Sharon Cretsinger reflects on her experience of coming out as persons of plural identities.
Asylum magazine strives to link the politics of mental health to broader progressive political struggles, social movements and campaigns. For example, Extinction Rebellion has been calling attention to the devastating impact of climate change. It has already had significant transformational impact, at least on public consciousness, not dissimilar to that of the #MeToo campaign in raising awareness of sexual violence.
In one of Georges Simenon’s short novels, Maigret’s Doubts, Inspector Maigret receives the visit of a man who suspects his wife of wanting to poison him. The man tells of having been off colour recently and accuses his wife on the basis of having found some rat poison in the broom cupboard. Inspector Maigret is left questioning (hence the doubts of the novel’s title) whether his visitor is mentally insane. He consults a number of psychiatric books and he is left with the impression that “by investigating the anomalies of human behaviour, classifying and subdividing them, in the end it was impossible to tell what a man of sound mind might be”. As the investigation leads Maigret to get acquainted with the man’s private life and his close relations, he begins to understand: “he felt, finally, that he was dealing with people of flesh and blood, men and women with passions and interests”.
In 2003, in my first job as a junior doctor in psychiatry, I was asked to interview a middle age woman, I will call her Mrs A. She was an inpatient receiving Electro-Convulsive Therapy (ECT). She had been diagnosed with treatment-resistant psychotic depression for the past two years. She believed that she was being controlled by a little man inside her who made her behave oddly, commanding her to crawl instead of walk and to babble like a new born rather than talk. She was prescribed two antidepressants and an antipsychotic, as well as sleeping tablets and a course of ECT. While I was diligently conducting my semi-structured psychiatric interview, checking how many hours she was sleeping per night, was she waking up early, had she lost her appetite, could she concentrate on watching TV or reading a book – and I will spare you the rest – I noticed a very brief exchange between Mrs A. and her visiting daughter, which made me question whether some family trouble may be contributing to her depression. Questioning family relationships was not part of the semi-structured interview, but it led to a referral for a family therapy meeting, at which I was present. An hour interview with an experienced family therapist unravelled the secret history of this patient, secret because it had never been told outside the domestic walls. That one interview was enough to make us begin to understand.
Mrs A. had run the family business and brought up three children all single- handed for many years. Her husband had had several mistresses during their marriage and had spent lots of the family money on expensive holidays with them. Nevertheless, they stayed together and played the happy couple at family gatherings or for the local community. During all that time Mrs A. had managed without developing a mental illness. But then three years before, her husband had fallen ill with cancer and Mrs A. had become his full time carer. He had no more mistresses now, and even after his recovery, he remained faithful to her and a permanent asset to the domestic environment. He had however taken over control of the family finances and patronised her into following him in expensive holidays that she did not enjoy. That is when she had developed depression. Now I understood why she believed that she had a little man inside her controlling her and making her crawl rather than walk and babble rather than talk. Or at least I thought I understood. There were tears shed in the family meeting. It seemed like the elephant in the room had materialised and was brushing its tail against our eyes, and those of the lady, and her children. Her husband was the only one to remain unmoved and said little.
The family meeting had been an eye-opening experience for a junior psychiatrist.
A few years afterwards when I was working as a Specialty Registrar, I teamed up with a general adult psychiatrist to set up what we called ‘the systemic assessment clinic’ (SAC). Both of us had had extensive experience of systemic family therapy and had come across repeated instances of epiphanies in ‘heartsink’ cases similar to those of Mrs A. The SAC was a weekly clinic where we assessed patients who were referred to his general adult psychiatry team with a different model from the one used as a standard in general psychiatry. We asked referred patients to bring along anyone they felt was significant to their lives. Patients brought their partner, their parents, their adult children, siblings or, sometimes, a close friend. In the spirit of family therapy we shifted the focus from assessing the symptoms in the individual to investigating the ‘problem’ in the system. We felt that at the end of these assessments we could almost always say: “we begin to understand”. We asked patients and carers to rate their satisfaction with the process and scores were high.
