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We all say things that we don’t mean sometimes. Perhaps the time that you snapped at the end of a long day or said that deliberately hurtful comment in the heat of an argument. Sometimes these instances are easily recognisable (perhaps easily apologised for). However, often our language conveys more subtle messages as well. Even everyday expressions may carry connotations we have not considered and speak to ideas we don’t condone. The words we use when we talk about self-harm and suicide show just that; while our language can convey compassion, provide hope, empowerment and optimism, we can also unwittingly express messages that divide and stigmatise.



I’m definitely guilty of this – while I may not like to admit it, my undergraduate notes are littered with phrases that now make me uneasy. Far from meaning to be impertinent, I was passionate about battling the silence and taboo surrounding mental health and in particular getting people talking about suicide. But, to be honest, at that point I don’t think I’d ever thought carefully about the language used when doing the talking. Then I had a conversation with a lady whose son died by suicide and realised that phrases like ‘committed suicide’ weren’t simply a case of well, it’s just what you say. For the first time I felt some of the impact of our everyday language and understood why accurate, non-stigmatised terms really matter. I’m grateful that she took the time to explain to me how challenging she found some words. That conversation prompted me to mind my ‘commits’ (‘C’s) and ‘suicides’ (‘S’s), as well as reflect further on the potential inadvertent messages conveyed by the language we choose.

The term ‘committed suicide’ has perhaps prompted the most publicised opposition. Although commit can mean a number of things, if we think about other times we use the word, it tends to be associated with negativity and wrong-doing. People commit crimes. People commit moral atrocities. People die by suicide. While opinions about suicide vary, we don’t usually associate the term commit with a public health concern, or mental health tragedy and the phrase goes no way to acknowledging the turmoil faced by someone prior to taking their life. Historically, suicide was deemed a crime. Not anymore (not since the 1961 Suicide Act in the UK). While we’ve updated our legislation appropriately, we haven’t updated our language; suicide is a cause of death and our language should reflect this. In no other situation would we say that someone committed their death, regardless of any personal or lifestyle factors which may have contributed to the outcome.

People commit crimes.
People commit moral atrocities.
People die by suicide.
The word committed in relation to suicide is not only unnecessary, inaccurate and outdated, but for many it can be insensitive language which amplifies the distress of an already difficult situation. Those affected by suicide, whether through having experienced suicidality personally or via the experiences or loss of a loved one, are vulnerable and often stigmatised [1]. Stigmatising language with its residual connotations of illegality, shamefulness and sin only exacerbates this [2, 3].

Stigma can be life-changing and life-limiting. It reduces both the propensity to help-seek and the provision of help-giving behaviour [4]. Stigma is also faced by those who have experiences around self-harm. For some, phrases like ‘self-harmers’, ‘cutters’ and ‘ideators’ (describing people who have thought about harming themselves/taking their lives, but have not acted on these ideas) are also loaded with difficulty. Language here could be seen as dismissive and pejorative. Some feel such terms take away from individual identity; typically, self-harm affords people a means of dealing with intolerable (and often deeply distressing) emotions. It may be someone’s coping response. It is not who they are. We all hold multiple identities which intersect with each other and it is imperative that our language reflects this. Being respected and valued first and foremost as an individual is important to wellbeing and this may be especially pronounced in situations where people have traditionally been labelled, perhaps diagnosed, by others. Adopting such shorthands may be unintentionally offensive, but damaging nevertheless.

Because of this, many advocate for the use of ‘people first language’ [e.g., 5]. That is to say, to make references to ‘people who self-harm’, rather than ‘self-harmers’. Such an approach can also increase the accuracy with which we use words; unlike phrases like ‘self-harmer’, person first phrasing can easily accommodate further information regarding recency (e.g., people who have self-harmed in the last 6 months) and frequency (e.g., more than 5 times) etc. Here, language matters as it helps to shape our attitudes and ideas. Phrases that can accommodate temporal dynamics encompass notions of change and recovery. These things are really important as the possibility of change is laced with hope. And hope is vital. Hope keeps people alive.
Phrases that focus on a single behaviour, such as ‘cutter’, also present challenges to accuracy. Such terms may be seen to imply that individuals only engage in one form of self-harm. This over-simplified account might lead us to miss important details and obscure the scope of behaviours. Indeed, research shows that a change in behaviour, or engaging in multiple behaviours, is common [6]. Additionally, phrases commonly employed in medical settings, such as the term ‘deliberate’ in relation to self-harm, arguably cannot reflect the ambivalence often reported and convey unhelpful and naïve messages regarding the controllability of self-harm. This perception may lead to negative emotional responses, as well discriminatory behaviours [7].

Other common phrases that also have negative connotations include referring to non-fatal outcomes as ‘failed’ attempts and any potentially dismissive comment regarding the ‘superficial’ nature of injuries. Medical severity doesn’t tell us about the magnitude of distress [8] and crucially it is paramount that we don’t inadvertently suggest that the behaviour and associated suffering isn't as valid. Similarly, by the logic of this language practice, to have ‘failed’ is to be alive. This is not a failure, this is an opportunity. It is important that we take any attempt seriously, that we recognise the distress and provide appropriate and timely, compassionate support. Any notions of ‘failure’ don’t contribute to that.

Of course everyone is different. People may be comfortable with different words and phrases and it’s important that individuals are free to tell their story in their own words. We can’t always anticipate what language people will be most comfortable with, but we can ensure that our words are considered and sensitive. And if we are unsure, we can ask the people we are talking to if they have preferences. We need more people discussing suicide in an informed, compassionate and open way, and we need to be clear that talking about these issues is OK and unlikely to lead to someone harming themselves [9]. By creating healthy, hopeful environments where people acknowledge emotional distress and relate sensitively about all aspects of suicide we will help to support survivors of suicide loss and help to save lives. By having an awareness of the historical context of terms, and listening to people’s feedback on language commonly employed, we can make sure our words don’t build unintentional barriers that exclude those who most need to be heard.

We have an opportunity to lead by example, to consider the choices we make and to politely and helpfully challenge those around us. We can all be part of a cultural shift. Starting with such a small and simple change, that’s quite something…

Emma Nielsen (@EmmaLNielsen) is an Associate Fellow of the Institute of Mental Health and PhD student in the School of Psychology (This email address is being protected from spambots. You need JavaScript enabled to view it.)
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Further information and great advice for media reporting of suicide is available from the Samaritans and Mindframe
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If you need someone to talk to, Samaritans are available round-the-clock (and free to contact) on 116 123 (UK & ROI)

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[1] Cvinar, J. G. (2005). Do suicide survivors suffer social stigma: A review of the literature. Perspectives in psychiatric care, 41(1), 14-21.

[2] Maple, M., Edwards, H., Plummer, D. & Minichiello, V. (2010). Silenced Voices: Hearing the stories of parents bereaved through the suicide death of a young adult child. Health and Social Care in the Community, 18(3), 241-248

[3] Sommer-Rotenberg, D. (1998). Suicide and language. CMAJ: Canadian Medical Association Journal, 159(3), 239.

[4] Reynders, A., Kerkhof, A. J. F. M., Molenberghs, G., & Van Audenhove, C. (2014). Attitudes and stigma in relation to help-seeking intentions for psychological problems in low and high suicide rate regions. Social psychiatry and psychiatric epidemiology, 49(2), 231-239.

[5] Guidelines on language in relation to functional psychiatric diagnosis (2015). The British Psychological Society, Division of Clinical Psychology, accessed 08-01-2016

[6] Owens, D, Kelley, R., Munyombwe, T., Bergen, H., Hawton, K., Cooper, J., Ness, J., Waters, K., West, R. & Kapur N. (2015). Switching methods of self-harm at repeat episodes: Findings from a multicentre cohort study. Journal of Affective Disorders, 180, 44-51.

[7] Corrigan, P., Markowitz, F. E., Watson, A., Rowan, D., & Kubiak, M. A. (2003). An attribution model of public discrimination towards persons with mental illness. Journal of health and Social Behavior, 44(2),162-179.

[8] Haw, C., Hawton, K., Houston, K., & Townsend, E. (2003). Correlates of relative lethality and suicidal intent among deliberate self‐harm patients. Suicide and Life-Threatening Behavior, 33(4), 353-364.

[9] Zortea , T. (2016) Is it dangerous to ask or talk about suicide? IHAWKES (Institute of Health and Wellbeing Knowledge Exchange Students) blog, accessed 14-01-2016.

A few years ago, if you had said to me that I would be celebrating the publication of an academic research paper, I would have laughed. In 2007, attempting my MPhil nearly broke me, and this, amongst other life pressures, caused me to have a psychotic breakdown. I was in and out of hospital that year, and was eventually given a diagnosis of paranoid schizophrenia. That diagnosis felt like a death-sentence, and I felt hopeless about the future. My wife and kids and my faith kept me going, but my life was very different now – unpredictable psychotic episodes, plus medications that clouded my thoughts, made me feel emotionally numb and sedated.

*

It was in December 2010 that a key-worker in a mental health day-centre I was attending approached me with a leaflet looking for service users and carers to be trained in research methods and design. The course was designed by researchers at the University of Manchester and the University of Nottingham. I wasn’t sure it was for me and whether it would lead to anything fruitful, but I decided to go for it. After an interview process, I was invited to attend the training – one day a month in Manchester for six months from January to June 2011. We looked at general study skills, the research process, literature searching, how to read a paper, qualitative and quantitative methods and ethics. I found it hard to concentrate at times, but I learned so much and really enjoyed the course. The course was actually cited as an example of good practice by NICE [1].

Following the training, in 2012 the research team invited me to be a co-applicant on a programme of research which would become known as ‘EQUIP: Enhancing the quality of user involved care planning in mental health services’ [2]. I then became a Research Associate in the School of Health Sciences, University of Nottingham in February 2013. I realised that the researchers wanted service users and carers to collaborate as part of the research team – that they actually placed a great deal of value on my own lived experience, and that this could be used to help shape the research programme. This for me is where my life really turned around!

