April 2016 – Recovery in the Bin

Yippee!

Hurrah! We did it! THANK YOU to everyone who contributed to our appeal to raise funds to train 16 volunteers to support people who experience mental distress, before and up to ESA/ PIP tribunals.

We have reached our target of £2250 so we can pay for the trainer, Tom Messere, to travel to London to do the training, provide lunch, and contribute to participants’ travel expenses.

We are also planning a follow on training on appeals/tribunals after June with another trainer Paul Treloar who has kindly offered us a days training.

And at least one participant has committed to train others where they live so the training can be spread far and wide.

The appeal is open until Friday 29 April so you still have time to contribute so we can fund the follow on training.

BACKGROUND

The DWP have £22 million to represent themselves in Personal Independent Payments (PIP) and Employment and Support Allowance (ESA) tribunals (Benefits and Work). Since 2013, people challenging benefit decisions are no longer allowed to get legal aid. This saved the Ministry of Justice – wait for it – £22 million. (CPAG)

In the meantime, disabled people have been struggling to claim the benefits they are entitled to and many have to appeal the DWP decisions – over half the ESA appeals succeed. However, there isn’t enough support for people throughout the process of claiming because Citizens Advice Bureaux and other advice services are overwhelmed by the demand.

People with mental health problems are at a particular disadvantage when claiming PIP and ESA. The criteria are framed in terms of physical impairment and the impact of assessments are having a negative impact on our mental health – an article in the Journal of Epidemiology and Community Health in November 2015 links WCA tests for ESA with possible additional 590 suicides, increased mental health problems and hundreds of thousands of antidepressant prescriptions.

Jobs

The following blog post on Critical Mental Health Nurses’ Network has been contributed by Jonathan Gadsby.

This week in the Guardian newspaper published an opinion piece by columnist George Monbiot on the subject of neoliberalism. Those interested in critical ideas about mental health will have noticed that it is a word which gets mentioned increasingly. Before Monbiot’s piece, I would have recommended David Harvey’s introductory book (see below), but Monbiot hits the major themes in just a few thousand words.

Monbiot’s claim is that our collective lack of understanding of that word is like imagining that the people of the Soviet Union had never heard of Communism. So asking where does the rubber of neoliberalism hit the road of mental health practice? turns out to be a complex question: other people have frameworks and ideologies, but we see the world as it is… our own assumptions are always more difficult to spot than those of others. Yet neoliberalism arguably finds expressions from service commissioning to the most intimate of our conversations.

In this post, instead of trying to capture that wide-angle view, I just want to focus on one element. This surrounds the way that employment and mental health are becoming viewed as the same thing. Here is Anna Kirkland, editor of a fabulous 2010 book about health and morality:

My thought about this began with a beautiful idea of the geographer David Harvey. Harvey writes fabulously polemical books about how globalization affects people’s visceral lives. In Spaces of Hope, Harvey writes that under capitalism sickness is defined as the inability to work. When I first read that thought, I could not breathe in the face of its profound truth (Kirkland, 2010, p28).

Here, the words are globalisation and capitalism; neoliberalism is a term which overlaps with both, a particular ideology of free-market self-regulating capitalism, with a particular kind of selfhood.

Essentially what is being said here is that (without denying that what people do with their time has an important effect on their mental health) there is something about our current culture which has made paid work – of any quality – a primary measure of health. It has become common to think that if a person is working then they are not unwell or not unwell anymore. It isn’t long before nursing becomes hijacked with the idea that getting someone back to paid work, or ensuring they do not lose it, is our primary purpose, or at least one of them. Recovery means working, working means recovered. On a related note, can anyone remember when it was that we mental health nurses routinely started to use the word ‘functioning’? I’m sure we thought people used to have ‘activities of daily living’, didn’t we?

Some nurses may not feel that this is a problem. Don’t we all know that, deep down, our self-esteem is very much attached to what we do? Why shouldn’t we try hard to find similar meaningful roles for our service-users? There is so much that could be said. We could talk about what exactly these meaningful roles are. I was recently CPN to a young woman who felt she had failed in employment because of her poor performance at the one job she had tried (helped into by her previous care-coordinator): full-time cold-calling telephone sales. There was a big screen displaying the ranking of each worker in terms of sales, and she was always at the bottom and was sacked after a month. I have worked in one or two difficult work environments, but I cannot imagine I would survive that job for long (or be able to guarantee the safety of the screen, either). But questions such as these aside (they are very important questions about the changing nature of work under neoliberalism), it is important to note that we nurses are not quite on the sharpest end of this idea. We might support our service-users with employers or employment, we might come up with various suggestions, but actually we are not the people who they mostly have to talk to about these things.

