3 Self-management and study skills

SARAH VICARY

And the last two perspectives that I’d like you to talk about are those … exactly those. The critical perspective and integrated. So, first, could we start with critical?

GAVIN DAVIDSON

Thanks, Sarah, Gavin here. In the critical perspectives, I think an important acknowledgement to start off with is that an awful lot of these ideas came from within the, sort of, main way of thinking at the time, which is the, sort of, biomedical perspective, as Ciaran Mulholland has talked about. There’s some seminal sort of work challenging the medical model, especially from the early sixties on. And again, these were largely perspectives from within psychiatry. Some of the most famous people, R.D., or Ronnie Laing, who wrote The Divided Self, who really suggests that some of the things we were characterising as mental illness were better framed as seeing responses to an insane world. He wrote a lot about this, sort of, the interactions within families and the impact on people’s mental health. Thomas Szasz, also another psychiatrist, wrote a book called The Myth of Mental Illness, which suggested that it was misleading, in a way, to think about mental health problems in the same way as physical health problems because, in his view, although I think this has been fairly robustly challenged, he felt that they couldn’t be sort of framed, tested for, responded to in the same way as physical health problems. And for him, that meant there were implications for other aspects of how we think about mental health. So, for example, for him, that meant that because somebody was experiencing mental health problems that wasn’t a justification, for example, for compulsory intervention under mental health law. And also the implication that, from his perspective, that, I think, this is a very important and reasonable response to when somebody is involved in some form of crime which is directly related to their mental health, that we allow for that – that they’re not responsible, or not as responsible, as they would be if it wasn’t associated directly with their mental health problems. He suggested that wasn’t justifiable. It’s a very challenging perspective, I think. And then later, there were again ideas which are sometimes framed as sort of post- or critical psychiatry. So, Laing and Szasz and so on, it’s often framed as sort of anti-psychiatry, whereas later the sort of more critical or post-psychiatry ideas … Bracken is one of the sort of main writers around that. It wasn’t rejecting the, sort of, the medical perspective, the traditional medical model, but was suggesting that there were big issues which needed to be addressed in terms of the power dynamics within mental health services and the need to move the person’s own voice, the person with the lived experience perspective, to the centre of how we understand and respond to their distress. From the critical perspective, another sort of not from psychiatry, but I guess Goffman’s book on asylums. It’s extraordinary that The Divided Self, The Myth of Mental Illness and Asylums are all published in 1960 or 1961 – so, an exciting time for the development of ideas. But that was, really, and it’s still a fascinating book to read. It’s looking at the role of services and how we can … how we organise services, how we provide care and support for people can play an important role in, at times, unfortunately adding to their difficulties. So we need to be alert to that.

CIARAN MULHOLLAND

Yes, thank you, Gavin. If I just pick up on some of the themes. I mean, psychiatry has had a difficult history, there’s no doubt about that, and it has been very much open to criticisms and has drawn criticism deservedly. And if we look back, there were some strange treatments employed, you know, for example, something that was called insulin coma therapy, which meant that individuals were given insulin deliberately in order to induce a coma or a pre-comatose state and at the last possible moment, when they were beginning to develop a seizure, beginning to fit, they were given a sugar infusion to bring them back round again. That was carried out right up into the 1950s. And earlier, something called malaria treatment was used and that meant that patients were deliberately infected with malaria, which meant that they then had episodes of high temperature, or pyrexia, which led also to fits or convulsions. And this was carried out over periods sometimes of weeks or even months or even years. Now these treatments might seem very odd – and they are odd – but we have to remember that back in those days there were no other treatments, nothing else could be done, and the psychiatrists in the old asylums … you might have an asylum with two or three thousand in-patients and you might have had two or three psychiatrists, and most people went into the asylum and stayed there for the rest of their lives. And some of these ideas, there was actually something behind it, there was a little bit of evidence that these treatments worked for some people some of the time, and there’s a rationale behind that, but in the main it wasn’t good and treatments were poor and sometimes even barbaric. And the worst example was the period from the 1930s to the 1950s when there was a widespread use of brain surgery, brain surgery in order to cure mental illness, and for most people it did little good, and for many people they were actually worse afterwards, it caused severe problems. So we can see why psychiatrists like Ronnie Laing, in the 1950s, looked back over those decades and thought about their own experience and came up with ideas that became known as anti-psychiatry. Now, some of the anti-psychiatrists didn’t describe themselves as anti-psychiatrists, and some of them, as Gavin said, were more content with the term such as critical psychiatry.

SARAH VICARY

The last perspective that we’ve looked at is what we call an integrated perspective, biopsychosocial model.

JIM CAMPBELL

Hello, this is Jim here, and myself and Ciarán will contribute to this next perspective. Essentially, the integrated perspective tries to bring together a range of models, a range of critical perspectives which help us understand the person we’re trying to help in their totality. The biopsychosocial model has been used for a number of decades to try and bring together the biological, psychological and social in a way that we have tried to discuss today. But also we need to move away from old-fashioned binary approaches to mental health services, where medical … it’s medical … medical model is predominant and the social model is marginalised, is rarely heard, towards a more integrated approach where psychological ideas, sociological ideas and medical ideas can be brought together in a unified way to help understand the needs of someone who’s been traumatised or is in stress or has a serious mental health problem. And we need to not just think about clinical expressions of the model but also look beyond the clinical setting and towards wider social contexts in terms of the person’s integration with society, with issues of unemployment, with issues of relationships outside, within families and how we can understand and find ways of building resilience for individuals’ families and communities. And finally, as Ciaran and Gavin have alluded to in the previous discussion about critical psychiatry, nowadays we really need to get beyond a professional discourse about what is right and wrong for people who have experienced mental health problems. We need their voices to be raised, to be heard, to have space to talk about what it has been like for them to use mental health services. So, this other … the voice of the lived experience really needs to be more integrated into treatment methods and approaches to dealing with the needs of people with mental health problems. And maybe Ciarán would like to add a little bit more.

CIARÁN SHANNON

Thank you, Jim. Ciarán Shannon here again. I guess, as a clinical psychologist working in the mental health services, I interact with various professionals who have multiple different perspectives on psychological distress. People come to see us that have multiple different perspectives on psychological distress. So, actually, being quite purist about how you understand these experiences and how you approach treatment just won’t work. So, in most people’s heads there has to be some form of integration, there has to be some form of valuing other perspectives. So, in our chapter, we do explore those perspectives. The biopsychosocial model that sees mental health problems as caused by biological factors, social factors and psychological factors, and that treatment of mental health problems needs to include all of those factors. There’s some absolutely terrific research on brain and environment. The brain is an organ designed to interact with the environment, it is moulded by the environment and in turn moulds the environment, so it would be very unusual if stress did not affect the brain and the brain did not affect the environment. And we explore some of those ideas that, actually, distress, mental health problems, have to be taken from multiple perspectives.

SARAH VICARY

Thanks very much, everybody, that’s been a really helpful introduction and overview of a range of perspectives