Creative Positions in Adult Mental Health: Outside In-Inside Out

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This book presents cutting edge developments in Adult Mental Health through the presentation of creative and innovative applications of systemic theory to practice. The first section deconstructs the medical model with some of the current beliefs and practices shaping services whilst placing adult mental health in a wider social and political context. The second half of the book showcases good practice from the field. At either end of the volume "bookends" invite current clients and staff to write about their experiences with the aim of bringing a powerful personal context into the work. We intend to create a shift from third person objectivity to a first person experience as a political act which flows through the book.

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Preface: The Moving on Groups

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Sue McNab

Some years ago, the Moving On Group started as a multi-family group working with families where a young (and at times not so young) adult has got “stuck” living at home with their parents as a result of mental health difficulties. For some families, psychosis has taken over their lives: for others extreme anxiety, Asperger's syndrome, and obsessive–compulsive disorder means that they are, as yet, unable to take up an independent lifestyle. Sometimes, the young adults come to the meetings, but more often the parents come on their own.

The group, based on systemic principles, offers a facilitated space to share stories about their situations and worries, to offer mutual support, and to find ways of living alongside chronic struggles if they cannot be moved beyond. Its members might describe it as a “sort of family” where people can bare their souls safe in the knowledge that they will be understood and accepted. They tell each other their individual family stories, report progress or lack of it, and witness and take pride and pleasure in the “high points” of others’ progress even when their own situations are highly stressful and painful. The quality of listening within this group is quite exceptional and moving to witness.

 

CHAPTER ONE Psychiatric diagnosis and its dilemmas

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CHAPTER ONE

Psychiatric diagnosis and its dilemmas

David Harper

n the West, the dominant discourse for understanding mental distress is a psychiatric one and a key element in this discourse is diagnosis. Systemic practitioners encounter diagnoses every day because they are enshrined in their institutional contexts. In the

USA, for example, practitioners are required by insurers to give clients a diagnosis from the American Psychiatric Association’s (2013)

Diagnostic and Statistical Manual of Mental Disorders (DSM). In other countries, diagnoses from the World Health Organization’s (2010)

International Classification of Diseases (ICD) might be required for a range of administrative reasons. In addition, in the UK, the National

Institute for Health and Clinical Excellence (NICE) has published a range of clinical guidelines based on diagnostic categories. Systemic therapists have a range of responses to diagnosis. For example, in their study, Strong, Gaete, Sametband, French, and Eeson (2012) noted

 

CHAPTER TWO Missing the point: the shy story of disappointment

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CHAPTER TWO

Missing the point: the shy story of disappointment

Duncan Moss

And time yet for a hundred indecisions,

And for a hundred visions and revisions,

Before the taking of a toast and tea.

(Eliot, “The Love Song of J. Alfred Prufrock” (1963, p. 14)

t was all going to be so different. I was going to clear some space in the usual diary mess. I would sit, drink tea, and elegantly and productively enjoy this process of explorative writing, an activity rare to the point of extinction, it seems, if you are employed as a university lecturer in clinical psychology.

Yes, right. Instead, the “cleared space” has become more of a frantic, grumpy swipe at a never diminishing “things to do” list of university “blah”, to stonily bleed out what follows. What a disappointment.

Fortunately, it is all rather apt.

This chapter is, in fact, about “disappointment”. I have been interested in this (perhaps strange) topic for many years and want to share something of why, hoping that it might strike a chord with you.

 

Introduction: “The Soul Within the Symptoms”

ePub

Sue McNab

Curiously, and quite by chance, I sat down to write this introduction on the very day, 11 February, that Sylvia Plath took her life fifty years ago. Also by chance, it was snowing outside, but, unlike her, we were not in the grip of one of the coldest years on record, 1963. Various commentators, writers, and journalists are still weighing up Sylvia's life and death and, perhaps fittingly for this volume, they wonder how much of her untimely death can be ascribed to a lack of modern medicine and other medical treatments and/or attributed to the various contextual tragedies in her life.

On the day of her death, Sylvia was living in London with her two very young children, having recently separated from her husband, the poet Ted Hughes, whom she suspected had already embarked on another relationship with Assia Wevill. Sylvia, a highly intelligent woman, was trying to find her voice as a poet in the early 1960s in a land not of her birth. Her novel, The Bell Jar, which charts some of her earlier struggles with depression, had recently been published under a pseudonym. Her poetry told of the early death of her father and its effect on her. Her story—perhaps putting her brilliance to one side—is not so uncommon for those of us working in mental health services and its sense of complexity and tragedy seems somehow a well-timed place from which to begin a description of this book.