As part of EQUIP, I’ve been involved in conducting focus groups and interviews with different stakeholders, assisting with the development of a new Patient Reported Outcome Measure (PROM) in user/carer involved care planning, in co-delivering a training intervention for mental health professionals, and am now involved in doing some follow-up questionnaires. It’s been so varied and I’ve developed so many different skills – it’s been wonderful. Outside of my part-time hours on EQUIP I’ve also taken on other projects, some of which are based at the Institute of Mental Health [3]. I’ve had some really great mentors: Prof Patrick Callaghan and Dr Oonagh Meade have been so very understanding and have really helped me develop and flourish. But it’s the ethos of the School of Health Sciences and the Institute here at the University that makes the difference – really valuing Patient and Public Involvement (PPI) in research.

I’m so excited that my very first academic paper, bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives, has now been published [4]. It’s a topic that I have had a lot of personal experience of, and one that I’m particularly passionate about. But if it wasn’t for the PPI ethos of the University here and at Manchester, I would never have had this opportunity to do this work. I’m so thankful and can’t wait to see what happens for me next…

Andrew Grundy
Research Associate, School of Health Sciences

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* Puss in Boots Google doodle by Sophie Diao.

References

[1] https://www.nice.org.uk/sharedlearning/enhancing-the-quality-of-service-user-involved-care-planning-in-mental-health-services-equip
[2] The EQUIP project website can be found here: http://sites.nursing.manchester.ac.uk/equip/
[3] For example, http://www.institutemh.org.uk/x-research-/managed-innovation-networks/youth-mental-health-and-wellbeing-min
[4] Grundy et al., ‘Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives’ Journal of Psychiatric & Mental Health Nursing (Dec 2015) http://onlinelibrary.wiley.com/doi/10.1111/jpm.12275/abstract
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This blog-post summarizes independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (grant reference number RP-PG-1210-12007). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.

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Dear readers,

Thanks for following us through 2015! It has been great to have so many people sharing experience, research, views and opinions - the blog really wouldn't be the platform that it is without you. We hope you have a brilliant festive season and look forward to sharing some great new content with you in January.

  Remember: if you end up with a little time to spare over the holiday season and you would like to write something, please get in touch as we would love to hear from you.

Happy holidays!

IMH blog team

         

The character in crisis is the bread-and-butter of fiction, so we shouldn’t be surprised to find mental health issues depicted on the page. But for those with insider knowledge – as service users, clinicians, academics and/or friends and family – the suspension of disbelief required to enter the world of the novel can be severely challenged when the topic is mental health. Our enjoyment can be compromised by a diagnosis of schizophrenia presented as split personality; psychotherapists who continually blur boundaries; or straitjackets in use on the contemporary psychiatric ward. As a former clinical psychologist turned novelist and book reviewer, I hope you’ll find me a sufficiently trustworthy guide to some novels that address mental health issues without setting your teeth on edge.

From my reviews of novels that feature mental health issues across the life span, from early childhood to old age, I’ve selected three debut novels published this year (one of which is my own) in which the main character is an adult of working age.

How to Make a Friend by Fleur Smithwick

As a shy, and somewhat emotionally neglected, child, Alice found solace in the company of her imaginary friend. Now in her early twenties, a car crash renders her comatose for three weeks. When she wakes up, who should she find at her bedside, but Sam, her imaginary friend from childhood, now grown up. As she tries to regain a normal life, Sam proves to be both a comfort and an embarrassment: no-one else can see or hear him and friends and family are bemused when she talks to him in public. Of course they’re concerned for her sanity but, as Sam develops his own identity, that could be the least of her problems. Sam becomes as dependent upon her as she is on him and, regardless of her own desires, he wants her for himself.

Alice’s relationship with Sam is reminiscent of the relationship many voice-hearers have with their voices. The novel works so well because, despite a somewhat outlandish premise, the author herself “never thought of as Sam as anything other than a sentient being”, which again has parallels with the way in which contemporary therapists now work with voice-hearers, accepting the validity of voices rather than dismissing them as was deemed good practice in the past. The novel is also very effective as an exploration of how manipulative characters prey on the lonely and vulnerable.

The Zoo by Jamie Mollart

High-powered advertising executive, James Marlowe, is delighted when he wins the brief to create a new campaign for an international bank. But his involvement in the corporate world comes at a heavy cost, as he becomes increasingly dependent on drugs and alcohol to keep the unethical nature of this endeavour out of mind. This distances him from his friends and family and, eventually, from himself, as a psychotic breakdown lands him in a psychiatric hospital, terrified by a collection of plastic and metal animals and figurines which he calls The Zoo. It’s there that the reader first meets him, and there that we sit alongside him as he gradually pieces together the sequence of events that has brought him to the lowest point of his life.

I found James’ psychotic experiences extremely convincing, articulating the physical, as well as the mental, torment which is often overlooked. (The author has said that he found the darkest scenes easiest to write.) His depiction of the hospital ward, although rather bleak, is also highly credible (apart from the references to ‘orderlies’ and doctors in white coats), with the relationships between patients more powerful than those between patients and staff, with some points of humour in the unwritten rules. (I don’t know where the author did his research, but the novel is set very close to home in Nottingham and Leicester.) This is very much a novel that explores the social and psychological origins of psychosis, as well as the dark side of consumerism in the modern world.

Sugar and Snails by Anne Goodwin

Middle-aged psychology lecturer, Diana Dodsworth has sacrificed her career prospects, and the opportunity for intimate relationships, in order to keep her past identity a secret. When she meets Simon at a dinner party, their connection over a shared interest in Cairo brings the promise of something more. Yet the conversation triggers unwelcome memories for Diana of the teenage decision that radically changed her life. As the relationship develops, she becomes conscious of the widening gap between the woman she is and the woman she feels she ought to be. Now she must make another decision to embrace the part of her she’s been at pains to deny.

Diana feels such a sense of shame at the core of her identity, that she’s constructed a false self to hide her secret behind. She’s the kind of person who could potentially benefit from psychotherapy services, except that past experience has left her very suspicious of any kind of help. She’s self-harmed since childhood (with a rather vivid and visceral description of cutting in the first chapter) and found the conflicts of adolescence almost too much to bear. Unfortunately for Diana, her involvement in mental health services in the early 1970s, when a course of aversion therapy (albeit sympathetically administered) from a clinical psychologist and a “good talking to” from a psychiatrist weren’t a great deal of help. In contrast, the contemporary strand of the novel shows how care packages for those with similar identity issues have improved (somewhat).

Bridging fiction with the real world, the publisher of Sugar and Snails, Inspired Quill, is donating 10% of profits to a relevant youth charity. A review copy is waiting to be claimed from The Psychologist.

All three novels are available in paperback and e-book versions – which will you read first? …………………………………………………………………………………………………………

Anne Goodwin is a former clinical psychologist and employee of Nottinghamshire Healthcare NHS Trust. Catch up on her website annethology or on Twitter @Annecdotist. ……………………………………………………………………………………………………………………

If you need someone to talk to, Samaritans are available round-the-clock, on 116 123 (UK)

On 11^th March 2015, The Green Party's Caroline Lucas presented a private members' bill to reverse key elements of the government's health reforms. The bill called for the purchaser-provider split within the NHS to be abolished and the role of private companies restricted. Caroline Lucas said: "Our NHS is being dismantled piece by piece. A fragmented, market-based structure isn't the 'national' service that so many people fought for so courageously. It mustn't be reduced to a set of transactions, contracts and bidding wars that hollow it into little more than a logo - and waste resources that could be spent on front-line patient care." ¹
In a Queens Speech debate on 3^rd June 2015, Baroness Hollins (Crossbencher) observed that “In Her Majesty’s Speech, we heard that her Government intends to, “secure the future of the National Health Service.” She went on to say that Government has recognised the need to “to improve access to mental healthcare” and that this is a very welcome promise, because during the last Parliament, funding for mental health was cut in real terms by 8.25%—almost £600 million.” ²  She also observed, “a staggering 7 million people experience mental illness at any one time, touching an estimated one-third of all households” and “a further 2 million British people are expected to experience mental illness by 2030.”  She made the point that “we need public mental health prevention strategies, not just better access to treatment.”

An earlier news article, ‘Austerity and a malign benefits regime are profoundly damaging mental health’ (Guardian - Mental health, April 2015), contained a letter signed by 442 psychotherapists, counsellors and academics. Referring to the disturbing psychological and quality-of-life implications of government’s cuts and policies it condemned government plans to provide online cognitive behavioural therapy to 40,000 employment and support allowance and jobseeker’s allowance claimants and people on the Fit for Work programme and to put IAPT therapists in more than 350 jobcentres.

Viewed as being ‘most important and distressing of all’ was the issue of benefits claimants, including disabled and ill people, being subjected to a ‘quite new, intimidatory kind of disciplinary regime.’ The letter said that where this includes the linkage of social security benefits to the receipt of ‘state therapy’, this is unacceptable, as ‘Get to work therapy is manifestly not therapy at all.’

It went on to say that, ‘the wider reality of a society thrown completely off balance by the emotional toxicity of neoliberal thinking is affecting Britain in profound ways, the distressing effects of which are often most visible in the therapist’s consulting room.’ It suggested that the letter sounds the starting-bell for a broadly based campaign of organisations and professionals against the damage that neoliberalism is doing to the nation’s mental health. ³
The government is placing increasing pressure on our NHS, with constant reorganisations and an administrative stranglehold. While publicly promising to support it they are underhandedly causing it to fail, to justify bringing it under corporate control for private profit, copying the American model. ⁴ This is all part of a Neoliberal class warfare being waged worldwide.           It ensures that most members of society are kept needy and greedy, hooked on technological trivia, gambling and consumer credit. The growing emphasis on promotion of profitable technological innovation at the expense of real human empathy and connection is serving to divorce us from our roots as citizens and turning us into self-interested consumers. ⁵
We are conditioned on a daily basis by a corporate controlled media designed to distract us with scare stories and the use of news as ‘infotainment’, from real underlying issues about how we live. We are manipulated through a subtle engineering of consent and creation of voter apathy, to accept policies that are against our own real common good as a society. All too often we blindly accept neoliberal economic policy and control of public opinion by our government leaders, in the name of so called Democracy, because ‘it is good for us.’ ⁶
In a Telegraph newspaper article, Jeremy Hunt said: “Britain is failing to meet its obligation to the elderly because some people lead such "busy, atomised lives" that they don't even know whether their relatives are dying.” ⁷ This is clearly more ‘people bashing’ and denial of real responsibility by the government. We need to ask now, what are the government and big business strategies that create and maintain the ‘atomisation’ of society, turning so many people into passive, isolated and indebted consumers, rather than active engaged citizens? What impact do these strategies have on public mental health and family/social cohesion? These questions are comprehensively and clearly addressed in, Robert McChesney’s Introduction to ‘Profit over People - neoliberalism and global order,’ by Noam Chomsky. ⁸
My own poetry, written some years ago, remains relevant in relation to current economic policy, increasing poverty and mental illness and need for on-going social action. The first poem was circulated around the world, via the 2002, Johannesburg Earth Summit.⁹



 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The Institute for Fiscal Studies projects that nearly five million British children will be living in absolute poverty after housing costs by 2020-21, under current government policies. (June 2015)              The impact of economic reforms elsewhere in Europe is far worse. A group of UK left-leading MPs, union chiefs and charity leaders have recently signed a letter calling for a debt relief conference for Greece, and an end to austerity.

