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Making A Difference Early On


He stayed at a friend's house for Easter that year and ended up taking an ... Sarah saw the psychiatrist the day after her admission, and was asked why she ... – PowerPoint PPT presentation

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Title: Making A Difference Early On

Making A Difference Early On
  • Dr. Jan Wallcraft

Alternative to biomedical discourse
  • I began my thesis seeking an alternative to
    biomedical discourse to look at how people go
    into a crisis or breakdown in the first place
    often when young and because they are unable to
    cope they are forced to seek help or others
    seek help for them.
  • This was my own experience at age 22 when I was
    admitted to psychiatric hospital after a
    breakdown. I spent 6 months in hospital, and it
    was enough to ensure I never wanted to go back,
    and somehow I managed to avoid hospitalisation
    ever since
  • Later, I met many people, through the service
    user /survivor movement, who had got into
    psychiatry in a similar way, but who had been
    caught up in it for far longer. I had struggled
    to cope in my life but I realised I was probably
    fortunate in managing not to have a long-term
    involvement in the mental health system

Caplan theory
  • In my thesis I wanted to set aside the assumption
    that psychiatric hospitals and diagnoses were
    inevitable, and pose the question what was
    going on for people when they found themselves in
    crisis, how did they experience psychiatric
    intervention, and what happened during and after
    the crisis? I looked for an analytic framework
    which was not medical, which did not assume
    people had been ill or diseased. I used
    Gerald Caplans crisis theory as a model. It is a
    theory of systems, and looks at how people
    respond to their internal and external
    environment, how mostly we cope with life by
    trial and error, learning and developing, but
    sometimes things can get beyond our control, and
    our normal coping mechanisms become overwhelmed.
    We seek help, with ever greater urgency, until at
    some point we can no longer cope at all, and that
    is when institutions step in and take over.

Turning points to and from patienthood
  • Caplan created his crisis model to show how there
    are turning points in this process, where people
    move sharply towards greater disintegration or
    towards positive outcomes,
  • If communities were more aware of the process of
    psychological crisis, suitable help could be
    provided at the right times, not at all
    necessarily by doctors, perhaps better in fact
    not, ordinary, non-medical professionals who
    encountered a person needing help and recognised
    the signs of life-crisis.
  • If societies had the confidence to intervene, in
    many cases, the person in crisis might never need
    to become a mental patient.
  • Caplan was a psychiatrist, but he wanted
    communities to learn the mental health skills
    they needed to maintain people in the community
    rather than handing them over to psychiatry,
    which he believed often caused deterioration and
    institutionalisation, and revolving door

Crisis 4 phase model
  • Phase 1 Initial rise in tension from the impact
    of the stimulus calls forth habitual
    problem-solving responses.
  • Phase 2. Lack of success and continuation of the
    stimulus leads to a further rise in tension, with
    feelings of upset, helplessness and
  • Phase 3. Tension rises past a third threshold,
    stimulating the individual to mobilize internal
    and external resources, reserves of strength and
    emergency problem-solving mechanisms.
  • Phase 4. If the problem cannot be solved
    satisfactorily nor avoided, the tension mounts
    beyond a further threshold or increases over time
    to a breaking point. Major disorganization of the
    individual then occurs with drastic results.

My thesis questions
  • I asked 26 people about their first experience of
    a crisis which had led to hospitalisation.
  • I sought people whose first experience was in the
    last 5-10 years.
  • A number of them described breakdowns when they
    were young.

  • Michael, a young Irish man with a visual
    disability, was devastated by his mothers death
    during his A level year, and became steadily
    more depressed during his first year at
    University. He had also become aware that he was
    gay and was afraid to tell his parents about
    this. He stayed at a friends house for Easter
    that year and ended up taking an overdose and
    being admitted to hospital.
  • Id been getting more and more distressed and
    trying to hold it inin the middle of the night I
    was pacing up and down and, feeling very very
    wound up, feeling that I couldn't actually handle
    it any more..I found several tablets, um and I
    sort of took the bottle (267)