Nevertheless, our many attempts to get support or endorsement of the SAC from our local NHS Trust failed. We were told it was not ‘evidence-based’ and were encouraged to apply for a NIHR grant – 56 pages long, it took a year to write, it pulled together a team of 8 experts and was rejected.
Trying to provide some evidence for the SAC’s benefits, I carried out a service evaluation. I compared outcomes for 22 patients seen in the SAC from 2013 onwards and 22 comparable patients who were assessed in standard psychiatric assessment during the same period of time. All patients were new to psychiatric services. Outcomes were measured as: time spent in psychiatric services after assessment, type of services used, and number of times patients were referred back to psychiatric care after discharge. Follow up was between 2 and 3 years after assessment. The results were very interesting and some of them impressive. In both groups, the immediate post- assessment use of psychiatric services was comparable: a small fraction was discharged back to their GP immediately, the majority were referred for an intervention lasting between 6 and 12 months, and a small minority were referred to tertiary services. Rates of referral to psychology and psychotherapy were comparable across the two groups, although – perhaps surprisingly – somewhat higher in the standard assessment group. In both groups the mean time from assessment to discharge from psychiatric services was comparable, although the number of patients discharged within 6 months was 11 for the SAC and only 6 for the standard assessment group. The great surprise came when we counted the number of times patients were re- referred to psychiatric services once discharged. For the standard assessment group 9 of the 22 patients were re-referred within the 3 years period, and of these, 5 were re-referred twice (for a total of 14 re-referrals). But for the SAC group, only 1 patient out of 22 was re-referred once within the next 3 years. You may conclude that the SAC scared people off from coming back to psychiatric services… Our impression was that, by engaging people in meaningful conversations from the start, it allowed for the development of a purposeful care-plan which was recovery-oriented, while standard assessment tended to make them chronically ill.
The interesting part of the story comes now.
Conscious of the fact that such a small study could not gain attention in the main clinical press, in February 2016 I sent a paper summarising its results to the Bulletin, a journal published by the Royal College of Psychiatrists and which specialises in the publication of audits and opinions. It has an insignificant impact factor but it has the advantage of being circulated to all psychiatrists in the UK as an addendum to the prestigious British Journal of Psychiatry, with the potential to reach a sizeable audience. After submitting, I was surprised to hear from the Editor that he was not going to send my paper out for peer-review. I wrote back, politely but passionately asking him to reconsider. The Editor sent the paper to a member of the editorial board for a
second opinion, and they enthusiastically replied that the paper should be sent for peer-review. The Editor obliged. I therefore resubmitted to the Bulletin in April 2016 and received a positive opinion from the reviewers, who suggested some revisions, which I dutifully carried out. In June 2016 the revised copy was resubmitted to the Bulletin. In September 2016 I received confirmation that the resubmission satisfied the requested changes and could therefore, according to the reviewers, be published. However the Editor stepped in and declared that he was still “unable to accept this paper for publication” and nothing could be done to alter his opinion. He justified himself by saying that he did not believe the validity of the data. I was gutted but in November 2016 I had the moral strength to bring the matter to the attention of the then President of the Royal College of Psychiatrists. I expressed my concern that following a lengthy review process the Editor had decided single- handed to go against the recommendations of the peer-reviewers and to stop the publication of the paper. In January 2017 the President replied that the Editor’s opinion should be upheld and I was advised not to “ waste any more time and energy on this submission”.
This experience has made me think, and I am still thinking about it. Psychiatric interventions (particularly biological ones) are tested on a large scale on the basis of a diagnostic system which is founded on the standard psychiatric interview. Or shall we say, that the standard psychiatric interview is founded on the official diagnostic system? It’s a chicken-and-egg situation. On this chicken-and-egg is grounded all the evidence that determines whether therapeutic interventions are efficacious or not. And yet there is absolutely no evidence-base for the diagnostic system (and many have written about this), and there is no evidence-base either – and this is the best kept secret in psychiatry – for the standard psychiatric interview. Most evidence-base in psychiatric research has been built on quicksand.