 

Chapter One - Psychiatric Diagnosis and its Dilemmas

ePub

David Harper

In the West, the dominant discourse for understanding mental distress is a psychiatric one and a key element in this discourse is diagnosis. Systemic practitioners encounter diagnoses every day because they are enshrined in their institutional contexts. In the USA, for example, practitioners are required by insurers to give clients a diagnosis from the American Psychiatric Association's (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM). In other countries, diagnoses from the World Health Organization's (2010) International Classification of Diseases (ICD) might be required for a range of administrative reasons. In addition, in the UK, the National Institute for Health and Clinical Excellence (NICE) has published a range of clinical guidelines based on diagnostic categories. Systemic therapists have a range of responses to diagnosis. For example, in their study, Strong, Gaete, Sametband, French, and Eeson (2012) noted “counsellors shared a diverse range of views on the DSM: everything from an enthusiastic embrace to dismissal or even subversion” (p. 97).

 

CHAPTER THREE Dancing between discourses

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CHAPTER THREE

Dancing between discourses

Sue McNab

et us begin by telling a story—after all, this is what patients do when they come to an appointment with a mental health professional. How the story is told will be shaped by their view of their problem and their idea about who is listening to it, but it will also be moulded by the listener. As systemic practitioners, our listening ears attempt to hold as many positions as possible so that the story develops more depth, meaning, coherence, and purpose. This is no easy task and involves us in a number of continuing and complicated dance steps as we work to engage with the patient, their family, our professional colleagues, and the wider context.

Our story starts with Jim, a thirty-four-year-old man who has a longstanding relationship with psychosis and a diagnosis of schizophrenia. He has been attached to mental health teams since he was eighteen, when his difficulties encroached on his life to such an extent that he could not work, found living independently very stressful, and had a number of psychotic episodes. Our psychiatric colleagues have worked hard over the years to determine an appropriate and effective medication package and the clinical team has offered support in accessing assisted housing, return to work schemes, and ongoing supportive conversations. The team has been aware for some time of

 

Chapter Two - Missing the Point: The Shy Story of Disappointment

ePub

Duncan Moss

And time yet for a hundred indecisions,
And for a hundred visions and revisions,
Before the taking of a toast and tea.

(Eliot, “The Love Song of J. Alfred Prufrock” (1963, p. 14)

It was all going to be so different. I was going to clear some space in the usual diary mess. I would sit, drink tea, and elegantly and productively enjoy this process of explorative writing, an activity rare to the point of extinction, it seems, if you are employed as a university lecturer in clinical psychology.

Yes, right. Instead, the “cleared space” has become more of a frantic, grumpy swipe at a never diminishing “things to do” list of university “blah”, to stonily bleed out what follows. What a disappointment.

Fortunately, it is all rather apt.

This chapter is, in fact, about “disappointment”. I have been interested in this (perhaps strange) topic for many years and want to share something of why, hoping that it might strike a chord with you. Disappointment is one of those words that is perhaps both obvious and subtle at the same time. It is, of course, in some ways, a very familiar word, but in the exploration here I want to present it as a “shy story”. Partridge (2005) explored the way in which families produce narratives about “our family”, often dominant narratives, or “boastful stories”, to be rehearsed and retold, and held and propagated by those in the family who hold more power. At the same time, however, families are likely to have “shy stories”, less visible, less comfortable perhaps, held by less powerful family members and sometimes at odds with the more dominant family narrative.

 

CHAPTER FOUR Coming to reasonable terms with our histories: narrative ideas, memory, and mental health

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CHAPTER FOUR

Coming to reasonable terms with our histories: narrative ideas, memory, and mental health

David Denborough

truggles for mental health matter to me. My extended family and friendship networks, like most, know the heartbreak and acts of bravery that accompany significant mental health struggles. My work for Dulwich Centre Foundation takes place with groups and communities who are responding to mental health concerns in the context of broader trauma and injustice. Whether it is those in my own community who are struggling for mental health, or those in communities with whom we work in partnership in Rwanda,

Palestine, Iraq, or elsewhere, the suffering and courage that I regularly witness is the backdrop to this chapter. In the following pages, I wish to mention a number of hopeful recent trends, or “movements”, in the field of mental health and then link these to some of our current explorations of narrative practice.

S

Some recent “movements” in mental health

 

CHAPTER FIVE “Where the hell is everybody?” Leanna’s resistance to armed robbery and negative social responses

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CHAPTER FIVE

“Where the hell is everybody?”

Leanna’s resistance to armed robbery and negative social responses

Allan Wade

eanna (thirty-five) and Jane (sixty-four) were robbed at gunpoint while closing a department store for the night, with

“the take” for the day in hand. Two months later, Leanna phoned me to arrange counselling. We met six times over about six months while Leanna recovered and made some important life decisions. I found Leanna’s descriptions of her experience especially compelling and, two years later, asked if she and I might record a conversation about the robbery. She agreed and allowed me to use the interview for training purposes. This chapter centres on a twentyminute segment of this interview during which Leanna and I develop accounts of her responses to the robbery and to the series of negative social responses she experienced afterwards. As we explore Leanna’s responses in detail, using active grammar and descriptive terms,

Leanna emerges as an upright person who showed courage and composure while resisting the robbery and is justifiably indignant about the negative social responses she received.