Michael - emergency treatment
  • I rememberwaiting in casualtyit wasnt long,
    they were er pumping my stomach (p) and I I
    wanted my friend to stay with me all the time
    but he wasnt allowed (p) while that was going on
    and I remember, (p) all the horrible feeling you
    get when um, when they do that youre awake,
    youve got to keep it water down while they get
    it all outits just horrible, I couldnt believe
    it could be that painful

Michael on the acute ward
  • they put me in a bed and I was crying and stuffI
    remember this nurse saying If you cant make it
    with your life, um, dont bother us with it and
    everybodys got to carry on sometime, some
    wayI said I cant cope but she said oh weve
    all got to cope, and then just went awaythat
    was in the early morning and I dont think I saw
    a nurse all dayWhen I did finally see one and
    asked what was going to happen they said, oh
    well, the chief psychiatrist will be here to see
    you shortly
  • Michael spoke to one of his sisters on the phone
    during this stay
  • When Id finished that phone call I remember
    crying buckets and buckets of tears and nobody,
    absolutely nobody coming to see how I was

The diagnostic interview turning point to
  • Eventually Michael saw a psychiatrist
  • he said to me, do you believe that people are
    talking about you and I said yeah, I do I
    thought that people were laughing at me in the
    street, which, it turns out they werehe said,
    so, youre hearing voices then and I said, no,
    I didnt say thathe said have you always been

The diagnostic interview turning to long-term
  • I said, I dont know, I spose so he said, and
    what about, your love life, have you got a
    girlfriend?I said, no, I I m gay, I thinkhe
    said oh well, are you the active or the passive
    partner? I said. What do you mean exactly?,
    because I was actually a virgin then, about 18
  • He said well do behave like a man or a woman in
    bed adopts abrupt tone well, I lost it then I
    said I dont know what the hell youre talking
    about, and hows this helping me? I said, me
    mothers died, Im lonely, I cant cope and
    youre asking me how I behave in bed I said ,
    Ive never even been to bed with anybody.

The diagnostic interview turning to long term
  • He said, well (p) I m going to give you these
    tablets and, I want you to take them and I m
    going to refer you to a clinical psychologist,
    and Im going to send a CPN community
    psychiatric nurse to see you.
  • I got these tablets and I remember these, was
    Melleril, Ludiomil and Temazepam.
  • Anyway I got them on the Friday and on the
    Saturday I took them all with a nice bottle of

Making a crisis worse
  • Michaels treatment by professionals was
    experienced by him as insensitive and dismissive,
    particularly in the response to his sexuality
    issues. He tried to spell out what he saw as his
    problem, which was related to his loss of his
    mother and his loneliness at college.
  • The doctor did offer a clinical psychologist and
    a CPN, but perhaps this did not substitute for
    Michaels immediate need for acceptance and
    understanding from the doctor himself.
  • The doctors questions about Michaels sexual
    behaviour seemed completely unnecessary and
    inappropriate to him. The overdose may have been
    partly an angry response to this treatment. There
    is a clue to this in his next statement
  • I didnt take all the sleeping tablets because I
    realised, in the middle of it that I was, well I
    thought I was going to dieI was so confused
    because I didnt know whether I wanted to die or
  • If Michael was taking the overdose partly out of
    anger, this might account for his confusion about
    whether he really wanted to die. He may have
    needed to show the doctor how hurtful and
    unhelpful his behaviour had been.

Sarah who took an overdose
  • I got away from my parents who I never (p) felt
    understood meI was quite naive because all the
    problems followed me, and they seem to have got
    worse (Sarah, 1916)

Sarah on the emergency ward
  • It was just horrendous, in terms of the
    treatmentI went with a friend to A E, and,
    nobody, would really talk to me, none of the
    staff would really talk to meor if they did they
    would ask me rather.philosophical questions
    such as do you want to die?I said well, you
    know, its not as simple as that laugh I mean,
    how long have you got, I could discuss it with
  • I actually said that to one young bloke and he
    just looked terrified and literally shot off and
    I didnt see him again the nurses would look,
    um, not impressed with what Id done their
    expressions on their face showed it - they didnt
    say anythingthey would give me the old potions,
    a mix to make me throw uptheyd look at me as if
    this is like a punishment