And that is why what is going on in Job Centres right now is very important. There are several strands to this. The first is simply that in linking mental health and employment, those in distress in society, even those experiencing the extreme mental states we mental health nurses care for, are viewed, first and foremost, as being in desperate need of a job. Is this what the fine ideals behind ‘the Recovery Movement’ and ‘social inclusion’ have become? Last month, a letter by the Mental Wealth Foundation took issue with this simplistic idea, putting it in a way I doubt many mental health nurses could disagree with:

Current DWP policy intended to reduce the socio-economic causes of mental illness to the one simple fact of unemployment is clinically and intellectually ridiculous.

I recommend reading the letter in full, partly because it is a good letter, and partly because the Critical Mental Health Nurses’ Network chose to sign it, along with a plethora of activist groups. The letter is written in response to a statement by the British Association of Counselling and Psychotherapy about government plans to include psychology input in Job Centres. It might seem strange to pick up this thread in the middle of correspondence like this, but (a) I think the letter holds many of the main points and (b) this is not just an internal affair within psychology. In fact, part of what has prompted this post are discussions I have witnessed between mental health nurses considering taking up positions in Job Centres – and some already have.

The letter also describes concern over the very idea of merging DWP activity (such as Job Centres) with health activity. This is the second strand of concern, about the combination of mental health promotion/psychology and unemployment services. In response to this idea, Friedli and Stearn wrote:

Increasingly, [activities required to receive benefits] include interventions intended to modify attitudes, beliefs and personality, notably through the imposition of positive affect. Labour on the self in order to achieve characteristics said to increase employability is now widely promoted. This work and the discourse on it are central to the experience of many claimants and contribute to the view that unemployment is evidence of both personal failure and psychological deficit. The use of psychology in the delivery of workfare functions to erase the experience and effects of social and economic inequalities, to construct a psychological ideal that links unemployment to psychological deficit, and so to authorise the extension of state—and state-contracted—surveillance to psychological characteristics (Friedli and Stearn, 2015, p40).

Just how serious is this problem? Haven’t we all had to do ‘labour on the self in order to achieve characteristics said to increase employability’? Perhaps, although employability is not simply about personal characteristics, is it? And what begins with ‘positive psychology’ (not psychology’s most well-evidenced idea) to be more employable can startlingly quickly become a new way to fail and be sanctioned, perhaps even ending up with a new quasi-psychiatric label: ’employment resistant personality’. This delightful term has been coined by Adam Perkins of the Institute of Psychiatry at Kings in London, author of ‘The Welfare Trait’ And yes, Adam Perkins is a eugenicist. Sounds a little bit extreme? Then try this article by him, in which he claims thatwelfare dependancy can be bred out.

The idea that people deserve their position in society, either intrinsically because of their genetic inheritance, or else because of their attitudes and characteristics, is one simple and easy way for people to account for all the inequality, as Owen Jones, author of The Establishment: And how they get away with it, said on Ian Hislop’s recent BBC documentary. It seems that this idea (essentially ‘meritocracy’) in the UK is, post banking-bailouts and Panama Papers, wearing more than a little thin. Positive psychology for the unemployed is part of a political attempt to make the unemployed wholly responsible for their unemployment, the distressed responsible for their distress. Once the ‘psychological defect’ of unemployment becomes a new kind of ‘personality disorder’, Perkins’ style of genetic posturing (it is not genetic science) may not be far behind.

One unusual aspect about this issue is that it has the potential to unite nurses who don’t agree about the causes of mental health problems. It really doesn’t matter if you think that distress is caused by broken genes, broken brains, broken thoughts, broken families or broken Britain – supported with whatever ‘evidence’ you enjoy most – you will still probably find you can agree that your service-user is not going to be miraculously ‘fixed’ by a call-centre job. You may feel comfortable describing all this as an illness-related ‘disability rights’ issue, or perhaps you are at the other extreme, seeing it as a further oppression of the State in addition to the oppression of diagnosis following the oppression of discrimination and inequality. However, whatever your views, you can probably agree that this merging of Job Centre and health service compromises our role and greatly over-emphasises the idea that paid work – of any quality – is the cure for distress. To then reinforce that view with the very real threat of actual destitution is just plain scary. Even if you are a nurse who has been fully recruited into the neoliberal philosophy that distress is a failure to take responsibility for oneself, you would probably feel aggrieved if an untrained and inexperienced Job Centre employee, perhaps subcontracted by G4S (yes, that was included in the letter, too), started telling you what your service-user needs (or, more likely, not telling you at all).