 

Chapter Three - Dancing between Discourses

ePub

Sue McNab

Let us begin by telling a story—after all, this is what patients do when they come to an appointment with a mental health professional. How the story is told will be shaped by their view of their problem and their idea about who is listening to it, but it will also be moulded by the listener. As systemic practitioners, our listening ears attempt to hold as many positions as possible so that the story develops more depth, meaning, coherence, and purpose. This is no easy task and involves us in a number of continuing and complicated dance steps as we work to engage with the patient, their family, our professional colleagues, and the wider context.

Our story starts with Jim, a thirty-four-year-old man who has a longstanding relationship with psychosis and a diagnosis of schizophrenia. He has been attached to mental health teams since he was eighteen, when his difficulties encroached on his life to such an extent that he could not work, found living independently very stressful, and had a number of psychotic episodes. Our psychiatric colleagues have worked hard over the years to determine an appropriate and effective medication package and the clinical team has offered support in accessing assisted housing, return to work schemes, and ongoing supportive conversations. The team has been aware for some time of complex family relationships, which resulted in a referral for family therapy.

 

CHAPTER SIX Psychiatry, emotion, and the family: from expressed emotion to dialogical selves

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CHAPTER SIX

Psychiatry, emotion, and the family: from expressed emotion to dialogical selves

Paolo Bertrando

amily and emotion entered the field of psychiatry together in the late 1950s as a result of working with families who had a schizophrenic member. On one side of the Atlantic, this process generated the different approaches to schizophrenic families that eventually gave rise to family therapy (Broderick & Schrader, 1991) and, on the other side, led to what has been defined as expressed emotion (Leff & Vaughn, 1985).

From that moment, the family fell, partly at least, within the domain of psychiatry. Under the psychiatric gaze, the family itself became a kind of “patient” and family problems slowly came to be considered as family pathologies. It was too easy to see a family with problems as a deviant or pathological family.

Interestingly, the American approach to family and schizophrenia, the then paradigmatic psychiatric illness, gave little emphasis to emotion, stressing instead the cognitive, as well as relational, aspects of both psychopathology and family life, as the very concept of double bind (Bateson, Jackson, Haley, & Weakland, 1956) exemplifies. The

 

Chapter Four - Coming to Reasonable Terms with Our Histories: Narrative ideas, Memory, and Mental Health

ePub

David Denborough

Struggles for mental health matter to me. My extended family and friendship networks, like most, know the heartbreak and acts of bravery that accompany significant mental health struggles. My work for Dulwich Centre Foundation takes place with groups and communities who are responding to mental health concerns in the context of broader trauma and injustice. Whether it is those in my own community who are struggling for mental health, or those in communities with whom we work in partnership in Rwanda, Palestine, Iraq, or elsewhere, the suffering and courage that I regularly witness is the backdrop to this chapter. In the following pages, I wish to mention a number of hopeful recent trends, or “movements”, in the field of mental health and then link these to some of our current explorations of narrative practice.

Some recent “movements” in mental health

I have recently returned to Australia after a visit to the Northern hemisphere that included the Hearing Voices World Congress1 in Cardiff, which marked the twenty-fifth anniversary of the Hearing Voices Movement. It was an inspiring event. One of many highlights was meeting Joseph Atukunda from Heartsounds Uganda.2 Joseph is one of the “mental health champions” of Uganda—people who have known their own struggles and are now determined to build grass roots “consumer-led” mental health responses in Uganda and, eventually, in other African countries. I learnt from Joseph Atukunda of the ways he is using the Tree of Life (Denborough, 2008; Ncube, 2006) in his work and how they are seeking to transcend stigma in relation to mental health.

 

CHAPTER SEVEN Open dialogues mobilise the resources of the family and the patient

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CHAPTER SEVEN

Open dialogues mobilise the resources of the family and the patient

Jaakko Seikkula and Birgitta Alakare

n a severe mental health crisis, it should be normal psychiatric practice for the first meeting to take place within a day of hearing about the crisis. Furthermore, both the patient and family members should be invited to participate in the first meeting and throughout the treatment process for as long as is needed. In these meetings, all relevant professionals from primary care, psychiatry, social care, and other appropriate authorities who have contact with this family are invited to participate and openly share their thoughts and opinions about the crisis and what should be done. These professionals should stay involved for as long as required. All discussions and treatment decisions should be made openly in the presence of the patient and family members.