Sarah and the psychiatrist
  • Sarah saw the psychiatrist the day after her
    admission, and was asked why she had taken an
    overdose, and when she explained, he simply told
    her not to do it again and referred her back to
    her GP. She also saw a social worker who said
    you look like a strong lass..things should work
    itself out, which she says she found so
    patronising and unhelpful (1987). Sarah
    explains what she had hoped for
  • I suppose I wanted someone to talk to, to listen
    to me, and not to be treated in some
    ways barbaric wayheartless and callous wayI
    suppose I did expect a lot more from them, but it
    was just like a conveyor belt, we just want
    topump all the rubbish out of you but well
    still make assumptions about you at the end of
    the dayand when I leftI felt really emptyId
    lost a lot of emotion and feelings, I just felt
    theyd taken all that away as well, its hard to
    explain, its, everythings gone

Taking everything away
  • Sarahs experience, like Michaels, was of basic
    medical care following her attempted suicide,
    coupled with critical and dismissive attitudes
    from staff which she found distressing. She was
    asked questions, but in a manner that suggested
    that the questioner was not willing to take the
    time to listen and understand without judgement.
  • I interpret her description of having had her
    emotions taken away along with the overdose as a
    statement that she had needed the opportunity to
    feel and express her pain, and had been denied
    this because of the cold and impersonal treatment
    she had received. This had left her feeling that
    the opportunity of the crisis had been wasted.

Evidence of trauma as an underlying cause
  • Eight of the interviewees spoke about early abuse
    or trauma that they linked to their crisis
  • It started off I think very, very early in my
    childhood I was, I suppose, physically abused by
    my parents then, sexually abused by a friend of
    the family (Mark - young man)
  • my father had killed himself, thats really the
    root of my problemId been planning this for a
    long time, like years, Id dabbled in the idea of
    trying to kill myself (Lucy - young woman)

Evidence of trauma
  • I was abused from the start, I was physically
    abused by my father, not sexually as far as I
    know, but he, um. He beat us up, yeah, he was
    given to uncontrollable rages and he would just
    smack us around and he had, we were powerless and
    he had all the authority, and he had the
    authority to smash us up any time he wanted, and
    for years any time anybody made a movement
    (Alice - upper class woman)

Evidence of trauma
  • There was the childhoodI was abused, off me dad,
    and he damaged one of me testiclesand I went
    away to boarding schoolslocked away in boarding
    schoolsthey was very cruel to me at one of the
    schoolsthey used to tie me to beds and
    that.later the school got closed downboarding
    school for backward people or something (Donald
    man with learning disabilities)
  • I couldnt accept it bereavement because I
    never had any brothers and sistersmy mother
    died at 30 crossing the road (Martin -
    middle-class man who broke down when his wife

Evidence of trauma
  • some of my mental health stuff goes back to my
    childhood, which my dad was an alcoholic, I
    actually watched my dad beat my mum up when you
    try and talk about it hurts its easy to think
    youve forgotten about it, but its still like
    there in the back of your mind Ive tried
    suicide ten times since the age of 13 and I've
    actually done self-harm (Philip, young gay man)
  • Id just come out of an orphanage, to be abused
    by me dadwhen you told people about it, nobody
    believed you, in the 60sI told the priests, cos
    thats all I know of then, and I got a
    hidingfrom the priest, he slapped me (Irish

Evidence of trauma
  • I didnt learn all the social skills and how to
    be with people and how to interactbecause I was
    locked up as a youngster, Im suffering from sort
    of low self esteem now, and my parents are very
    good at making me feel inadequate, because of the
    way theyve been brought upI realise that, so I
    know why they do what they do, but I cant
    forgive them (Bina, young Asian woman)
  • Well, when I was 16 I started feeling hellish
    anxiety. My fatherd been going on for a few
    years he was going to chuck me out when I was 16.
    so when I turned 16 I got all this anxiety
    stuff my mother packed her bags and leftfather
    started chucking me out of the house (Roger,
    white man)

Difficulties in finding help
  • Philip describes a reluctance to ask his mother
    for help
  • my mums already had a breakdown previously,
    before I had mine, somaybe I didnt want to
    upset her any moreI didnt want to depress her
    and make her worse, so I just bottled it all up
    for a whole year
  • Lucy mentioned an ultimately unsuccessful search
    for help from friends
  • I suppose it was a build up of complete anger
    that no one was helping me and I was going to
    different friends trying to get help and they had
    no understanding.