What can I do about all this?

There are many things that can be done. Here are two. Feel free to add more:

If Monbiot is right and our collective knowledge about neoliberalism is so limited that it would be like people of the Soviet Republic not having heard of Communism, then we are at a stage when raising awareness is a primary concern. We need to be reading books like the three listed below to learn how health is being used to promote certain values that we may not agree with, or at very least have not had adequate chance to think through. If we do not reflect on these issues, we mental health nurses are destined to reproduce them instead.
Many nurses would agree that it is important for us to dissent from the parts of our roles which are not about health but are about other people’s political agendas. With mental health nursing, that has always been a very hard thing to decide upon – some are going to feel that most of what we do is unproblematically health related, others are going to feel that we are pawns of the State the moment we so much as pick up a biro. But this issue – this dangerous combination of workfare + psychological input + sanctions is something that even the most trusting of us should be concerned about. Dissent comes in many forms. I have been inspired by the group Psychologists Against Austerity. I am indebted to Recovery in the Bin collective. I think Jay Watts has hit the nail on the head. It is a moment to seek out allies of all kinds and have some dialogue. But, above all, to come back to our best instinct: when in doubt, be kind. The Job Centre is not a kind place right now.

References:

Friedli, L., Stearn, R., 2015. Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes. Med Humanities 41, 40–47. doi:10.1136/medhum-2014-010622

Harvey, D., 2007. A brief History of Neoliberalism. OUP Oxford.

Jones, O., 2015. The Establishment: And how they get away with it. Penguin.

Kirkland, A., 2010. Against Health: How health became the new morality. New York University Press.

You look fine… you don’t need help!

WOMEN’S EXPERIENCE IN THE PSYCHIATRIC SERVICES – APPEARANCE AND ARTICULACY

Following a few comments on our Facebook Group, about how some of us were lounging about in our PJs on a Sunday afternoon, a discussion about how women’s appearance and behaviour can affect how we are seen and treated in the mental health system. Joanna said there was potential for a conference and research on the issue of women’s appearance in Mental Health services as it impacts on diagnosis, assessment of needs and risk.
So we decided to start with a blog post based on a couple of discussions in the Facebook group.

HOW WE LOOK

Joanna: ‘Dishevelled/smelly (I currently qualify) required for SZC/psychosis. [Joanna is currently waiting for a plumber to fix the water supply in her flat!]. Medical student told me that during her MH placement a psychiatrist said he knew if a woman had BPD “just by looking at her” and he referred to “too much eyeliner” or skirts being “too short”.

Joanna: Some women have been refused help because they looked ‘too smart’

AE: Many women I know need to dress well when feeling bad and put on make up in order to get the strength to leave the house at all. Like putting on a costume and mask to hide behind when in public.

Joanna: for some women putting on reasonable clothes, looking clean, bit of makeup has nothing to do with ‘care’ or function even. It can be as you say the only way to face the outside world. It can also be a protection because looking dishevelled actually draws attention. It might also be the only thing a woman feels able to do for herself taking a lot of effort

Michelle B: make-up has had the thumbs up that I am well enough if I am wearing make-up — this is a sexist thing make-up hair die and so on, clothes yes angry if in red yellow or other colours

Victoria: I will never forget a comment from a nurse when I was 17 – 17-“”you silly girl, you’re pretty, there’s no need to hurt yourself”….?!?!?!?

Anon: When I was 17, my first hospitalisation… From a nurse, “but you look like a model! You shouldn’t be in here…”

Deborah: The first time I saw my psychiatrist he said in front of the ward round that I was ‘an extremely attractive young woman” and then seemed to use it to negate my description of how bad I was feeling. Sadly from then on because I hated being called that and for fear of not being believed I looked after myself less and less, doubled in weight, barely washed by hair and only wore black. At least 15 years later (after I had moved 100 miles away, still had a couple of appointments with him a year but didn’t feel under constant scrutiny) I dared to wear something brighter and put on some lipstick. And yes, you’ve guessed it, he immediately said how much better I was!

Katy: I asked my friend to buy me prison-style garb last time I was in hospital coz I was being treated like a criminal offender or a thug…a nurse in the PICU braided my hair to complete the look smile emoticon

Lydia: In my craziest days I used to test out the system. If family claimed I was ill and I had to be assessed I used to wear something slightly outrageous and it would always be picked up on by a psychiatrist. (Shows I WAS off my head to risk that). I can’t tell you the number of times my appearance has been commented on in nursing reports though, and I have spent hours changing trying to decide what to wear to give a psychiatrist or social worker the right impression e.g. not red — he already thinks I’m angry. And that’s too bright = high. Lawd what a pain!

