The following is a report of a UK-based student mental health nurse discussion group. The mixed group of eight mental health nursing students comprised some who were working towards a Masters-level pre-registration qualification, some working towards an undergraduate award, one of whom is on a degree-level apprenticeship programme, and their tutor (also a mental health nurse). It was part of the work of a final-year university module called Nursing Care: Mental Health, which includes exploring critical perspectives about mental health services and also includes skills sessions in therapeutic approaches. The report has been written by the tutor and checked by the students to make sure it represented their views.
Our discussion was centred on a new piece of (open access) work by author Haley Peckham:
Peckham, H. 2023. Introducing the Neuroplastic Narrative: A non-pathologizing biological foundation for trauma-informed and adverse childhood experience aware approaches. Front. Psychiatry 14:1103718. doi: 10.3389/fpsyt.2023.1103718.
_________________________________________________________________
The Neuroplastic Narrative in the classroom
Overall impression: Peckham’s paper contained many elements with which we feel a strong affinity. The piece seems to contain plausible and well-researched explanations for the lived experience of people we have already met and worked with in mental health services. In discussion, some questions about it and its implications grew.
Firstly, having just had some classes in which themes about reductionism had been explored, we were very impressed at the accessibility of the first sections of the paper which readably deal with complex and technical ways in which life experiences become part of biology. Far from biology (genes, neurology) being just determining parts of our experience, Peckham demonstrates many ways in which it is something that is readily altered by what happens to us and what we do, from before birth and throughout the lifespan. Students noticed that this has a strange effect on our mental health nursing connection with biology, which is stripped of its capacity to be an adequate causal explanation for distress/mental health problems yet simultaneously reinstated as a key field for understanding the way people experience distress, the patterns and responses we commonly encounter and also something that could be part of helping someone recover. This feature of the paper was really helpful: we have talked at length in our class about the desire to be biopsychosocial and it may be tempting for mental health nurses to think that “there has been too much emphasis on the bio bit” and so “we need to add back the psycho and the social, for balance”. However, with Peckham’s work comes a thought that perhaps the “bio” that is given as an explanation in mental health services (i.e. mental illness having probable genetic causes, or chemical imbalances leading to illness) is not over-emphasised but actually plain misleading, and the body is as missing from commonly given psychiatric explanations as any other part of biopsychosocial! Helpful as this was, it also led to one of the key questions we had about the paper (which will be explored later).
The paper seemed so fresh (mind-blowing?!) and so different to the understandings students had so far received from their experiences in mental health services that they really wanted to know how it is being received by other readers. For example, although they were previously aware of ideas such as Attachment Theory and the high prevalence of Adverse Childhood Experiences amongst our service-users, one student said that neither were discussed “unless a service-user has chosen to disclose something”. This seemed to chime with others’ experience too – when service users are asked questions, it is about their feelings – symptoms – in the present, and the past is only relevant if they make it so. In fact, the paper has helped students reconsider time. Very often it seems that mental health services view mental health problems and possible solutions in the present, neglecting the past. Peckham’s work raises the importance not only of a person’s past, but is set in much deeper timeframes, too.
There were four questions that our discussion became most centred upon. The first of them we believe we were able to resolve as we understood the paper better. The second remained a little less clear. The third question was begged by a strange omission and we would love to put it to the author. The fourth we found perhaps hardest to resolve.
Question 1: We wondered if the opening premise – that “trauma-informed approaches lack a biological narrative linking trauma and adversity to later suffering” (p1) – seemed a little uncertain. In the class, students had already been introduced to Bessel van der Kolk, and they were already aware of Nadine Burke, Bruce Perry and others. Can it be right to say that that trauma-informed approaches lack a biological narrative?
Our understanding of this question changed once we realised that Peckham also valued van der Kolk’s work. If she presented it in the paper, how could she be ignoring it? This led us back to the diagram of her “neuroplastic narrative” (p7). Our thought is that Peckham views work like that of van der Kolk, Judith Herman and others as part of the middle of three concentric circles, and closer to exploring how the outside world becomes written into our bodies. Her own work she sees as adding the third circle, an explanation of why people might have the kinds of responses to trauma and adversity that they do, for which Peckham leans on evolutionary biology. This seemed helpful for us to realise.
Question 2: Peckham claims that “The Neuroplastic Narrative is not intended to replace the medical model but to sit as an alternative framework from which to understand and respond to emotional and psychological suffering” (p2). This statement was hard to understand, because so much of the paper seemed to us to not only undermine the scientific basis of psychiatric “medical model” claims but also repeatedly states that patterns of distress, even when highly embodied, should not be considered a pathology, an illness. How can the two co-exist?
Having just looked at the work of Joanna Moncrieff in our class, we saw a similarity. Moncrieff’s is a practicing psychiatrist who prescribes psychiatric drugs. Her views about psychiatric drugs (that we need to move from a “disease-centred” perspective to a “drug-centred” perspective) might at first seem to only amount to a “tweak” in understanding mental health problems. Yet we had also seen that her view does undermine some of psychiatry’s strongest claims too. Unless we are much mistaken, psychiatrists believe that they are able to diagnose medically locatable and measurable illnesses (explanations may rely on projected future knowledge) that have their root in biology and that their medical “treatments” counteract – and may correct – the underlying causes of these illnesses. We cannot see how the biological science that is articulated in Peckham’s paper can leave that view intact. This leads to a suspicion that very few psychiatrists would see this as an alongside alternative, but as a direct threat. One student felt the paper did much to “flip positions of power”.
Question 3: The word “psychosis” does not appear in this paper. Neither does “hallucination”, “voices” “delusion” or even “belief”. This fed into a question we could not resolve: is this paper only supposed to be applied to the patterns of distress/mental health problems and behaviours that psychiatrists describe as “personality disorder” or perhaps PTSD, or is it provided as a wider explanation for the distress/mental health problems of other people that we work with in mental health services?