The antipathy for my paper is much more telling and significant than if the paper had been accepted. My paper was the tail of an elephant, brushing against the eyes of the psychiatric establishment: like Mrs A’s husband, they would rather be left blind.
Maria is now a lecturer at Queen Mary University of London
This is a Sample Article from Asylum 26.2. Subscribe to Asylum magazine.
Vincenzo Passante Spaccapietra came to the UK from Trieste, home of the Italian democratic psychiatry movement. He was surprised by what he found.
Some people do not fit into our society, they are neglected by unfair social structures and become desperate. What should we, as members of society, do about this? In the UK (and elsewhere) we still assume that psychiatric hospitals are justifiable;
alternative ways of thinking about care are not currently on the menu. We avoid working on different premises, even though hospital admissions far too often lead to the very opposite of safety. The procedural efficiency of the system takes priority to the well-being of the people it is supposed to help.
Staff members are provided with risk management templates that temporarily provide the illusion of controlling suffering. We persuade patients that they are thinking about their life in the wrong way and they must change to fit the requirements of the society that failed them. The most scientific way to repress the symptoms of society’s failure is defined as “best practice” and any other approach is looked at with suspicion.
Far from gradually moving away from the asylum system, psychiatric hospital care has been on the rise in the UK: there has been a 2.4% increase in detentions in 2017/18 compared to the previous year and a recent research article found that rates of detention have at least trebled since the 1980s and doubled since the 1990s. If you are black you are more than four times more likely to be admitted to hospital and seventeen (!) times more likely to be diagnosed with a severe mental disorder than if you are white. There are disparities for other social groups as well.
This is often seen as having nothing to do with society, politics or psychology, but a medical issue that coincidentally seems to affect the brains of social groups that society dislikes. How can all of this be the result of “best practice”? The science behind the system ends up defending dominant social groups from the suffering of those who get left behind and this oppression is presented as an objective necessity for society. Otherwise we would have to accept that there is no magic box where society can safely dispose of the problems it causes.
This mentality, that the more we repress the expression of madness, the more we can cure it and ensure safety, takes shape in different ways. It goes well beyond the mental health sector: it can affect schools, universities, families and every other human organisation. Citizens face an intrinsic hypocrisy – we live an intellectual crisis where many of us want to fight stigma, but we re-enforce it in our habits, policies and procedures. In turn, to protect ourselves, we justify the actions we undertake as necessary or even therapeutic. This ensures the perpetuation of prescriptive rituals, where individuality is denied, and emptiness is endemic, an emptiness that gets inevitably filled by tragedies.
Life is more complex than any safeguarding procedure. Mental health professionals have to apply a simplistic and unidimensional idea of “risk” to complex phenomena that society refuses to address holistically. Dangerousness becomes the only important aspect of self- harm, suicidality, aggressiveness, or even hearing voices, that a psychiatric hospital system cares about. However, it is by no means the most relevant, let alone the only, element to consider in the practice of creating safety.
I qualified as a Psychologist in Trieste, an Italian city that led a national revolution in the 1970s which closed all psychiatric hospitals. The implementation of the new legislation was generally poor, and this led to a range of problems which are yet to be addressed.
Despite this, in the minority of cases where it was implemented as intended (Trieste being the most prominent example), it proved that a different way forward is possible. There is still a small, open door, general hospital psychiatric ward in Trieste for acute psychiatric emergencies: and its existence is still questioned by some of the reformers. The system is almost exclusively focused where it should be, in the community, with the provision of beds in open door community mental health centres, in a relational context where the person is considered much more important than the disorder.
In 2014, given the chronic lack of career opportunities in Italy, I came to work in Britain (not as a Psychologist, in the UK you need a doctorate for that). I crashed into a care system that in Trieste had been defeated by Franco Basaglia and others many decades ago. I quickly realised that hardly anybody knew anything about this situation (Asylum magazine is a virtuous exception). The training I got was the opposite of what I learned in Trieste (a widely internationally recognised setting for training). I realised I would not even have the right to believe, for instance, that doors should be kept open to bring about safety. Years and years of training became suddenly pointless, or even wrong, and I had no opportunity to discuss this with managers, because they knew nothing about any of this.