Joanna: Assumptions are made about women who self-harm in relation to their appearance and mental state. For example, “what’s a pretty girl like you doing this for?”, and “you’ve defaced yourself”

Joanna: Through to accusations of “flaunting” of the body if any scar is visible

Joanna: Weight and assumptions. It’s always assumed that any woman with an above “normal BMI” through to “morbid obesity” has a “good appetite”. I have seen friends in hospital going doolally through lack if nutrition but staff ignoring because of their weight & assumptions. Conversely, thin women harassed endlessly about eating.

Tincey: From ignoring weight as a factor to not understanding metabolism and stress, policing the body seems to occur (at least for women, can’t speak for men) across the board in medical or other services, along with moral judgement. I was seriously ill and having a lecture on being overweight, not taking into account the various factors involved (so common to have issues in PTSD and CPTSD). So many services still espouse the idea that it’s calories in/calories out and that it’s down to our beloved ‘lifestyle choice’ so lectures along the lines of everything will be fine if you stop being a pig — miracle cure.

Joanna: Not eating, weight loss, dishevelled is the correct appearance for women SUs

Sue: I rarely leave the house without full make up /extra defence mechanism/protective layer which apparently means all is OK. And I agree with the BMI thing-still not malnourished looking enough for help apparently and if I try to lose more weight to tick their anorexia boxes I’m obviously acting out using BPD attention seeking tactics.

Liz: My favourite thing I read about myself is that once in an appointment I “sat down very aggressively”

Liz: Oh I have long been told “clothing” part of my various pathologies, this is nothing new comrade……dark clothes all the same colour safer.

Lydia: I’ve always felt that my image doesn’t help. There’s some idea that I’m a quiet wallflower, which is clearly not the case, and the more I try to act in the way that’s expected the less I am me, but I’ve also tried being myself and it means a very long section. Compliance is the key.

We made the links between appearing smartly dressed and being perceived as articulate — professionals often mistake these as meaning the person is functioning and not in distress. Alternatively, articulacy can increase the risk of being diagnosed with BPD or confused with pressure of speech and hypomania.

ARTICULACY

Katy: My ‘articulacy’ was called hypomania…I told that shrink that I was not being hypomanic — it was my intelligence talking and if he could not keep up I’d talk more slowly for him !

Jane: Yeah I had pressure of speech because the psych reviews were less than 10 mins and he wouldn’t let me get a word in. So in 2 mins a week I was meant to cover everything.

My psyche has always commented on my being intelligent and articulate, and if quiet & less arsey would be more worried re mental state

Sandra: Also I think noting if had not bothered looking better dressed. GP frequently tells me her comments on my insight. Think can be misleading re how feeling

Sandra: Maybe we would all be shocked to see how we are perceived in notes by all profs

Joanna: “Insight” doesn’t = coping or not at risk. Every woman I’ve known who has died by suicide was intelligent & articulate & had “insight”. They just couldn’t get support.

Sandra: Yeah that the most scary when I have felt at real risk have been seen to be coping well.

Joanna: I’ve been considered suicidal when I haven’t & never been accurately ‘assessed’.

Sue: ”You’re obviously an intelligent woman-I don’t know why you can’t deal with your traumas in a more appropriate manner”
Joanna: Intelligence meaning that automatically means there’s no distress
Joanna: Why is this not said to Stephen Fry?
Sue: Because he’s rich and privileged
Joanna So only poorer intelligent people supposed to think their way out of distress
Sue: Yes and PD diagnosis = “at it”
Joanna: Intelligence = insight
Sue: Intelligence=insight=manipulation.

Anon: I can relate to this so much. One example I can give is phoning the (needless to say useless) CPN’s once when very distressed & suicidal, to be told “you’re an intelligent woman, you tell me: who’s in charge of your actions? Who’s in charge?” as if that would be “empowering” in some way…

Anon: Also being denied crisis care because I was “articulate” “intelligent” and “displayed good insight”… If you can describe your experiences of mentalness then you don’t need support. And if you can’t communicate them you don’t need support either, because “we’re not mind readers! ”

Anon: I came to the conclusion months ago that the only way to get support in a crisis is through actions, not words. Which obviously is incredibly risky. And “manipulative”

Sue: Being processed through the self harm team telling them I’m going to OD again without extra support and being told that’s my choice.