The recent UK Government spending review with its reversal of immediate cuts to tax credits does not signal any change in policy. The same people are going to be hit in the same way – just a little later on, with the introduction of Universal credit.

This brief review of some recent news articles and political debate relating to mental health and current government reforms is written as a ‘creative reflection’ to stimulate further debate on the issues raised. Combined with my own comments and poetry it is intended to highlight the on-going destructive nature of Neoliberalism and its impacts on mental health in the UK and around the world.

Tony Devaney.  (Revised November 2015)

Service User Consultant

Fellow of The Institute of Mental Health

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References

(1)  http://www.bbc.co.uk/news/health-31768259
(2)  Most hospitals are in debt, beds are cut to 2.95 per 1,000 people (compared with Germany’s 8.2). Meanwhile, 4,000 community mental health nurses are gone, plus 1,500 mental health beds.           The tyranny of A&E targets results in operations cancelled to save bed space. Half our hospitals have 10% of beds blocked by social care cases, and that dovetails with 26% cuts in community care.      (www.theguardian.com/ 2015/feb/17/jeremy-hunt-nhs-bully-in-chief-health-secretary-staff)

(3) http://www.theguardian.com/society/2015/apr/17/austerity-and-a-malign-benefits-regime-are-profoundly-damaging-mental-health
(4) The Dalton review, a government-commissioned report which last year concluded that private companies could oversee management of NHS hospitals, was advised by a panel of experts that included Jim Easton, the managing director of private health firm Care UK. The report claimed panel members were advising “in a personal capacity, rather than as representatives of their organisations”. But documents obtained under the Freedom of Information Act reveal Easton was in fact representing the NHS Partners Network, the UK’s primary lobbying group for the private healthcare sector. (www.theguardian.com/society/2015/jul/05/private-health-lobbyist-nhs-privatisation-dalton-review)

(5)  http://www.theguardian.com/media/2015/apr/12/matthew-crawford-distraction-is-a-kind-of-obesity-of-the-mind-the-world-beyond-your-head
(6)  “The conscious and intelligent manipulation of the habits and opinions of the masses is an important element in a democratic society. The intelligent minorities must make use of propaganda continuously and systematically…because they alone understand the mental processes and social patterns of the masses and can pull the wires which control the public mind. This process of ‘engineering consent’ is the very essence of the democratic process.”  (Edward Bernays).                    
(See ‘Profit over People – neoliberalism and global order’ (p.53), Noam Chomsky)

(7) http://www.telegraph.co.uk/news/health/elder/11709356/Thousands-are-dying-alone-and-unloved-Jeremy-Hunt-warns.html
(8) Profit over People – neoliberalism and global order, Noam Chomsky (Seven Stories Press, 1999) With Introduction, (copyright 1998) by Robert W Chesney.

(9) Reflections on Health and Care in a Consumer Society, Tony Devaney, (2010) http://www.hacw.nhs.uk/our-services/big-recovery/creative-reflections/poetry/

Dear reader, Do you have something to say about mental health, integrated health care or wellbeing? Are there any issues that you feel passionately about and would like to communicate to a wider audience?

Well good news….we are looking for content and would love your input! We would welcome anything broadly related to mental health and health care, this could include discussions of interesting research, personal accounts, reviews of events, book reviews etc. So please feel free to give it a go, it would be great to hear from you.

Emma Nielsen, ESRC PhD Student, Psychology (This email address is being protected from spambots. You need JavaScript enabled to view it.) Katherine Dyke, PhD Student, Psychology (This email address is being protected from spambots. You need JavaScript enabled to view it.) Jo Higman, mental heal nurse and health writer (This email address is being protected from spambots. You need JavaScript enabled to view it.)

 

Maternal or 'perinatal' mental health has been in the spotlight recently, following the inquest into the tragic case of Charlotte Bevan.  An exhibition currently on display at the Institute of Mental Health highlights the devastating effect perinatal mental illness can have on women and their families.  At the heart of this exhibition however, is a celebration of what can be achieved when communities come together to support one another on the path to recovery.  It's Not The Baby Blues is a moving collaboration between local artist Debra Urbacz, photographer Paul Dale and Nottingham based peer support group Open House.


Open House was founded in 2012 by two women who had both been in-patients in a specialist mother and baby unit.  Sarah and Geraldine were recovering from postnatal depression and found that there was little in the way of self-help in the community. Open House has gone from strength to strength and now meet weekly, offering support to those recovering from perinatal mental illness. They also aim to raise awareness of this condition and have recently secured a grant from Nottinghamshire County Council.

It's Not the Baby Blues features women who have used Open House following a period of perinatal mental illness.  Their stories are told through beautiful photographs and delicately typewritten extracts of their personal illness narratives.

The idea for the exhibition emerged from a late night conversation between Debra and Geraldine, following the tragic death of actor, Robin Williams.  Concerned by what she saw on social media in the days that followed, Geraldine was keen to do something positive to raise awareness of mental illness and suicide.


Debra contacted photographer Paul Dale, knowing he would approach the project with sensitivity.  He spoke of having to reconsider his original ideas for the project, stripping the concept 'right back to basics' in order to 'represent the pain, the guilt, the dark hours of PND.'

"I decided to work with the words they spoke and the stories they told me. We would chat for up to an hour before deciding on a space, usually in their home, and the props we would use to portray a moment in time when they were either at their lowest, or in the place where they felt safe.
Paul went on to say how grateful he is at having the opportunity to help raise awareness of this area of mental health.

"I was humbled by the sitter's stories, yet felt heartened by the hopes they had for the future and the coping strategies they had devised, often with family or friends. I would do this project again in a heartbeat."

Once she saw how powerful the images were, Debra felt that it was important to give each woman the opportunity to share their personal illness narratives.

"I typed out their stories on my typewriter as I felt the idiosyncrasies in the type would add to the feelings of despair and hopelessness. I made them into little books, one for each of the ten women, and chose to bind them together with threads in blue tones to match the blue in their photographs. The covers were made of handmade paper so the books have a delicate, almost fragile appearance, this is so that the reader handles them with the care and sensitivity the stories within deserve."
One of the 'sitters' Claire, talks about her experience of taking part in the project, and what she hopes it might achieve:

[facebook url="https://www.facebook.com/openhousenotts/videos/171335399661089/" /]

If you've been affected by the issues raised in this article, or would like to learn more about perinatal mental health, click here to go to the Open House information and support page.

Jo Higman is a mental health nurse and health writer: This email address is being protected from spambots. You need JavaScript enabled to view it.
Photos reproduced with kind permission by Debra Urbacz

As a PhD student in Psychology I have come across and read (or at least attempted to read) an array of books probing the human psyche and the complexity of the human brain. These prescribed texts have undoubtedly increased my knowledge and helped me throughout my studies, however I often feel that they are missing a critical human element. What I mean by this is that there is a tendency in academic writing (particularly in neuroscience) to describe a condition in detail and then skim over any details relating to the person. This makes it particularly refreshing to come across books like ‘The Man Who Mistook His Wife for a Hat –and other clinical tales’ by Oliver Sacks.

Oliver Sacks was a practising neurologist with a talent for writing. Over the course of his lifetime he wrote engaging, informative and empathetic articles about the people he worked with and their various neurological conditions. ‘The Man Who….’ describes a range of different case studies which refer to different brain functions and what can happen when things go awry; including a man who can recognise music but not the faces of familiar people, a woman who lost awareness of her own body and twins with extraordinary mathematical skills. The wonderful thing about this book is that it explores the fascinating aspects of various neurological conditions without forgetting the people who experience them. The book is beautifully written, informative and always very human.

Books can inspire, inform, entertain and comfort.  In particular books discussing mental health can provide valuable insights into topics which are not always openly discussed. If you have a book you’d like to discuss, please write in and share!

Kat Dyke (This email address is being protected from spambots. You need JavaScript enabled to view it.)

PhD Student, School of Psychology

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Following a traumatic car accident in 2001, and subsequent attempts to recover, I suffered severely disabling illness in 2004, with rapid onset Rheumatoid arthritis and Fibromyalgia.

There have been times since 2004, when I have experienced profound depression and frustration at the lack of adequate care and support available. But through mindfulness and a sense of spiritual connection I have always known myself to be more than my illness.

As a creative writer I have continued when possible to write poetry and articles addressing immediate topical issues and commenting on wider health and social concerns.

In October 2009, I listened to a radio programme called 'Metaphor for Healing', (Radio 4), presented by Doctor Phil Hammond, exploring narrative based approaches to primary care. His comment at the end of the broadcast, that there should be ‘room for a little poetry in healthcare,’ echoed my own growing conviction that I had something of real and enduring value to contribute in this area, through my own personal narrative and poetry.

In 2010, I became a member of SureSearch, an organisation for mental health service users and their allies who wish to become involved in health research, education and training. During recent years I have established a wider role for myself as a service user researcher/consultant and narrative practitioner.

