The (UK) Twitter world has been full of discussion about Channel 4’s recent ‘4 goes mad’ season, a series of programmes about mental health stigma, particularly in the work place. It culminated last night with ‘The world’s maddest job interview’ (http://www.channel4.com/programmes/worlds-maddest-job-interview/4od) in which a number of candidates, some with, some without, histories of mental health problems were put through a series of tests and assessed by psychiatrists/psychoanalysts and potential employers for both traits of mental health problems and their aptitude for work. I’ve just caught up on the programme, given that last night I was engaging in my own favourite leisure activity of salsa dancing (with some great friends and a very special, talented teacher who has been both a great support as a friend and also a fantastic teacher who has facilitated the recent salsa opportunities, see https://pd2ot.wordpress.com/2012/07/25/116/ ‎ for my reflection on the role of salsa in my recovery).

I have to say I was a little anxious about watching, given the response I observed on my Twitter feed, and many of the objections seem valid. This blog post is not intended to be a review of the show, but more a personal reflection on some of the key points that I took from it. I suspect some of the issues will develop into more in depth blog posts in the future.

The power of label

I suppose the first thing that struck me about the whole #4goesmad concept was the use of the word ‘mad’. Like many, I questioned the appropriateness of a supposed ‘anti-stigma’ campaign being based on a word that was stigmatising, in itself. Initially I had that ‘ouch’ feeling every time I saw a trailer or read the hashtag, but perhaps on reflection is it such an issue? If, for example, channel 4 had named the series ‘4 challenges the stigma of mental health problems’, would it have captured our imagination in the same way? Would we have had so many discussions on social media about the complexities of labels and societal judgements? Would the person with little understanding of mental health problems have paid any attention to the series? I suspect not. Channel 4 has always been a broadcaster that takes risks and sometimes steps over the line. While I’ll never be comfortable with the use of words like ‘mad’ or ‘crazy’, I can understand why it was branded in such a way. I also think the programmes did a reasonable job in highlighting mental health problems in a serious and fair light. Perhaps a feature on the power of labels and their contribution to stigma would have been the ideal compromise.

Another aspect that caused me to reflect was the frequent use of the word ‘suffering’ by both professionals and those with the mental health problems. I recently started a discussion on Twitter about my intense dislike of the description of people to be ‘suffering from OCD/depression/bipolar/personality disorder/psychosis etc.’ I am a pretty placid person, but both the attribution of the word ‘suffering’ to a person’s experience of ill health, as well as describing someone as ‘anorexic/schizophrenic/autistic’ are things that I will step on my soap box about. I was relieved to find a number of service-users and professionals shared my view that this use of language was unhelpful. It feels far too reductionist to see people as only their diagnosis, and puts them into a helpless ‘victim role’ to assume they suffer with their illness. I suppose the aspect that prompted further reflection was how many of the candidates on ‘The World’s Maddest Job Interview’ said that they had ‘suffered from bulimia/OCD/clinical depression’. I wondered how much of this was almost conditioned into them by society and medical professionals, that they used the term without thinking about how it felt for their identity. I also wondered how many of them felt that their illness was something they suffered. I believe it is a very fine line. Mental illness can be some of the most extreme torture that a person will experience, and the person does suffer. However, I don’t think it is helpful to give all the power to the illness and adopt a powerless victim role. I’ve talked before about how much I value Dialectical Behavioural Therapy (DBT) and one of the key, founding, assumptions of the therapy is that the person engaging with DBT is not responsible for the problems they have or the events that caused them, but they are responsible for how they respond and manage those problems. I think this is a much healthier approach to both Personality Disorder and also other health conditions. The person with the illness did not cause it but they can do all they can to manage it. I felt cautious of applying this logic to something with a very biological origin, like cancer, especially as a person can’t have full control of determining if a tumour grows, but feedback I got from the Twitter conversation is that there are few areas where it helps to adopt a helpless victim role.