British mental health care is in a state of emergency. Harmful practices are often defined as "best practice" and taught as the only acceptable view. In Trieste I was taught to avoid seeing complex behaviour through the limiting and stigmatising lens of dangerousness. Here I found myself in a position where my level of competence was evaluated against
skills like remembering to ask patients: “Do you have any thoughts of hurting other people?”; at every contact. This was meant to “ensure safety”. It applied to every patient, regardless of whether there was or was not a concern for their state of mind (this, to be fair, does not happen in every service). Imagine if we applied this mentality to other social groups, if for instance we asked every black person that entered a shop: “Do you have any thought of robbing the shop?” Would that be an acceptable way forward? Would that ensure safety?
This is the type of thinking that in Trieste we call “stigma”; and we commonly attribute to poorly informed individuals who are worried about the supposed dangerousness of mad people. Lack of funding has a role in all of this, but these concerns go well beyond the (important) issue of austerity. Call me mad but sometimes I feel we are living through a large scale “Milgram experiment”, a famous social psychology experiment where subjects were persuaded to administer lethal electric shocks to other people for the sole reason that the experimenter had told them to do so. My perception is that workers persist in carrying
out questionable procedures without objection, for the sole reason that the establishment tells us that it is necessary to follow the rules.
Action must be taken. Whereas in Trieste I had endless debates with my supervisors about questionable aspects of care, here in the UK I find myself confused, caught in the dilemma of leaving the system or staying in. In a small way, by staying in, I have already seen change happen in places where I worked, despite remaining in an intrinsically contradictory position.
For these reasons, a friend and I recently started to host a podcast: “A place of safety?”, in which critical voices are legitimate. We question whether safety measures, like hospital admissions, can be defined as such if they lead to tragedy, or whether an intervention is really “best practice” if it ignores things that could be done better, differently. If we could become less dogmatic about our beliefs, we could find healthy spaces for debate. More democracy must be the first step. Without the right to disagree no change is possible. When I came across Asylum magazine, I realised we had a similar ethos and history. So they were one of the first places I turned to for help. This quickly is turning into establishing a closer working relationship, where we hope to put our resources together to widen this important debate. Any contribution you want to give, we are here to listen.
Our “;A place of safety?”; podcast is available on the main platforms: iTunes, Stitcher, Spotify…
Twitter and Instagram accounts: @apospodcast.
We will keep you updated,
Vincenzo Passante Spaccapietra
This is a Sample Article from Asylum 26.2. Subscribe to Asylum magazine.
‘At the end of 1984 a conference was held at Wakefield, concerning the plans to close the mental hospitals. The day was dominated by reports and discussions of the Italian experience of just such a policy. Many were impressed with the work of the radical reforming group, Psichiatrica Democratica, which had cut across the crippling disciplinary boundaries of mental health care in Italy, and had produced very significant results.
It became apparent at that time that a number of mental health workers and ex-patients in the region thought that a forum for debate was sorely needed. A forum that was non-aligned politically, professionally or by trade union. A forum in which all views could find expression.
A group came together and decided that the first objective in a campaign for a more democratic pscyhiatry – to address all issues in the field, not just hospital closure – was to establish a magazine.
This is the first issue.
PARANOIA DEFINED – Professor Alec Jenner
HERSTORY OF MADNESS – Eleanor Longden
NOTES ON PARANOIA – Peter H. Donnelly
REVIEW: THE PANIC DIARIES by Jacqui Orr – Reviewed by Paul Henderson
MY EXPERIENCE OF PARANOIA – Peter Bullimore
EXPLAINING PARANOIA: PSYCHOANALYSIS vs PSYCHIATRY – Phil Virden
RETHINKING ‘PARANOIA’ – Dave Harper
PARANOIA & RECOVERY – Angelina Cosgrove
HUMAN APPROACHES TO PARANOIA – Peter Bullimore
THE PARANOIA GROUP – Peter Bullimore
PSYCHOLOGY & ‘THE WAR ON TERROR’ (2): PSYCHOLOGICAL WARFARE AND PARANOIA