Since 2011, I have been involved with developing ‘Recovery focused’ services in Health and Care Worcester NHS Trust. I co-edited and presented the Trust’s Recovery Vision and Pledge document to the Board of Directors and was involved with designing and developing the HACW Recovery website and the Recovery Newsletter. I also edit the Newsletter. Some of my articles, including ‘Why I Still Have Hope – Illness and Spiritual Growth,’ ‘Reflections on Health and Care’ and ‘Creative Ageing in a Consumer Society,’ have been published on the Recovery website and in the Recovery Newsletter.¹ I am currently involved as a service user consultant and project team member, with an AHRC large grant funded Research programme entitled, ’Creative Practice as Mutual Recovery - Connecting Communities for Mental Health and Well-being.’ ^{2, 3}                                                 Many of my poems and articles, including, ‘Recovery, Resilience and Wellbeing,’ (HACW Recovery Newsletter, winter 2013), contain similar insights to those expressed in the BBC News Blog of Vidyamala Burch’s story (see below) - and also in the quotes from the BBC news article and broadcast by the political philosopher John Gray, which follow it.

‘Vidyamala Burch lives with chronic pain having acquired two spinal injuries at an early age. At the age of 25 she experienced a major physical breakdown. While in intensive care she was introduced to meditation by a hospital chaplain. During a lengthy period of rehabilitation she tried different relaxation techniques and eventually found that one, called Mindful Meditation, worked well for her.

In 2000, now ordained as a Buddhist, Vidyamala Burch started a social enterprise called Breathworks, where people with chronic pain take an eight-week course to learn how mindfulness could help them cope better with their physical symptoms. The programme has been taught to thousands of participants, in over 20 countries. Burch is now a leader in this area and her company also trains practitioners. She sits on an all-party parliamentary group to incorporate mindfulness meditation into the NHS.’ ⁴                                                              In my own articles, ‘Why I Still Have Hope – Illness and Spiritual Growth,’ and ‘Recovery, Resilience and Wellbeing, mentioned above, I have stressed the need for recognition and acceptance of a wider spiritual purpose and social contribution in life for some people with long term health conditions. This goes beyond a total emphasis on immediate social function and economic considerations alone.

The following extracts are from the BBC programme, ‘A Point of View,’ by John Gray, political philosopher and author of ‘False Dawn: The Delusions of Global Capitalism.’

‘Belief in the supreme importance of being active is so embedded that we can hardly imagine any other way of living. Yet our exclusive concern with purposeful action crowds out a vital part of human fulfilment…. When we set aside our practical goals - if only for a moment - we may discover a wealth of meaning in our lives, which is independent of our success or failure in achieving our goals. Struggling to change things around us, we forget that another kind of change is possible - an inner change, through which we can enter a richer and more spacious world that was there all along.’ ⁵ Participation in Arts and health initiatives, including creative writing and reading for wellbeing, can change the way we view the world and may help to turn adversity and traumatic experience into an opportunity for creative growth.

Tony Devaney (This email address is being protected from spambots. You need JavaScript enabled to view it.) Service User Consultant Fellow of The Institute of Mental Health

For more information, see:

http://thehearthcentre.org uk/ www.creativitypost.com/psychology/turning_adversity_into_creative_growth …………………………………………………………………………………………………………………

References

(1) See: www.hacw.nhs.uk/our-services/big-recovery/creative-reflections/ (2) See also details of local research project at: www.wlv.ac.uk/connectedcommunities (3) www.healthhumanities.org/pages/view/creative-practice-mutual-recovery/ (4) www.bbc.co.uk/news/blogs-ouch-30534749?print=true (5) ‘A Point of View, The Doors of Perception’ www.bbc.co.uk/news/magazine-22648328

Like my colleague, Jo Higman, I recently completed an M.A. in Health Communication at the University of Nottingham. Many thanks to the support from Nottinghamshire Healthcare NHS Foundation Trust, the Clinical Research Network: East Midlands, and Learning Beyond Registration (LBR) funding.

The topic I chose for my dissertation was to closely examine the mechanisms by which the term ‘schizophrenia’ is frequently misrepresented in UK national newspapers. I will be sharing the main findings from my dissertation at a later point. However, for this short post I would like to restrict myself to making the suggestion that whilst journalists do bear a large responsibility for the grossly biased, negative picture of people diagnosed with schizophrenia that appears in the general media, they are not solely to blame for this situation.

The word ‘schizophrenia’ comes from the Greek words ‘schizein’ meaning ‘to split’ and ‘phren’ or ‘mind’. It can therefore be translated as "splitting of the mind". It was first used by the Swiss psychiatrist, Eugen Bleuler in 1908. His intention in using it was not to suggest that people can experiences a ‘split personality’, but rather to describe the separation of function that occurs in the condition between personality, thinking, memory, and perception that can occur in some people. This condition had previously been referred to by a German psychiatrist, Emil Kraepelin, as ‘dementia praecox.’ Bleuler thought that this term was misleading because of the implied emphasis on the inevitable gradual degeneration and decline of people with this condition. Therefore he coined his own word to describe the patients he saw in his clinical practice.

However, right from the very outset Bleuler’s chosen word for this mental health condition caused confusion. McNally (2007) points out that nowadays normal everyday usage of schizophrenia does indeed equate schizophrenia with meaning someone with a ‘split’ personality or behaving like a ‘Jekyll and Hyde’. This is not a recent phenomenon but dates right back to when the word was first utilised. Indeed Bleuler himself sometimes records examples of his own clinical observations of patients ‘splitting’ their personalities. This leads McNally to boldly assert that ‘there can be no mistaking that the responsibility for the schizophrenia as split personality myth, and everyone else’s subsequent usage, lie with Bleuler.’ (McNally 2007: 71). Kieran McNally also provides later examples of American psychologists in the 1920’s referring to schizophrenia as meaning ‘split souls’ or ‘divided minds’. The subsequent adoption by journalists of these notions of splitting can therefore be seen to have their roots in ideas first expressed in the writings of clinicians themselves. This would suggest that the current everyday misusage of the term schizophrenia in the general media is partially a product of the clinical professions themselves. Journalists then quickly picked up on these ideas and spread them throughout the general population.

Subsequently the term ‘schizophrenia’ has become frequently used as a metaphor within wider society – far beyond its original meaning as a specific clinical diagnosis. As well as being associated with split or multiple personalities its everyday use has now been expanded to include being used as a description of changeable, chaotic situations or people. For instance, the headline in a news report by the BBC reads ‘MPs warn of 'schizophrenia' over climate change targets’. (BBC, 11th October 2011). However a more worrying association with schizophrenia and mental health in general, is that it is now become strongly linked in public consciousness with violent behaviour. Another BBC report, this time entitled ‘Asda and Tesco withdraw Halloween patient outfits’ illustrates how large UK companies attempted to sell ‘mental patient’ Halloween costumes that included ‘ragged clothing, fake blood, a mask and a fake meat cleaver’ (BBC, 26th September 2013). The rapid public outcry led by quick responses from mental health charities made the retailers withdraw the items from sale and issue hasty apologies. However, this recent story illustrates the perception in some parts of society that the link between mental and violence is so obvious the ‘mad axe man’ has now become a widely recognisable stereotype.

Susan Sontag (1991) is the writer who has now become most commonly associated with discussions about the metaphorical usage of illness. Her ground-breaking book ‘Illness as metaphor’ was originally published in 1978 and looked at the history of both tuberculosis and cancer. She argued that the myths and the metaphors that built up around these illnesses over time increased the suffering of patients and inhibited them from seeking treatment. Indeed the persons themselves were often seen to be at fault in some way for contracting their illnesses.

Similarly it could be argued that because schizophrenia still has a still largely unknown aetiology, it lends itself quite readily to metaphorical usage - and so is still culturally surrounded by a discourse of fear, stigma and despair.

A discourse can be defined as ‘a set of meanings, metaphors, representations, images, stories and so on that in some way together produce a particular version of events’ (Burr 1995: 48). Baker (2006) says that an important aspect of discourses is that they are not fixed. Indeed discourses are ‘constantly changing, interacting with each other, breaking off and merging’ (4). For a potentially contentious concept such as schizophrenia there is no fixed consensus of opinion. As with any discourse ‘there are likely to be multiple ways of constructing it’ (Baker 2006: 4). There is also the possibility of multiple discourses co-existing side by side. These include the viewpoints of the clinicians who diagnose the illness, the people who have the diagnosis placed upon them, their families and carers, politicians, media outlets and finally the general public.

Some groupings in society have greater access to the necessary social, economic and political power needed to influence which discourses are preferred over others. These groups include the medical profession, but also general media outlets such as newspapers and television programmes. Given that a large number of people in society gain most of their information about mental health conditions such as schizophrenia from what they view on television and read in newspapers and magazines (Pirkis, Francis, 2012), this makes it extremely important issue for those people currently diagnosed with schizophrenia and for their families and carers. The representation of schizophrenia in the general media also has a significant role to play in how the illness is perceived by politicians who ultimately decide on government health policies.

Perhaps now is the time to consign the term ‘schizophrenia’ to the history books and so help bring to an end the misconceptions and neo-gothic stereotypes that have dogged the term from its very inception.

David Kelly (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Clinical Studies Officer - NIHR Clinical Research Network: East Midlands

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References
Baker, P (2006) Using Corpora in Discourse Analysis. London: Continuum

BBC (2011) MPs warn of 'schizophrenia' over climate change targets. (11 October 2011) http://www.bbc.co.uk/news/uk-politics-15249089 (Last accessed 28/07/2015)

BBC (2013) Asda and Tesco withdraw Halloween patient outfits (26 September 2013). http://www.bbc.co.uk/news/uk-24278768 (Last accessed 28/07/2015)

Burr, V (1995) An Introduction to Social Constructionism. London: Routledge

McNally, K. (2007) Schizophrenia as split personality/Jekyll and Hyde: The origins of the informal usage in the English language. Journal of the History of the Behavioural Sciences 43(1), 69-79

Pirkis, J., Francis, C. (2012) Mental illness in the news and information media: A critical review. Commonwealth Department of Health and Aged Care. Canberra

Sontag, S. (1991) Illness as a metaphor / AIDS and its Metaphors. Harmondsworth: Penquin.