The role of productive occupations

I think, on reflection, that this part warrants its own blog post with a little supportive reading and findings from relevant studies. However, like many, I was very pleased to hear the statement about work helping people get better. I do believe it is a far more complicated process than that. For example, a graded process building up to a goal of paid employment is more likely to be successful than simply jumping from hospital into a job. Similarly the job needs to be right for the person, finding the right balance of demand and personal growth with stress levels for each person. As with many areas I also believe that there are exceptions. Work will not help everybody. I think Occupational Therapists (OTs) have a fantastic opportunity, approach and skill-set to finding the right balance of occupational demands, collaboratively, with a person recovering from a mental illness. I think occupation is the key to recovery, and would like to explore the extent to which productive occupation facilitates recovery.

‘You wouldn’t know’

A common statement in last night’s programme seemed to be this expectation that mental health problems would be evident in some way. I suppose it caused me to reflect on how my understanding of mental health is different to the ‘average joe’. I’ve had the fortune of knowing a great many people who have had a variety of mental illnesses or recovered from them and so never had to challenge a misconception that a person with a mental health problem will be unable to function or not have any notable skills or positive attributes. I’ve also been aware of how easily hidden mental health problems are. I’ve lost count of the number of times I’ve been told that people had no idea of the extent of problems I had. From colleagues being shocked that one day I was at work, ‘fully’ functioning and the next sectioned and starting what would become a hospital admission lasting 16 months. I think it frustrates me that understanding can be so limited that people expect a person with mental health problems to appear ‘mad’. It also prompts me to think about the nature of mental health problems. Many people with such problems have difficulty displaying emotions, or perhaps developing trusting relationships in which they allow friends to know ‘the real them’. I often was frustrated by a trait of mine that was to show ‘apparent competence’. In the world of DBT this feature is assigned as the opposing dialectic to ‘active passivity’. I often struggled to relate to this particular dialectic but did feel aware that apparent competence made my life very hard. I was skilled at appearing fine, in control and competent as it protected me from people getting too close or understanding me. It also blocked all help, even in hospital I found it hard not to appear ‘ok’, even when in deep distress.


I suppose the other element that surprised me was the employers shock at hearing a person’s diagnosis or past experience. I suppose I am very accepting of the fact that I have had significant mental health problems and nearly not survived AND I feel that I am a stronger, more resilient and highly skilled person as a result of it. Perhaps I am a little naive to believe that my potential employers would not be put off if they were to know my history, but I also think they have no need to know. As things stand I have needed no adjustments to my course and passed a demanding placement with distinction, my needs are no different to a student without a history of mental health problems. I have been fortunate that my university have been supportive, and on the whole, value the experience I have. I suppose that is the point of this blog; to increase my own understanding of my limitations and strengths due to my history, and to make others aware of the contribution ex-service-users can make to the profession. I suppose I felt that the 4GoesMad season could have benefited from a broader inclusion of mental health diagnoses. While many of the people featured had experienced severe levels of mental illness, the absence of participants who had recovered from or were managing psychotic illnesses or personality disorders felt a little stigmatising. Perhaps the main focus was given to OCD and depression as they are illnesses that most people can attempt to understand the traits of. Given that a person diagnosed with Borderline Personality Disorder (BPD) may be a similar spectrum, in terms of the diagnostic criteria, with a person who considers themselves to not have a mental health problem, it would have been most beneficial to include some of the more ‘scary’ diagnoses in the programmes, in order to maximise the potential to challenge stigma.

As I said, possibly some of this needs more time and exploration, but that’s just a summary of some key reflections for now.

Summer of Salsa

The Summer seems to be a time of anniversaries/reminders for me. Some positive, some less-so. In fact, as the London 2012 Olympics are about to start it prompts me to reflect on how things have changed since the Beijing Olympics of 2008.

