find it hard to define ourselves. We need to have some challenging and difficult conversations to arrive at a consensus about what mental health nursing is. Or, conversely, we accept that we are comfortable with a range of theories and ideas, and embrace them all.

Many people who attended the workshop had experienced the feeling of disillusionment at some point in their careers. For the students who attended, this was particularly raw. Some felt that the inability to express critical perspectives was rooted in the hierarchical structure of the NHS (both within and across professions), and that it was particularly difficult to challenge ideas from the bottom-up.  In fact, some students felt that it was unfair for them to hear the message from academic staff that they must be the catalyst for change when they have been given very little power to do so.

There was a lot of debate about the need for a parallel curriculum that centres around peer support, promoting values, creating group identity and hence power to influence change. The process of change needs to occur not just within the health system but within society, so that people re-learn the meaning of mental healthiness .

Summary of Discussion

We know that nursing is caring but is currently experienced by users of the mental health system and nurses as “managing”.  Time with service users – contact, building relationships –  is vital to challenge this position. There was debate as to whether nurses have the opportunity to influence the organisation of their work though meaningful nursing leadership was recognised as important.

We all know that what we need to do is care but we get shifted towards task-orientated, non-person focused activities.  We need to understand – how does this happen and how can we change it?