Each year, September 10^th marks World Suicide Prevention Day. The theme this year, ‘Reaching Out and Saving Lives’, highlights not only the role that support and social ties play in combating suicide, but also the role that each of us has in saving lives.

Below is a piece from the International Association for Suicide Prevention, organisers of World Suicide Prevention Day, discussing just some of the guises that reaching out may take.

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Reaching out to those at risk of suicide
According to the recently released World Health Organization (WHO) report: Preventing Suicide: A Global Imperative, over 800,000 people die by suicide across the world each year. The report notes that this estimate is conservative, with the real figure likely to be higher because of the stigma associated with suicide, lack of reliable death recording procedures, and religious or legal sanctions against suicide in some countries.

We may not be able to pinpoint the exact figure, but we do know that each individual suicide is a tragic loss of life. It is hard to imagine the extreme psychological pain that leads someone to decide that suicide is the only course of action. Reaching out to someone who is struggling can make a difference.

'Preventing Suicide: Reaching Out and Saving Lives' is the theme of the 2015 World Suicide Prevention Day (WSPD), an initiative of the International Association for Suicide Prevention (IASP) and the WHO, a co-sponsor of meetings and events related to WSPD 2015. Since 2003, WSPD has taken place on 10th September each year. It serves as a call to action to individuals and organizations to prevent suicide. This year, the theme encourages us all to consider the role that offering support may play in combating suicide.

The act of showing care and concern to someone who may be vulnerable to suicide can be a game-changer. Asking them whether they are OK, listening to what they have to say in a non-judgmental way, and letting them know you care, can all have a significant impact. Isolation increases the risk of suicide, and, conversely, having strong social connections is protective against it, so being there for someone who has become disconnected can be life-saving.

Reaching out to those who have been bereaved by suicide
Suicide is devastating for families, friends and community members who are left behind. They may experience a whole range of emotions, including grief, anger, guilt, disbelief and self-blame.They may not feel that they can share these overwhelming feelings with anyone else. Therefore, reaching out to those who have lost someone to suicide is very important.

As a result of the stigma surrounding suicide, those who are bereaved by suicide are often perceived differently from those who lose a family member through another cause of death. People who are bereaved may find that they are avoided by people who don’t know how to broach the subject or offer their condolences. Or they may just feel that others do not understand the intensity of their emotional response to the death of their loved one.

Once again, a pro-active approach and offering a sympathetic, non-judgmental ear can make all the difference. Giving someone who has been bereaved by suicide the opportunity to talk about their loss, in their own time, on their own terms, can be a precious gift. Allowing them to express their full range of feelings can be cathartic, and can help them to take the first small step in moving through their grief. Starting the conversation may be difficult, but it will almost certainly be appreciated.

Reaching out to put people in touch with relevant services
Although the support of friends and relatives is crucial for people who may be at risk of suicide and for people who have lost someone to suicide, it is not always enough. Often more formal help is also needed. Such help can take many forms, and is likely to vary from country to country. In high-income countries, it may include specialist mental health services and primary care providers, both of which offer clinical care. It may also include a range of community organisations which provide non-clinical support, as well as support groups and self-help groups. In low- and middle-income countries, the more clinically-focused services are less readily available, and there is a heavier reliance on community organizations. Part of reaching out to vulnerable individuals can involve helping to link them to relevant services.

Reaching out to the suicide prevention community
There is strength in numbers. Around the globe, many individuals and organizations are involved in efforts to prevent suicide. We can learn from each other, and strengthen the evidence base for effective interventions. Reaching out to those who are travelling the same road increases the likelihood that our collective efforts to reduce the numbers of people who die by suicide, and the numbers of people for whom these deaths have shattering effects, will be successful.

Reaching out on World Suicide Prevention Day
On September 10th, join with others around the world who are working towards the common goal of preventing suicide. Check in on someone you may be concerned about, listen to what they say, how they say it and show them kindness and support. Investigate ways of linking in with others who are trying to prevent suicide in your community, your country, or internationally. Show your support by organising or taking part in a WSPD activity in your area and/or join in with IASP’s Cycle Around the Globe.

Please, reach out and save lives.
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If you need someone to talk to, Samaritans are available round-the-clock, on 08457 90 90 90 (UK)

What if there was a way to improve your memory, enhance your focus and change your mood using a technique which claimed to be safe, simple and effective. Would you be tempted, and if so what should you know?

Transcranial direct current stimulation (tDCS) is a non-invasive stimulation technique known to be able to temporarily alter states within the brain. It has been reported to be effective in everything from enhancing memory performance [1] and maths abilities [2], to improving symptoms of depression [3] and schizophrenia [4], but how much of this is evidence based and how does it work?


The technology behind tDCS is fairly simple, you place two electrodes on the head (an anode and cathode) and run a low voltage current between them; some of this current is able to travel through the skull and to the surface of the brain known as the cortex. The direction in which the current flows from one electrode to the other has been found to influence the effects, and can be used to either increase or decrease the excitability of a brain region.

In addition to being relatively simple, tDCS is also generally considered safe and low risk. Unlike its better known cousin electro convulsive therapy (ECT), tDCS uses very low electrical currents, so any side effects appear to be mild and transient, such as an itching sensation under the electrode [5]. However, it should be noted that the available safety information comes from controlled studies in which trained professionals apply stimulation using devices with a number of safety features. Until recently this wasn’t too concerning as brain stimulation outside of research environments was uncommon. However, this is slowly changing and it is now possible to find devices and DIY tutorials online. A number of manufacturers now offer a quick ‘brain boost’ at an affordable cost, but the research doesn’t necessarily back up their claims and individuals may not always be aware of relevant safety issues. Beyond the obvious concerns of using a non-regulated product, there are a number of more subtle issues potential users should be aware of.

Reasons to be cautious
When applying brain stimulation some basic neuroanatomy is required, you need to know where to put the electrodes to target a specific symptom or behaviour. Some available devices try to solve this problem using fixed electrode arrangements; however everyone’s head shape is different so the electrodes won’t necessarily be over the desired location. This isn’t the only problem, as even when electrodes are located correctly you could end up stimulating areas you weren’t expecting to influence. This is because the brain is a non-uniform conductor and every brain is different. Recent work using computational modelling has shown that the electrical current which reaches the cortical surface can spread to a wide area and that this is variable between individuals [6]. In non-research environments where it’s not possible to monitor the direct effects of the stimulation (using computational modelling, neuroimaging or alternative stimulation techniques) this could be problematic, particularly when stimulation is used regularly.

In research contexts tDCS is typically applied at intensities of 1-2mA, for up to 20 minutes no more than once a day. In home environments it may be tempting to increase the intensity or duration of the stimulation, but this isn’t necessarily a good idea. One study found that increasing the current intensity from 1-2mA changed the direction of the expected effects [7] and increasing the duration of stimulation on 26minutes has also been found to alter results [8]. The frequency at which stimulation is applied is another potential issue. Although the effects of a single session of tDCS are thought to last up to a few hours, when stimulation is applied more regularly (one daily for 5 days) it has been found to lead to more long lasting results [9, 10]. This could be critically important when used to help people with psychiatric and neurological illness, however, in healthy individuals aiming to boost their brain power at home this could lead to unexpected and unwanted changes. For example, one study reported that after 6 days of stimulation participant’s abilities in some cognitive tasks improved but other were negatively affected [11].

Another factor to be aware of is that not everyone responds to stimulation in the same way. Some people may show no response to stimulation, where as other may even show the opposite to expect pattern, for example a protocol which is typically used to reduce cortical excitability can actually increase it in some individuals [12]. This isn’t always clear from tDCS research as effects are often explored at a group level which means that individual variability is often hidden in the data; despite this variability is a real issue and should be given due consideration.

The future of home use tDCS:
At present some of the claims made by avocets of home tDCS use may not be fully founded in the scientific literature, and there are a number of practical and safety issues which should be addressed. Despite this, home stimulation itself may not be a bad thing and with proper information and guidance could become a useful technique; particularly in therapeutic contexts in which individualized treatment plans and proper monitoring could occur. For now the future of tDCS remains bright, but maybe not quite as clear cut as those marketing it would have you believe.

Kat Dyke (This email address is being protected from spambots. You need JavaScript enabled to view it.)

PhD Student, School of Psychology

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References

1. Richmond, L.L., et al., Transcranial direct current stimulation enhances verbal working memory training performance over time and near transfer outcomes. J Cogn Neurosci, 2014. 26(11): p. 2443-54.
2. Hauser, T.U., et al., Enhancing performance in numerical magnitude processing and mental arithmetic using transcranial Direct Current Stimulation (tDCS). Front Hum Neurosci, 2013. 7.
3. Brunoni, A.R., et al., Transcranial direct current stimulation (tDCS) in unipolar vs. bipolar depressive disorder. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2011. 35(1): p. 96-101.
4. Mondino, M., et al., Transcranial direct current stimulation for the treatment of refractory symptoms of schizophrenia. Current evidence and future directions. Current Pharmaceutical Design, 2015. 21(23): p. 3373-3383.
5. Poreisz, C., et al., Safety aspects of transcranial direct current stimulation concerning healthy subjects and patients. Brain Research Bulletin, 2007. 72(4): p. 208-214.
6. Datta, A., et al., Inter-Individual Variation during Transcranial Direct Current Stimulation and Normalization of Dose Using MRI-Derived Computational Models. Front Psychiatry, 2012. 3: p. 91.
7. Batsikadze, G., et al., Partially non-linear stimulation intensity-dependent effects of direct current stimulation on motor cortex excitability in humans. The Journal of Physiology, 2013. 591(7): p. 1987-2000.
8. Monte-Silva, K., et al., Induction of late LTP-like plasticity in the human motor cortex by repeated non-invasive brain stimulation. Brain Stimulation, 2013. 6(3): p. 424-432.
9. Alonzo, A., et al., Daily transcranial direct current stimulation (tDCS) leads to greater increases in cortical excitability than second daily transcranial direct current stimulation. Brain Stimulation, 2012. 5(3): p. 208-213.
10. Galvez, V., et al., Transcranial direct current stimulation treatment protocols: should stimulus intensity be constant or incremental over multiple sessions? International Journal of Neuropsychopharmacology, 2013. 16(1): p. 13-21.
11. Iuculano, T. and R. Cohen Kadosh, The mental cost of cognitive enhancement. The Journal of Neuroscience, 2013. 33(10): p. 4482-6.
12. Wiethoff, S., M. Hamada, and J.C. Rothwell, Variability in response to transcranial direct current stimulation of the motor cortex. Brain Stimulation, 2014. 7(3): p. 468-475.