In the Summer of 2008 I remember watching hours of Olympic sport, not because I was a fanatic, but because I was a patient on a Psychiatric Intensive Care Unit (PICU) and not allowed access to any of my possessions due to the level of risk I was at. I don’t remember any key events of that Olympics, I suspect while I was watching I wasn’t really taking much of it in.

In the Summer of 2009 I was still an inpatient in a psychiatric hospital, as I had been for 16 months at this point, but now on an acute ward on 1-1 observations. I was considering, reluctantly, transfer to a residential therapeutic community (TC).

In the Summer of 2010 I was nearing the end of my TC admission, I had spent 8 months as an inpatient and was finding my feet in the real world. As part of this I embarked on salsa classes to help build up social contacts in the new area I was living in.

In the Summer of 2011 I had completed an Access to Higher Education Diploma, to help get me back into the world of academia and had built up a great network of friends, as well as enjoying salsa dancing and voluntary work.

Now, in the Summer of 2012, I’ve completed my first year at university and loved my first practice placement.

Anyway, after that nice little timeline I’ll get onto the main point of this post, salsa! As a self-confessed #OTgeek the other incredibly meaningful occupation in my life is salsa dancing. Consequently I was thrilled to see on Ruby Wax’s Mad Confessions (http://www.channel4.com/programmes/ruby-waxs-mad-confessions/4od ) that salsa features as an activity for people receiving treatment at The Priory. During an OT intervention when I was in the TC the idea of finding leisure occupations that would be meaningful and also not self-defeating (as many exercise/sporting occupations had been for me) came up. The OT and I felt that I needed to explore a hobby that could be fun and that would help me make friends in the area I was living. As a child I had done some ballet and modern dance and really quite enjoyed it, but I was wary of this type of activity for someone who had a slightly shaky body image. I did some research and found a local streetdance class and decided to attend. While I enjoyed the class I found that most of the participants were 16-18 years old, despite it being an adult class. I then decided to try salsa, simply because there seemed to be a multitude of classes and I believed I was likely to find a wider age range of participants.

I picked a local salsa class that seemed to have a good structure format and a separate class for those who were attending their first class. While I was nervous about attending the first experience went well. The format was as I expected and being in a separate class was really helpful as it reduced the number of social interactions I needed to have.

The first few months were probably a little challenging and I don’t seem to have the energy (or possibly the desire) to reflect in detail on that but I will summarise in terms of the benefits and challenges I experienced as I started.


  • Enabled me to explore my identity as someone who was functioning and competent.
  • Helped me develop a healthy body image and discover how to use my body in a good way, rather than abuse it.
  • The structure of classes meant that the occupation was the main focus, taking the pressure off the social interactions and allowing me to increase my confidence with those, little by little.
  • It’s fun! Still after some really special nights I’ll find that I have such a buzz that it can be hard to wind down.
  • It doesn’t feel like exercise, therefore I get to be active without it slipping into eating disordered behaviour.
  • It’s difficult, so I don’t get bored and have to work hard to improve.


  • I did find it very hard to dance with, and be in close proximity to, lots of men. Often I wonder why I picked this sort of activity but I know it’s been a useful challenge to work through in therapy.
  • At the start I was still a member of the TC, inevitably small talk usually got onto questions about where I worked/what I did during the day and I found these awkward. It was so much easier several months later when I could say ‘I’m a student’
  • You get hot! I still wear long sleeves when I dance as I don’t feel comfortable with people, perhaps, making snap judgements about my arms. While I now do many other activities in short sleeves I don’t feel comfortable doing it at salsa, perhaps because it would involve ‘coming out’ to so many people who have known me for some time.
  • As mentioned in another blog post, wearing nice, feminine clothes was almost traumatic at times.

As time has gone on I am so much more comfortable in the salsa scene and have made some incredible friends. Including some close friends who I can rely on for support, should I ever need it. It has also brought great opportunities. In the past year I’ve attended salsa congresses and danced at lovely venues like the Blackpool Tower Ballroom. I’ve also recently joined a performance team, that will mean I get to perform all over the country, and even abroad. I don’t think I could ever have imagined that my first class would lead to my current situation.