Given that authors such as John Read have spent so many years connecting ACEs with psychosis, given that members of the Hearing Voices Movement also make the connection with trauma and voice-hearing (not their only view about voices) and that dissociation from trauma is an engine of future psychotic experiences… is this paper avoiding that question? Is that a problem that is also shared with some other trauma-informed work?
Question 4: This model does seem to be de-pathologizing, but would it be de-stigmatising?
Peckham’s repeated “non-pathological” premise is that, far from a view that certain traumatic experiences “damage” us, in fact we biologically respond to trauma in ways that seek to enhance our ability to cope with adversity, and we should not call something an illness if it has helped us, or our ancestors to survive. However, Peckham shows that, from an evolutionary perspective, there is no reason to think that such coping would lead to happiness, but rather to survival and to reproduction. From animal studies she describes an acceleration of physical development, problem-solving skills and seeking sexual partners that seems to come with facing early adversity and a non-nurturing environment: a life in which a person becomes physically and mentally more able to respond to the predicted future that a past and present of trauma has suggested to them. These abilities come at a high price. In mid-life, the abilities of animals on a “slower” life trajectory overtake the abilities of those on a faster, trauma-based pattern, which now offers diminishing returns and poorer health. The students found these explanations to be compelling (while acknowledging that they were being asked to assume that what applies to other mammals applies to humans).
We have also been studying older adult mental health and some students started to wonder if connections could be made there. Dementia does follow a social gradient and may follow from other poorer health outcomes and decisions. Does Peckham’s work on the relationship between life and neurology have anything to add within the field of dementia research?
However, although we agreed with the argument that evolutionary theory provides a set of reasons for trauma-related biological changes and resulting experiences, we speculated that perhaps explanations that locate patterns of distress and mental health problems as being expressed in the body will always be stigmatised. If Peckham’s Neuroplastic Narrative became a more accepted view, would the public see it as evidence that some people are “built wrong”, “hard-wired” for problems and a distressed life? And would sufferers themselves use it as a way to explain away their actions? We asked what role the Neuroplastic Narrative night play in a situation in which a violent assault had occurred. Could the perpetrator of such violence claim that it is themselves who are the true, life-long victim, and that they are not able to respond to emotions in a more proactive way because of their biology and are not to be held accountable? Yet we are also unsure is this a fair criticism of Peckham’s work since “mental illness” already provides similar public and professional conundrums about responsibility, as seen from family discussions to the ward round to the law court. Perhaps it partly depends on how able it is (with other trauma-informed approaches) to drive better ideas for therapeutic approaches and how effective we can be at promoting recovery using it. Just how many people, once within what Peckham calls a “fast life history”, can slow down? And to what extent? Such questions also led us to wonder if “fast” and “slow” could become a binary that would itself lead to labelling, discrimination and lowering of expectations. We also thought that any emphasis on sexual reproduction could lead to prejudice, too: again, not Peckham’s fault.
We considered ways in which “fast” life trajectories can be valued by society, such as when they are found in Olympic medallists and perhaps, Jon Ronson style: not just more action in the bedroom but more “psychopathic” behaviour in the board-room! The paper begins with biological science and leads to questions about societal values and the role of psychiatry within them, which seemed like something Peckham would want us to think about. Are “mental illnesses” wrapped up with an authoritarian linking of health with conformity more than they are something medical? We wondered if some would accuse this paper and the values that seem to be connected to living a healthier and slower life history as “middle class” (although we also found we disagreed with that accusation in a number of ways). What would Michael Marmot think of it? Questions were also raised about whether cultural difference could influence the adoption of a faster or slower life trajectory, largely based on the idea that perhaps non-Western cultures may have a more collective consciousness and there seemed something so individualist about the behaviours described as “fast” in this paper.
However, Peckham’s work is also grounding: people who suffer serious trauma and adversities are not just behaving differently, making different choices and subject to prejudice for not conforming. Their bodies become different. All of us felt a strong need to understand more and more about what would be required of us as mental health nurses to be better at listening to trauma, understanding its biopsychosocial effects, helping a person to counteract and reverse the patterns that have become so written into their biology. We felt the paper reinforced a nursing understanding that mental health may often be improved as a person moves from a more reactive life to a more proactive one. The Neuroplastic Narrative is also powerful understanding for why, when faced with great and immediate adversity, we tend to throw the dice with our future health. We felt that the end sections of the paper were a vindication of every mental health nurse who believes that it is the relationships we make with people that support their recovery, with most other “interventions” being secondary. One student described the notion of “shame-sensitive practice” feeling “like a light-bulb moment” for her, matching her observations of many aspects of the experience mental health services users have of their mental health and things that they encounter within the service. This led her to want to know who else is writing about that, and what current ideas there are about it.
In summary: Peckham’s article was extremely thought provoking for us. Now we want to know what everyone else thinks about it! We felt that it joins mental health and biology together in a non-reductionist way that is a good match for our experiences. It validates bio, psycho and social approaches and expands the importance of the body as a site in need of care and soothing, in ways we do not think are common in mental health services. It contributes to the many uncomfortable questions our class has been developing about the relationship between services and trauma: are they places in which abuse and trauma is explored and understood, or further swept under society’s carpets? We are left with a big question about psychosis and that seems very important: if this work were to be accepted by our medical colleagues, perhaps they would only accept it as a perspective on “personality disorder” because of the potential for the “flips” in positions of power.
Over to you, fellow nurses! Is this the biopsychosocial explanation you have been looking for? Or is it more like another piece in a puzzle that remains incomplete?
Critical Mental Health Nurses' Network 