Over the past few weeks I have been puzzling, as PhD students do, for a ground breaking, cutting edge, innovative and (lest we forget) high impact study idea.  So far my puzzle contains two parts:

Puzzle Piece 1: Social Networks
[caption id="attachment_1403" align="alignright" width="240"] Sillouettes of tomorrow (see end of blog for attribution)


For those of you who are as ignorant as I am, social networks can be mapped through social network analysis where people (actors, nodes or vertices) are connected to other actors through relationships (referred to as ties or edges).  From here one can look at relational aspects of the ties (strength, frequency of contact) or structural aspects (network size, network density, and centrality).  This technique allows the research to grasp the rich embedded context in which we are all situated.  Past research on social network analysis adhered to the notion that it is your position within the social network and general structure of your social network that influences behaviour (Berkman, Glass, Brissette, & Seeman, 2000). However, other researchers are now advocating a more holistic, all-encompassing view, where societal features, social networks, personality and biological mechanisms are investigated simultaneously (Berkman et al., 2000). This has got me wondering whether mapping social networks through social network analysis might be a useful pursuit for a psychologist like myself.  As a psychologist, my natural ground is looking at the individual, sometimes to the detriment of the environment they are immersed within.  Might social network analysis offer a good opportunity to break this cycle?

Puzzle Piece 2: Social Support
Social support on the face of it appears intuitive - it’s just helping people and being ‘there for someone’ when they need it, right?  It’s actually a more sophisticated, multi-dimensional concept than first glance might suggest (Faber & Wasserman, 2015).  Nothing is ever simple at PhD level. Social support can be split into perceived social support, enacted/received social support, and can also be viewed as the compositional, as well as structural, aspects of the social network in which the individual is situated (Lakey, n.d.).  Perceived support typically seems to be split into emotional support, informational support, and instrumental support (give or take depending on the focus of the paper you are reading) (Shor, Roelfs, & Yogev, 2013).  Emotional support tends to refer to the resources of sympathy, caring, and a general feeling of being loved.  Informational support is about the actors’ ability to obtain useful and relevant knowledge when needed.  Finally, instrumental support is the ability for the actor to receive support both financial and practical when needed.  Perceived support seems to be favoured over received support, due to its ability to better predict outcomes. The question now is how can one combine the perceived level of support with the compositional as well as structural level of support that social network analysis can analyse, whilst not forgetting characteristics of the individual?

Piecing the Puzzle Together
A neat example of how this can all be done was an article called Pathways to Happiness: From personality to social networks and perceived support by Zhu, Woo, Porter and Brzesinski (2013).  They looked at the relationship of the big five (Agreeableness, Extraversion, Conscientiousness, Neuroticism and Openness) both in a direct and indirect manner on the subjective well-being of a sample of first year college students. They hypothesised that the effects of personality would be mediated via social network characteristics and perceived social support. The social network measures they chose were: network size (number of actors one has ties too), closeness (those contact you have strong connection with), upper reachability (position of the network contacts in a social structure) and proportion of new contacts (number of new people met at college compared to previous contacts).  They found only one direct effect of Neuroticism negatively predicting lower levels of subjective well-being.  They found two paths where the personality characteristics of extraversion and neuroticism effect on subjective well-being were mediated by perceived social support.  The majority of the findings were through personality measures (extraversion, agreeableness and openness) predicting network characteristics (network size, closeness and proportion of new contacts) which in turn positively predicted both perceived social support and crucially subjective well-being.

The question that I put to myself and to readers that have made it this far, is can we emulate Zhu, Woo, Porter, & Brzezinski's (2013) success in creating a study that captures both the individual and their social contexts?

Thank you for journeying with me,

Alex Bradley,

PhD Student, School of Psychology, University of Nottingham

References
Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium. Social Science & Medicine, 51(6), 843–57. doi:10.1016/S0277-9536(00)00065-4

Faber, A. D., & Wasserman, S. (2015). Social support and social networks: Synthesis and review. Social Networks and Health, 29–72. Retrieved from http://dx.doi.org/10.1016/S1057-6290(02)80020-1

Lakey, B. (n.d.). Social Support and Social Intergration. Retrieved from http://cancercontrol.cancer.gov/brp/constructs/social_support/social_support.pdf

Shor, E., Roelfs, D. J., & Yogev, T. (2013). The strength of family ties: A meta-analysis and meta-regression of self-reported social support and mortality. Social Networks, 35(4), 626–638. doi:10.1016/j.socnet.2013.08.004

Zhu, X., Woo, S. E., Porter, C., & Brzezinski, M. (2013). Pathways to happiness: From personality to social networks and perceived support. Social Networks, 35(3), 382–393. doi:10.1016/j.socnet.2013.04.005

Photo credit: Silhouettes of Tomorrow via Photopin (licence)

Picture the scene. Here I am on an acute psychiatric inpatient ward, sat telling the psychiatrist that I have no hope. Nothing to live for. Imagine then, being given a gentle nudge, and I look at him through my tears and he says “Clare, I think you would make a very good peer support worker.”

The words flew over me, not quite knowing where to land, but right at that moment, a small seed of hope started to grow. I’m sure people don’t imagine inpatients completing application forms on a locked ward, egged on by the ward manager, but that’s exactly what happened……

Fast forward to now, five months later. I’ve completed the Peer Support Worker Training Course and submitted my assignment. I’m tempted to write that sentence out again as I can’t quite believe it myself! So why am I so amazed? Well there’s a few reasons really, one is that I had truly lost all hope. I felt that nobody could help me. Several sections and inpatient stays, numerous medications and some taking therapies, yet still I felt worthless and lost. I forgot who I was, and became somebody I didn’t know or like. I pushed everyone away no matter how well-meaning they were. I’d often walk out of courses and therapies as I either didn’t believe they would work, or it just felt too difficult. Then along came Peer Support. How strange and alien it felt, to sit in a room of people, many with shared experiences similar to my own. Then as I talked to others and shared some of my story, peer support became my new addiction.

How powerful and validating it is to sit and talk to someone who shares a direct lived experience. Just that knowing look and nod is sometimes enough.

As each day of the course went by, my confidence grew. Skills that had lay dormant for ages, were re-awakened in me and before long, I had a wonderful group of peers around me to learn and grow with. Of course, this isn’t a fairy tale (not quite) I did have the odd moments where the old ways of thinking would come back. ‘I can’t do this’ and ‘I’m not good enough to do this.’ But with a supportive group of peers, some great life affirming tutors and trust staff that believed in me, I was encouraged to keep going. I silenced those critical voices and completed the course.

In addition, my view of recovery has totally changed. Now I know that for me, it’s not a linear journey. I take comfort from knowing that there are peaks and troughs. My social networks have grown, my peer support group have already been out for a great curry after the training, where we sat and gave each-other some great, organic peer support. So I’ve got more friends too now!

The ultimate thing for me personally is that I’ve found a passion again. I have learnt so much about myself, about recovery and about restoring hope in others. Peer support training for me, has been life changing. I hope to now work in the field of mental health as a Peer Support Worker and have just submitted my application to do so. That’s great isn’t it, but what is even more powerful is the fact that even if this first application is not successful, I know I will be.

I hadn’t heard about Peer Support until that life changing day on the ward. I hope that Peer Support grows and grows and lifts more people out of their darkness. I hope that more people like me can find their passion and purpose again. I hope that Peer Support becomes available to all that want and need it. Did I just say hope? What a wonderful word!

To find out more about the Institute of Mental Health’s Peer Support Worker training, and to watch our film, please visit our website: http://www.institutemh.org.uk/-education-/peer-support

A post today by Jo Higman, who is a Research Nurse.  You can contact Jo if you'd like to discuss her research at This email address is being protected from spambots. You need JavaScript enabled to view it..

I’ve recently completed an MA in Health Communication at the University of Nottingham. When casting around for a topic for my dissertation, I was struck by the pervasiveness of mindfulness, in both popular culture and academia.

Mindfulness based cognitive therapy (MBCT) is recommended by NICE (2009) as a relapse prevention strategy for recurrent depression.  Furthermore, mindfulness in one form or another has been embraced by the academic and health community, as evidenced by the >1000% increase in publications on the subject in the last 10 years (Web of Knowledge, 2015).

In parallel, there has been a proliferation of features promoting mindfulness in popular media. (Presently, a mindfulness colouring book is amongst Amazon’s top 10 bestsellers.) I began to explore how this centuries old practice was being discussed, with a view to explaining in some small way its growing popularity. Leafing through magazines, blogs, newspapers and websites, it soon became apparent that, almost without fail, these articles referenced one man, or his company: Andy Puddicombe, founder of Headspace. Fig 1 shows just a few.

[caption id="attachment_1392" align="aligncenter" width="300"] Fig. 1


Headspace is an online and mobile application, offering a mindfulness meditation programme on a subscription basis. The website is colourful and inviting, featuring text and images to market their product (fig. 2).

[caption id="attachment_1393" align="aligncenter" width="300"] Fig. 2 (Headspace, 2015)


Given the rich visual data, I applied multimodal critical discourse analysis (MCDA) to interrogate the Headspace website. MCDA examines both language and images, with the aim of revealing hidden ideologies and power interests. Demonstrated as an effective approach for analysing websites by Thompson (2012) and Harvey (2013), it exposed some interesting findings, a brief outline of which are included here.

Modality refers to the truth value in text and images, and can often be found in modal verbs such as must, will, should, etc. But how is modality expressed through the visual choices made. Kress & van Leeuwen (2006) identify a number of ways this can be analysed, including colour, context, actor and props and so on. Initially, the Headspace website appears to consist largely of abstract images, low in modality. However, with the use of symbols, props and metaphors, modality is increased. Importantly, these images are clean, simple and replete with icons of modernity, such as laptops, mobile phones and (dare I say it?) beards. This is essential in lifestyle advertising and brings us on to the marketing strategies used by Headspace.