Help-seeking in crisis
  • The problems experienced by people seeking help
    from friends were similar to the problems in
    seeking help from family
  • However willing to help the friends were, the
    person going into crisis found problems of
    communicating the need for help, or perhaps their
    needs were too great.
  • Perhaps during the crisis, the person needed to
    talk in a way with which they and their friends
    were unfamiliar.
  • For many, the next step was to seek professional
    help from their family doctor or other community

Family doctors
  • People had varying relationships with their GPs,
    but the consistent factor is that GPs seemed to
    have little to offer beyond medication and
    referral to a psychiatrist.
  • This does not seem to have coincided with what
    the interviewees felt they wanted and needed at
    this stage, though the evidence suggests they may
    not have been clear about what they were asking
  • Medication was not found helpful and was
    considered to have contributed to the worsening
    crisis in some cases.
  • Some of the interviewees were clear that they
    wanted to be listened to or given therapy or
    social support of some kind

Day hospital
  • Sarah became a day patient at the psychiatric
    hospital. This treatment, she considers in
    retrospect, made things worse
  • unfortunately, it didnt help, all I got from the
    psychiatrist was, lots of drugsAntidepressants,
    Amitryptiline and sleeping tablets,
    tranquillisers, just one big cocktail which
    seemed to turn me into a bit of a zombie
  • I just couldnt think or feel or anything,
    everything just seemed to, be detached from,
    everythingmy partner seeing me in vulnerable
    powerless state he could abuse me in any way he
    wanted tobecause of the drugs, and because of
    the way the psychiatric system deals.I felt even
    more disempowered, I felt I couldnt think for

Going to the emergency clinic
  • Philip
  • I went to the Accident and Emergency and asked to
    see the Emergency Psychiatristhe kept saying
    are you hearing voicesit was really getting to
    me, Im not hearing voices, Im depressed, cant
    you understand that? what do you have to do, to
    make these people see thattheres mental health
    thats not just hearing voices and schizophrenia,
    and theres so many other different forms of
    mental health

Doctors and sexuality
  • Philips doctor was insistent that Philips
    problems were related to his homosexuality and
    tried to convince him to go straight.
  • I told the doctor Id been raped at the age of
    13and now hes saying, Im gay because I got I was trying to like, say look, my
    sexualitys got nothing to do with what happened
    there, in that moment of time
  • This made matters worse, confirming his
    experience that people would not really listen to
    him and respect his beliefs and his sexuality
  • You cant seem to get the help you want without
    somebody else criticising youyou get more and
    more frustrated and more and more depressed, cos
    youre bottling it all upits like being in a
    corner, like as if people were literally
    strangling you, not a good condition for me to
    get into

Lucy went to the college counselor
  • I.was really desperate and I went to see the
    student counsellor there
  • I said to her, aggressive tone yknow, you
    can't tell me not to kill myself can you cos
    that's not your job you're not allowed to say
    things like that are you?
  • I wanted someone to care, but not that it was
    really her, but I was so desperate that I thought
    it could be her.
  • I said to her, well I'm gonna kill myself, and
    that was the end of the sessionstraight after
    that I bought some razor blades
  • the next morning. I decided that I was gonna
    kill myself, and I spent approximately 2 hours
    cutting my wrists

Lucy second interview
  • I considered that Lucy was testing the therapist
    by her verbal challenge, and put this to her at
    my second meeting with her. She agreed
  • I said to her you are not going to tell me not
    to, if I say I am going to kill myself. You are a
    counsellor, and you cant tell people not to do
    or to do anything, and what I was implying was
    that she didnt careshe was crap, I mean
    universities are notorious for people killing
    themselves and I was practically asking her to
    intervene without getting down on my hands and
    knees and I was also throwing it in her face and
    I was being manipulative, but if she had cared a
    bit more about another humans lifeI was being
    nasty because I was on a death path, but even so
    it must have been obvious that I wasnt a really
    horrible person inside. When people are angry
    its usually because they are really really sad,
    everyone knows that, so why dont people act upon
    it and find out why people are feeling sad?