These are the basic guiding principles of the open dialogue approach, a treatment method that originated in the Western part of

 

Chapter Five - “Where the Hell is Everybody?” Leanna's Resistance to Armed Robbery and Negative Social Responses

ePub

Allan Wade

Leanna (thirty-five) and Jane (sixty-four) were robbed at gunpoint while closing a department store for the night, with “the take” for the day in hand. Two months later, Leanna phoned me to arrange counselling. We met six times over about six months while Leanna recovered and made some important life decisions. I found Leanna's descriptions of her experience especially compelling and, two years later, asked if she and I might record a conversation about the robbery. She agreed and allowed me to use the interview for training purposes. This chapter centres on a twenty-minute segment of this interview during which Leanna and I develop accounts of her responses to the robbery and to the series of negative social responses she experienced afterwards. As we explore Leanna's responses in detail, using active grammar and descriptive terms, Leanna emerges as an upright person who showed courage and composure while resisting the robbery and is justifiably indignant about the negative social responses she received.

 

CHAPTER EIGHT Narrative psychiatry

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CHAPTER EIGHT

Narrative psychiatry

SuEllen Hamkins

arrative psychiatry brings together narrative and biological understandings of human suffering and wellbeing. It relishes discovering untold but inspiring stories of a person’s resilience and skill in resisting mental health challenges while exposing and deconstructing discourses that fuel problems. It examines what the doctor’s kit of psychiatry has to offer in light of the values and preferences of the person seeking consultation, authorising the patient as the arbiter of what is helpful and what is not.

Narrative psychiatry, as I theorise and practise it, arises from the confluence of several streams of inspiration in my life. Postmodern philosophy (Foucault, 1979) and feminist theory (Gilligan, 1982;

Morgan, 1970) inspired me early on to discern and unpack operations of power in society. I studied medicine with the intention of becoming a doctor who could selectively draw from bio-medical discourses while resisting their hegemony, with hopes of attending more empathically to my patients (Lewis, 2011). Narrative psychotherapy (Freedman &

 

Chapter Six - Psychiatry, Emotion, and the Family: From Expressed Emotion to Dialogical Selves

ePub

Paolo Bertrando

Family and emotion entered the field of psychiatry together in the late 1950s as a result of working with families who had a schizophrenic member. On one side of the Atlantic, this process generated the different approaches to schizophrenic families that eventually gave rise to family therapy (Broderick & Schrader, 1991) and, on the other side, led to what has been defined as expressed emotion (Leff & Vaughn, 1985).

From that moment, the family fell, partly at least, within the domain of psychiatry. Under the psychiatric gaze, the family itself became a kind of “patient” and family problems slowly came to be considered as family pathologies. It was too easy to see a family with problems as a deviant or pathological family.

Interestingly, the American approach to family and schizophrenia, the then paradigmatic psychiatric illness, gave little emphasis to emotion, stressing instead the cognitive, as well as relational, aspects of both psychopathology and family life, as the very concept of double bind (Bateson, Jackson, Haley, & Weakland, 1956) exemplifies. The British version, however, centred on emotion, and, at the same time, subjected it to quantitative evaluation.

 

CHAPTER NINE Family needs, family solutions: developing family therapy in adult mental health services

PDF

CHAPTER NINE

Family needs, family solutions: developing family therapy in adult mental health services

Roger Stanbridge and Frank Burbach

Introduction n this chapter, we consider the needs of families where a member is involved with mental health services and the roles that family therapists might play in shaping and delivering both routine and specialist services. In considering this we begin by focusing on families’ experience of mental health services, the evidence base for family work, and the policy guidance. Although working in partnership with families is part of all national guidelines, feedback from families suggests that many mental health services have not, as yet, managed to achieve this routinely. We shall describe ways in which we have approached this in the county of Somerset and consider the implications for family therapists. We hope that our experiences will encourage the further development of systemic ideas and practice in other adult mental health services.

 

Chapter Seven - Open Dialogues Mobilise the Resources of the Family and the Patient

ePub

Jaakko Seikkula and Birgitta Alakare

In a severe mental health crisis, it should be normal psychiatric practice for the first meeting to take place within a day of hearing about the crisis. Furthermore, both the patient and family members should be invited to participate in the first meeting and throughout the treatment process for as long as is needed. In these meetings, all relevant professionals from primary care, psychiatry, social care, and other appropriate authorities who have contact with this family are invited to participate and openly share their thoughts and opinions about the crisis and what should be done. These professionals should stay involved for as long as required. All discussions and treatment decisions should be made openly in the presence of the patient and family members.

These are the basic guiding principles of the open dialogue approach, a treatment method that originated in the Western part of Finnish Lapland. The development of this new approach started in the early 1980s. This chapter has its background in Finnish Lapland, but describes elements that can be put into practice in other contexts. Our aim is to outline the significance of the open dialogue approach for patients and their families.

 

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