First of all, in order to offer a solution in the form of their mindfulness programme, Headspace need to construct a problem. This is done very skilfully on the site, through the lexical and visual choices they make. The website features a number of potential ‘problem’ areas, using buzzwords such as ‘creativity’ and ‘focus’ to tap into the zeitgeist of lifestyle consumerism. However, their main focus is that curse of twenty-first century living, stress. Whilst explicitly including stress as a topic on the site, they also discretely and repeatedly construct the notion within the consumer that modern life is hectic and stress is an obvious side effect.

Consider these two screenshots (fig. 3):

[caption id="attachment_1394" align="aligncenter" width="300"] Fig. 3 (Headspace, 2015)


Here, the ‘life as a circus’ metaphor is used to excellent effect. The clown like character in the illustration is clearly engaged in a number of circus activities, spinning plates and a balancing act (multi-tasking!). This is reflected in the still from Andy Puddicombe’s TEDTalk (TED, 2012), which he delivers whilst juggling tomatoes throughout. ‘Juggling,’ ‘spinning plates,’ and ‘a balancing act’ are all phrases we use to describe our lives, and here they are being reflected back at us. The viewer can easily interpret and identify these images through this skilful use of metaphor. It is your life that is a circus. You are the clown in the image, spinning plates in the hope that it all doesn’t come crashing down.

If the viewer opens the TEDTalk clip, the language used by Andy further reinforces these images: “We live in an incredibly busy world. The pace of life is often frantic. Our minds are always busy, and we’re always doing something.” (TED, 2012). Here the use of ‘we’ and ‘our’ suggests a conversational ‘we’re all in this together’ scenario, when in fact it is a means of making an individual feel as if they are being spoken to, when realistically they are part of a mass audience. Again, a strategy frequently found in advertising discourse.

The fortunes of a particular shampoo brand were reversed in the UK, when acclaimed advertising agency, GoodPilot did this (fig. 4):

[caption id="attachment_1395" align="aligncenter" width="300"] Fig. 4 (YouTube, 2015)


They gave us ‘the science.’ Now described by them as ‘the obligatory science message’ (GoodPilot, 2014) in health and beauty marketing, it is rare to find such an ad these days without a cascade of ‘science’ to support the benefits of the product. In that respect, Headspace are no different.

In the persistent navigation across the top of the page, there is ‘The Science,’ given added weight by means of the definite article. They frequently refer to ‘studies,’ ‘research’ and ‘scientists.’ The site is replete with icons and symbols to represent science: men (always men) in lab coats, test tubes, and so on. The text accompanying the images is high in modality, yet there is more hidden behind the images than is first revealed. A test tube is pictured emitting gas, but the gas has eyes. This personification of inanimate objects is a common strategy in New-Age self-help (Askehave, 2004), but is also a means of obscuring agency. That is to say, who is making the claims about science and brains changing shape? It is not explicit and we are distracted by the somewhat cute looking gas!

There is much, much more to the Headspace website, and this is just a snapshot of what may be revealed when using multimodal critical discourse analysis. If nothing else, I would urge you to have a look at the TEDTalk, which is a masterclass in skilful presentation and effective marketing. There are so many areas of the site which can’t be included here, but hopefully this has given a flavour.

It is important to end on this note; despite the analysis above, it is worth considering the Headspace programme in the context of an impoverished health service. The majority of those with depression and other common mental health problems are unlikely to access treatment of any kind on the NHS, less likely mindfulness. Given that a private therapist costs upwards of £60 a time, Headspace offers users an opportunity to try something which, for the price of a couple of lattes, may offer them a strategy to manage what can often be a chronic and debilitating disorder.

References

Askehave, I. (2004) If Language is a Game – These are the Rules: A Search into the Rhetoric of the Spiritual Self-Help Book If Life is a Game – These are the Rules. Discourse & Society 15(1): 5-31

GoodPilot (2014). http://www.goodpilot.co.uk/loreal.html [last accessed 27 October 2014]

Harvey, K. (2013). Medicalisation, pharmaceutical promotion and the Internet: a critical multimodal discourse analysis of hair loss websites. Social Semiotics 23(5): 691-714

Headspace (2015). https://www.headspace.com/ [Last accessed 6 July 2015]

Kress, G. & van Leeuwen, T. (2006). Reading Images: The Grammar of Visual Design. (2^nd edn.) London: Routledge

TED (2012) All it takes is 10 mindful minutes. http://www.ted.com/talks/andy_puddicombe_all_it_takes_is_10_mindful_minutes?language=en [Last accessed 27 October 2014]

Thompson, R. (2012) Looking healthy: visualising mental health and illness online. Visual Communication 11: 395-420

Web of Knowledge (2014) http://apps.webofknowledge.com/CitationReport.do?product=UA&search_mode=CitationReport&SID=P1Njh7nxwGEWNnx42qR&page=1&cr_pqid=6&viewType=summary [Last accessed 21 October 2014]

Deep in thought whilst on the way to see a show at Nottingham University Lakeside Theatre I couldn’t decide if I was looking forward to the show ahead or not. I had bought tickets to see The Mugenkyo drummers for my partner’s birthday in October. Andy (my partner) has played drums in a band for over 20 years and is one of those people who is constantly tapping out a rhythm to anything.

I was most impressed with the auditorium, the chairs, while small, were very comfortable (it does make a difference).  The show began with a vibrant piece which from the very outset captivated me. Following this, the group’s leader spoke to the audience. It was a story. This little word resonated throughout the evening with stories and legends of the different stories the drums told. The amazing thing was in the times of these legends portrayed by the drums, there were no social media outlets, but the stories kept on coming, and are still alive in groups such as the Mugenkyo drummers.

Some of you will know that I have been a service user/patient for many years in both physical and mental health services, and have been involved in different pieces of work with the School of Health sciences and the IMH around telling my story, which is not legendary.

Academics and other colleagues have stories to tell like I do, but the trend into hearing patients’ stories seems to have taken off. In Nottingham there are several talking libraries and storytelling workshops with volunteers who want to share their experiences be it in health or any other field.

In my 57 years the world has changed and I wear so many hats which I wouldn’t want to tell stories of. But people have told stories in many different ways to researches thus enabling medical diagnosis and prognosis have changed dramatically.

If you would like to chat to me or any of my colleagues who are working on the story-telling part of the dissertation module please find my contact details below.

Debbie Butler

This email address is being protected from spambots. You need JavaScript enabled to view it.

 
Today we relaunch the IMH Blog, and are thrilled to do so with a fantastic piece from Rupal Patel, a PhD student in the School of Sociology and Social Policy at the University of Nottingham.  Rupal's doctoral research has explored the reasons behind low rates of mental illness within the Gujarati community in Britain, and below she discusses the central findings of that research.
 
As a PhD student, I have become so familiar with the question ‘what is your PhD all about? Many of you may agree, the dreaded question is almost impossible to say in one sentence. After all it would do our years of work and findings injustice. However, after 2 and a half years of being asked the question on a monthly basis, I am more than closer to passing the back   of the envelope test.  My PhD explores the reasons behind low rates of mental illness prevalence amongst the Gujarati Community by addressing how they come to understand and conceptualise mental health and social and cultural barriers to help –seeking.  Here I seek to provide a brief overview of my PhD study and some of the findings that have been emerging.

 
Research Background
Diagnosing mental illnesses aids measuring mental illness prevalence. In the UK we can only measure rates of mental illness on a statistical measure of people using official health services. But, there are problems with measuring mental illness in this way.

Published information on prevalence tends to focus on admission to psychiatric hospitals. How do we know that everyone who has a mental health problem is approaching available western services? Secondly, prevalence rates and epidemiological studies use the category ‘South Asians’ which, according to Nazroo et al (2002), is too wide and misleading to be useful in health research. It isn’t correct to homogenise such a diverse population because it increases the risk of making cultural stereotypes. Therefore, previous studies that have focused on south Asian communities face problems of ecological fallacy that is an “error of assuming that inferences about individuals can be made from findings relating to aggregate data” (Bryman 2004:212). These studies are also rooted in western psychiatric practice and do not account for cultural differences in experience and somatic expression of mental illnesses (Kleinman 1986). For example, prevalence rates could simply present differences in pathways to treatment rather than differences in rates of illnesses.

Research focus
To avoid the extent of these criticisms, I used a qualitative approach which could capture these cultural and social experiences and opinions that perhaps other domains would lack. I will now begin to look at empirical data gathered from semi structured interviews with the Gujarati community in Leicester to demonstrate how culture shapes illness both as an experience and the way we understand mental health. I will focus on two broad areas: language and Religion and spirituality.

Language
Interviews that were conducted in Gujarati more commonly always said ‘depression’ in English when asked what mental illness meant to them. When probed, the participants could not explain what was meant by depression but vaguely thought it was to do with loneliness and exclusion. Interview data has suggested that language surrounding mental illness is not common in everyday language in Gujarati and thus they know more about depression post migration.

Additionally, it poses two problems; firstly my participants demonstrate that they are unclear on what is meant by depression and may use the word incorrectly as they are aware of it post-migration, and secondly are unable to express their emotional wellbeing clearly in Gujarati and this could be a reason why the community commonly express symptoms somatically (Kleinman 1986).

Additionally, the community relates to depression as a mental health issue; for example Pratik, a 49 year old male, who works as a full-time production engineer and moved to Leicester in 2005 with his family, for work opportunities stated:

 “If you ask me, one is worry if somebody is in a worried state I’m not calling that as bad mental health it’s just temporary kind of things then the other level is stress levels. That’s the second level in our kind of thing. Stress level is again 50/50 you can say its bad mental health but at the same time you can say it is a short term kind of thing and the third level is depression. And I always say that if you are in depression then it’s a bad mental health”.
This is interesting because, as Pratik suggests, emotions that come prior to depression may not be considered as a mental health problem but rather a way of life.  Kleinman and Good (1985) argue fundamental emotions such as anger and sadness cannot be assumed to be the same things in different cultures. There are two key things that need to be understood here.  Firstly language can be limiting for the community to express mental health and thus can be difficult to understand, express and diagnose. Secondly, understanding and opinions can be mistranslated from Gujarati to English; meaning different things and thus making it difficult to understand the true nature of mental health with the community.