Lucys challenge
  • The point she made about her challenging
    behaviour to the therapist was a general one that
    might apply to a number of the interviewees. It
    helps to explain why people often sought help but
    were unable to communicate the problem in a way
    that others could easily respond to, and why
    people are not always able to use help that is
    offered. Lucy wanted help from someone who was
    more mature, more knowledgeable and stronger than
    her. She wanted someone who could see the real
    person inside, which she was unable to show.

Lucys crisis nearly ended in death
  • I went up to the top of the roof, of the
    hospital and this porter came and got me down
    and if Id have jumped then I would have been
    deadThey took me back and they didnt do
  • .so the next day, I dressed up, in my best
    clothesand I ran out of the hospital, ran up a
    fire escape and jumped, from the 5th floor
  • I was taken to intensive care, and I woke up, and
    my whole body was in a plasterI just couldnt
    believe it , I was so angrythat time I think was
    the most time that Ive ever meant it, cos I was
    so, off my head
  • Lucys determination to jump from the hospital
    roof seems like an increasingly desperate attempt
    to be taken seriously even if this was only to
    happen after her death

Safety in hospital?
  • When Lucy had been brought back down from the
    roof the first time a nurse spoke to her in a
    sarcastic manner
  • You dont wanna be doing anything like that,
    Lucy, you dont wanna get sectioned, it wouldnt
    be good for your career
  • I asked her at the second interview if this
    comment had had an effect on her and she said
  • yes she was horrible. and it was like it
    was blackmail. They should have sectioned me.
    Ive got a right to be sectioned. I am
    desperately saying to them Im wanting to
    kill myself. I am 21. Had I been 31 it might have
    been different but at the age of 21 everybody's
    got the right to get a bit of support

Death and rebirth
  • She believes that she should have been sectioned
    at that time for her own safety, and that she
    needed medication
  • as a mental and emotional pain killer I needed
    professional care. my friends and my family
    werent enough. Or they werent what I needed at
    that timeI was immature. I wanted to be a baby
    again. I wanted to be reborn. I think that was
    part of my thing about suicide, it was trying to
    rebirth myself. I felt a sense of relief after I
    cut my wrist. because I thought then they were
    going to do something
  • For Lucy during her crisis period, death seems to
    have been preferable to being ignored.

Psychiatric ward to orthopaedic
  • Lucy, miraculously survived her jump from roof
    and was taken to intensive care
  • I was .given loads of morphine and that was
    great, yknow, when youre feeling shit, I mean
    morphine does make you feel good laugh
  • then they took me down to the orthopaedic ward
    after about eleven days, and um, I was in a room
    on my ownI had 24 hr nurse laugh obviously
    they were getting worried by that timethey
    hadnt taken me seriously when Id sort of said
    to them before that I felt really shit and I felt
    like killing myself and stuff
  • I got a different psychiatrist, and they gave me
    some medicationI gradually got better and I
    think that was to do with being in a normal
    environment, partlybeing in a general ward,
    with, yknow, normal peoplethere was more
    activity on that wardthere was a routine, and
    the nurses..spoke to you more

Seeking professional help
  • Many of the interviewees had turned to
    professionals hoping to find knowledgeable and
    skilled help, based on good listening and genuine
  • It may be that people need one-way help during a
    crisis which is free of the backlog of tensions
    that is common with family and friends.
  • The help people sought was rarely available.
  • The failure of professionals to understand and
    provide empathic and appropriate help, and the
    ill effects of medication appear to have provided
    the final turning point into crisis for a large
    number of the interviewees

How far did hospital meet peoples needs in
  • I found that most people were seeking appropriate
    treatment for problems which they considered to
    be related mainly to psychosocial causes.
  • Hospital services in crisis were valued by a
    number of people, but it seemed that their view
    of what they needed was a place of refuge and
    asylum, with talking treatments offered, rather
    than to be sectioned and forced to take
  • People valued those aspects of hospital that most
    closely matched their perceived wants and needs.
  • In most cases these needs were not fully met,
    with the response from psychiatrists and other
    hospital staff being primarily based on the
    discourse of psychopathology, which does not
    involve listening to and believing or respecting
    patients views.