Sandra: Never ever be angry, because that is only behaviour of loons, don’t get angry with receptionists at CMHT who are asking bloody personal questions cos of course none of these ppl ever get angry fuck fuck

Joanna: Anger is particularly not acceptable from women & black men

Lydia: And swearing is not acceptable from “respectable” women which means I’m not. Maybe I need to clarify that with my psyche next time I see him.

Megan: I am struggling right now, asked several professionals for help and was told no as I was articulate. Spoke to Social Worker and Support Worker and they seen I was struggling and said it was completely wrong to judge my mental state on whether I am able to complete a sentence or not. AHHHH!

Michelle CM: My GP told me I was “intelligent enough” to grasp the concepts of therapy from a self help book so I didn’t need a referral anywhere.

Naomi: I have had issues with being too ‘open’ in that they thought it was part of my BPDness and I should be avoided…
Joanna: but if you had not been open you would have been failing to engage.

Jane: relating this to appearance/articulacy — for a woman even being polite but distant is not enough — you have to come across as ‘genuinely’ warm, respectful, deferential, of staff. Also sense that if you do behave positively/politely but staff don’t believe you share their views then you are regarded suspiciously as manipulating them somehow. I think this reflects something I once read somewhere — in psychiatry ‘compliance’ isn’t enough you have to be brainwashed too — employees/workers just need to be polite/do what they are told even if they don’t agree — psychiatric patients have to agree with what is done to them or they are asked to do — domination not just of the body but the psyche too

CONCLUSION

When women seek help from services, especially when in crisis, we are judged on what can be seen and rarely given the chance to explain our distress. Workers refuse to believe we can be as distressed as we are because we can look ok and we are not given the chance to explore what is really going on beneath the surface. We believe this is based on sexist and sanist assumptions and on the pressure on workers to refuse services to cut costs.

As Michelle said “people judge you by this idea of femininity rather than as a person”

——

These are excerpts from two long discussions – we have only included comments from the women who agreed to be included.
We have rearranged the order of the comments in places to make it read a bit more coherently.
The discussion also included some linked issues:

sexual harassment and abuse within psychiatric services
judgements on our sexuality – our sexual behaviour, relationship status and our sexual orientation
the intersections between gender and race and class
women’s experiences in forensic and criminal justice services

We think these deserve more discussion – look out for future blog posts on these topics.

Fuck Neoliberalism

Fuck Neoliberalism by Simon Springer, Department of Geography, University of Victoria

Email: simonspringer@gmail.com Twitter: https://twitter.com/AnarchistGeog

Read the whole paper at https://www.academia.edu/23908958/Fuck_Neoliberalism

Extract:

Abstract: Yep, fuck it. Neoliberalism sucks. We don’t need it. Keywords: fuck neoliberalism; fuck it to hell

Fuck neoliberalism. That’s my blunt message. I could probably end my discussion at this point and it wouldn’t really matter. My position is clear and you likely already get the gist of what I want to say. I have nothing positive to add to the discussion about neoliberalism, and to be perfectly honest, I’m quite sick of having to think about it. I’ve simply had enough. For a time I had considered calling this paper ‘Forget Neoliberalism’ instead, as in some ways that’s exactly what I wanted to do. I’ve been writing on the subject for many years (Springer 2008, 2009, 2015; Springer et al. 2016) and I came to a point where I just didn’t want to commit any more energy to this endeavor for fear that continuing to work around this idea was functioning to perpetuate its hold. On further reflection I also recognize that as a political maneuver it is potentially quite dangerous to simply stick our heads in the sand and collectively ignore a phenomenon that has had such devastating and debilitating effects on our shared world. There is an ongoing power to neoliberalism that is difficult to deny and I’m not convinced that a strategy of ignorance is actually the right approach (Springer 2016). So my exact thoughts were, ‘well fuck it then’, and while a quieter and gentler name for this paper could tone down the potential offence that might come with the title I’ve chosen, I subsequently reconsidered. Why should we be more worried about using profanity than we are about the actual vile discourse of neoliberalism itself? I decided that I wanted to transgress, to upset, and to offend, precisely because we ought to be offended by neoliberalism, it is entirely upsetting, and therefore we should ultimately be seeking to transgress it. Wouldn’t softening the title be making yet another concession to the power of neoliberalism? I initially worried what such a title might mean in terms of my reputation. Would it hinder future promotion or job offers should I want to maintain my mobility as an academic, either upwardly or to a new location? This felt like conceding personal defeat to neoliberal disciplining. Fuck that.

Read the whole paper at https://www.academia.edu/23908958/Fuck_Neoliberalism