Religion & Spirituality
The majority of Gujarati residents in Leicester are historically twice migrants, moving from India to East Africa and then to Britain.  Despite this, Guajarati’s have remained conservative and religious (Bachu 1985). Bachu (1985) puts forward that a reason for maintaining conservative is migrating with family networks which also catalysed their settlement in the UK.

Exploring religion has revealed two key threads: helping people live a way of life which reduces mental health problems and religion playing an influencing role in help-seeking behaviour.  For example, Manish put forward:

“If someone asked me personally because I am very much involved in this kind of things by God’s grace I studied so many things I am always trying to co-relate the faith the religion along with the human things how our dharma how our religion can be used in order to cultivate positive things in human beings. So if somebody asked me then you know I can try to help them psychologically and spiritually”.
This suggests that religion is viewed as an aid that helps people to think positively and thus promotes good mental health supported by Geertz’s (1975) argument of religious beliefs offering meaning to existence and a positive guide for living. If religion is such an integral part of people’s lives it could be argued that it has an impact on help-seeking and when things do go wrong religion could provide meaning or help. Similarly, Manish explores how religion helps him and people to increase spirituality which can be positive for your psychological level as well as your physical health. However, in terms of help-seeking there has been mixed opinions but there is consensus that the thought God had destined people to go through certain struggles, pain and worries is old fashioned.

Concluding Remarks
My empirical data from my interviews has begun to demonstrate that attitudes towards mental health are not as simple as being educated about it but rooted deeply in cultural practices, beliefs and traditions. Rightly so as Dogra et al (2005) argues conceptualisation and expression of mental health can vary across cultures and thus these need to be considered when looking at ethnic groups.  I agree with Shaw and Middleton (2000) and argue that once this is established, social support and treatment can then be effectively provided, be it a medical approach of drug treatment or other therapies. However, this will need to be negotiated with the community; if alternative routes such as Ayurveda are working successfully amongst the community then perhaps a medical approach and other professions can learn from this.

References
Bachu, P. (1985) Twice Migrants East African Sikh Settlers in Britain, London, Tavistock publications

Bryman, A. (2004) Social Research Methods, New York: Oxford University Press

Dogra, N. Vostanis, P. Abuateya, H. and Jewson, N. (2005) ‘Understanding of mental health and mental illness by Gujarati young people and their parents’, Diversity in Health and Social Care, vol.2, pp 91- 97

Geertz, C. (1975) The Interpretation of Cultures, New York: Basic Books.

Kleinman, A. & Good, B. (1985) Culture and Depression. Los Angeles: University of California Press.

Kleinman, A (1986) ‘Somatization. The interconnections among culture, depressive experiences and the meaning of pain’ in A Klenman, B Goods (eds), Culture and Depression, Berkeley CA: University of California Press

Middleton, H. & Shaw, I. (2000) “Distinguishing mental illness in primary care”, British medical Journal, pp 1420-1421

Nazroo, J. Fenton, S. Karlsen, S. and O’Connor, W. (2002) ‘Context, Cause and Meaning Qaulitative Insights’, in Sproston, K. and Nazroo, J. Ethnic Minority Psychiatric Illness Rates in the Community EMPIRIC, UK: Her Majesty’s Stationery Office, pp 137- 155.

You may have noticed that this blog has been quiet of late; as it frequently does, 'real life' got in the way.  However, we are back as of next month, and we need YOU!  If you would like to contribute an article to the blog, we would love to receive it.  Our remit is very open - we look for content from academics, service users, carers and clinicians, on a wide range of topics covering the broad remit of the IMH to mental health and well-being.

If you would like to contribute, please do get in touch with Amanda at This email address is being protected from spambots. You need JavaScript enabled to view it..

Elizabeth Cotton has recently written on the Centre for Health and the Public Interest blog about precarious work and mental health.  The first paragraph is here, the full post can be found on the CHPI's website here.
"One of the hidden factors driving the UK’s mental health services to its current tipping point is the working conditions of the people who deliver them. Mental health services have always been the poor cousin of the health family but with our health bodies, NHS England and Monitor, proposing that mental health services should face an additional 20% cut in funding those of us working in mental health should officially be concerned about our individual and collective states of mind. From Psychological Wellbeing Practitioners, Employment Advisors to community health workers, working in mental health care settings might be posing significant health risks to both clients and clinicians.

Psychotherapists offer us a graphic case study in the precarious work of the UK’s mental health services. An estimated 6,000 people a year qualify as counsellors and therapists and approximately 4000 clinicians have been trained to deliver Increased Access to Psychological Therapies (IAPT) services through the NHS. However we do not know how many people now work as psychotherapists, who their employers are and what their working conditions are like. According to the Health and Social Care Information Centre (HSCIC) there is no data on psychotherapists who work for agencies and information on Bank staff (the NHS’s own agency) is only this year being collated, due to be available at the end of 2014."

The recent decision by the Supreme Court in Cheshire West and Chester Council v P (2014) UKSC 19  reconsidered the definition of ‘deprivation of liberty’, construing it much more widely than previously understood, and bringing many more people within the scope of the Deprivation of Liberty Safeguards (DoLS).  The implications of this decision is currently presenting seismic challenges for health and social care services, particularly for the Local Authorities who act as the administrative bodies for the deprivation of liberty process. This will not be a 'one off crisis', remedied by quick fixes; the challenges presented by the decision, and resource requirement implications are for the long term.  And yet, what timing, just as cuts to Local Authority budgets, which have hit social care dramatically over the past 3 plus years, are really beginning to bite.

But, why has the Supreme Court’s decisions caused such panic? Should services not have been better prepared in their contingency planning for the decisions made by the Supreme Court?  Considerable resources are spent in emergency planning by local authority services and their partners in preparing for floods, excessive snow falls, major incidents and the like.  These cases have been coming through the court system now for almost six years – why is there no contingency here?

It seems that, when it comes to the rights of those most vulnerable in our communities, those whom society deem as needing the most protection for themselves and often from others, contingency planning doesn’t really seem to come into it.  But where the majority of individuals are totally dependent upon the statutory sector to look out for and to meet their needs, where does the responsibility lie in terms of protecting their human rights?  Is it not implicit in undertaking a duty of assessing, reviewing, maintaining, advocating and providing assurances that the person’s human rights are central to that personal care plan? Is the structure and facilitation of personalisation not required to be built on the foundations of human rights?

If there is one major concern that continues to be demonstrated, amongst the plethora of other issues, it is that the level of activity post-Cheshire West once again illustrates that those in our society who are the most vulnerable, least able to represent themselves, are still largely 'out of sight' and often 'out of mind'. Again the current situation demonstrates just how many people, be they in care homes, hospitals, in their own homes or other types of community housing/care schemes are just not on the radar of many services.

In the fall-out from Cheshire West, many Local Authority’s Supervisory Bodies for DOLS, are reporting more referrals in a month than for the whole previous year, some even twice that number. Many have taken on extra staff, both for administration and for assessment, with teams doubling/trebling in size to meet the demand.  Locally, 75% of the East Midland Supervisory bodies are reporting that they are unable to meet the statutory time limits required by statute.  But taking staff from other front line services will have consequences, particularly as this situation will continue indefinitely

But should anyone really have been surprised by this?  The judgment was of two joined cases, both of which began their journey to the Supreme Court many years previously, as long ago as 2009 in the case of the sisters P and Q.  The judge held that these living arrangements were in the sisters' best interests and did not amount to a DOL. The Court of Appeal in their judgment  dismissed an appeal.  As with the Cheshire West leave of appeal to the Supreme Court was granted.

How well briefed were the local authorities by their lawyers and ‘MCA and DOLS watchers’ to understand that these cases were of such significant importance as to likely have substantial consequences? The Supreme Court's hearing commenced in October 2013, with the decision of the Court made public on the 19th March 2014, notably only a few weeks after the House of Lords Select Committees review report on the MCA was published.

Given that many local authorities had disbanded their cross agency and partner arrangements for the management of MCA and DOLS, how able were they to keep a ‘watch’ and to undertake contingency planning?

I would suggest that it is a reasonable assertion that the Supreme Courts decision should not have come as a surprise! Indeed that the decisions were largely predictable. The cases referenced were fundamentally and directly about the need for ensuring and protecting those individual’s human rights. They were not about the quality of care, nor as to where or by whom their care should be provided by. The courts looked at the nature and degree of the care required, making careful examination of the type and level of restrictions/controls exercised and how ‘routine’ this was. How should this be lawfully maintained and authorised to ensure that the individual’s human rights were upheld?

The new programme in town is ‘TLAP’. ‘Think Local Act Personal’ present in a ‘care strategy and guidance’ on how services can be provided/rationed. Twenty plus national organisations including government departments, professional bodies and care providers have signed up to TLAP. Peter Beresford reminds us “…the move to personal budgets and personalisation has generally not been one based on messages from evidence”[1].

This brings me to the nub of this article. What is the essential and unequivocal difference between person centred planning, personalisation, 'Think Local Act Personal' and the legal requirements of the MCA and DOLS? Noting that we are talking about the most vulnerable and dependent of people requiring care!

If ‘person centred planning’ is at the very core of assessing need to inform access and entitlement, why had the fundamental human rights of so many other people in similar care arrangements not been picked up earlier? It appears that human rights and personalisation have existed in separate worlds and only now is this being addressed as a consequence of the Supreme Court’s decision.

At the core of the MCA is personalisation. Human rights and the protection of those most vulnerable in our communities must surely be core to person centred planning. MCA and DOLS is not a separate branch of care. It is about you, my neighbour, our ‘personalities’, our history, and our beliefs, culture and at times our frailties.  At times of greatest dependency upon others for care the protection of human rights should be fundamental and not panic reaction. For too long this has been ignored or just considered too difficult.  As an aging social worker trained in a very different era, I commend highly the Supreme Court’s decision.

[1] Beresford P. [2013] Personalisation: From Solution to Problem? Policy Press, Bristol University