How far did hospital meet peoples needs in
  • Some people experienced turning points towards
    long term patient-hood because of poor treatment
    within the medical model, while a small number
    experienced turning points towards recovery
    because of finding respectful listening coupled
    with practical support.
  • Some people did accept the discourse of
    psychopathology and believed they needed to
    continue taking medication because they had had a
    further crisis after discontinuing it.

What my research showed
  • This research offers confirmation and validation
    of psychosocial theories, including crisis theory
    and trauma theory, along with some evidence of
    psycho-spiritual aspects to crisis.
  • It adds substance to these theories by showing
    the of how crisis and crisis intervention is
    experienced, and why some interventions work
    better than others.
  • It also gives substance to critiques of the
    discourse of psychopathology from the
    psychosocial and from the self-advocacy
    perspectives, by showing exactly how and at what
    point people found themselves let down by
    professional treatment within the discourse.

What people said they needed
  • they keep saying take this pill try this pill
    try this pill .I keep saying well its not
    about pills, its other things (Joseph)
  • I have tried very hard to actually do something,
    thats why I get aggressive with people in
    authority, or whatever, because theyve never
    given me a chance (Donald)
  • I think I needed a lot of confidence-raising,
    which I was not getting (Alice)
  • we need user sensitive people working rather
    than what we have in the health service at the
    moment, they dont really have any idea (Bina)
  • I wanted to get back to work.I dont want to go
    into hospital any more.I prefer to become
    a.respected citizen again and get on with my
    life (Mary)

  • People found help for their recovery outside
    health and social services in terms of
  • increasing self-knowledge
  • learning to manage their problems
  • making their own choices about medication
  • mutual support
  • relationships with their friends and family
  • making their own choices about medication
  • finding enjoyable activities and work
  • exploring spirituality and culture
  • Recovery was more difficult if these factors were
    absent, in particular where people were isolated.
  • Lost relationships and current isolation led to
    feelings of anger, hate and violence in some

Other research on alternatives
  • Strategies for Living user-led research found
    that people create their own coping strategies
    for on-going survival, crisis or life-saving,
    symptom management and healing.
  • What people find most helpful is acceptance,
    sharing experience and identity, emotional
    support, finding a reason for living, peace of
    mind and relaxation, taking control and having
    choices, security and safety, and pleasure or
    enjoyment in life.
  • Strategies for Living researchers recommended
    that mental health professionals, service
    providers and policy makers recognise the
    expertise that service users have to contribute
    to mental health, and work with them to look at
    how services can support peoples own strategies
    through Expert Patient programmes,
    self-management training and support, and more
    investment in healthy living, health education,
    health promotion and positive images of people
    living with mental health problems.

Healing Minds
  • Complementary and alternative therapies can be
    shown to work for people with mental health
  • Active therapies such as exercise, yoga and
    relaxation can reduce anxiety and depression and
    help people reduce medication
  • Massage helps people feel more positive about
    themselves, reduces stress and uplifts mood
  • Nutritional medicine/therapy can be effective in
    schizophrenia and depression, though more
    research is needed
  • Herbal medicine some herbs can be effective for
    depression, anxiety and insomnia

Research on alternatives
  • I have argued strongly that there is a need for
    more research to be done on the types of
    treatment that service users want, including
    talking treatments, complementary therapies and
  • The reasons this does not happen more are
    financial and political governments do not want
    to offend the pharma industry, and rely on pharma
    to fund most psychiatric research

Healing Minds
  • Acupuncture can be effective in schizophrenia
    but more research is needed. Some evidence for
    its value in depression.
  • Complementary therapies such as aromatherapy and
    reflexology work well alongside talking
    treatments, helping to open up feelings for
    exploration in therapy, or helping to calm a
    person down after an emotional session.
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