I do believe that salsa has a very important role in keeping me recovered. It gives me energy and enthusiasm for life and has increased my confidence in so many areas. Many of the skills I developed through salsa have been transferable to other occupations.

While on placement I reflected on how easy I found it to build therapeutic relationships quickly. Much of this I attribute to salsa. Every time I dance with someone, myself and my partner has to work collaboratively, adjusting to each other’s strengths and weaknesses, to make the dance work. I also have got more comfortable chatting to and working with such a variety of people, and even getting on with those whose behaviour/manner I find difficult.

So yes, for me dancing and really participating (in terms of the DBT mindfulness skill, ‘participate’) in salsa helps my sense of self and is now an integral part of my identity. I think part of the value of salsa for my recovery was that while it linked to areas I had previous experience of, ie. a dance class, it was not something that had any real connections to difficult stages in my life.

The Power of the Pie! (2nd Annual Blog Carnival for World OT Day (27th October 2012): Exploring Balance)

Time-Use Analysis and Occupational Balance

Click to see my Time-Use Pie Charts created when in the Therapeutic Community

One of the most helpful parts of Occupational Therapy, for me, was time-use analysis. Initially we used a diary sheet to note down what we had been doing in each thirty minute section of one twenty-four hour period, and used it to reflect on whether we felt we had ‘occupational balance’.

After attending a Learning Network for Personality Disorder and Occupation I, and occasionally other clients, would transpose the results into a pie chart. I’d attended a talk from another PD service that advocated the use of pie charts to document change and progress, with respect to occupational balance. My ‘inner geek’ (this quality I now understand and share with many #OTGeeks on social media sites) embraced the idea and enjoyed producing the chart and trying to devise an Excel spread sheet that automatically produced the graphs. This was easy for the pie charts that showed the split of occupational domains, but less straightforward for the charts I liked that displayed time-use, by domain, on a donut that illustrated where in the day I was engaging in the occupation types. I never did create a formula to automatically create those ones!

As a service-user it was quickly apparent that dividing occupations into 4 ‘simple’ domains was a challenge. Could an hour spent cycling to quieten the eating disordered thoughts really be called ‘leisure’? What about time spent planning for suicide, was it a productive occupation as it provided issues that kept professionals employed, self-care by finding a way to reduce mental suffering, or something I was engaging in to provide some renewal from real-life stresses, akin to a leisure activity? Often, making plans was sufficient to stop me trying to act on the impulses, so while suicide planning would be unlikely to be considered by many people as a positive occupation it did improve my mental well-being (on a relative level), it also kept my mind occupied and provided relief from reality. So, not only did I struggle to assign ‘negative occupations’ to the OT domains I was presented with, I also struggled to just assign them to one category. When I started my OT degree I was interested to read Karen Whalley Hammell’s Paper, ‘Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational “categories”’ (2009b) as I found myself in agreement with many of the key messages of the paper. Despite being white and middle-class, which Whalley Hammell argues is the background the traditional occupational domains is exclusively suited to (2009a), I found I was aware of the function of my occupations on a much broader level. Had I read the papers when I was in therapy I may have decided to try implementing some of the categories suggested by Whalley Hammell. However I would suspect that at the start of my therapy, when I was still very distressed and hopeless, I would have struggled with applying the suggestions of ways people experience occupation;

“as restorative;

as ways to contribute and achieve a sense of connectedness;

as ways of fulfilling duties, responsibilities, and interests;

and as ways to connect the past and present to a hopeful future”

(Whalley Hammell, 2009b, p112),

However, I did gain significant benefit with persevering with the common domains of productivity, leisure and self-care, with an additional category for rest, but perhaps not in the way people might expect.

When I presented the first pie chart to my OT, showing fairly equal divisions in time-use, I remember feeling almost judged by the statistics. I felt like it was proving, ‘look, there’s no issue, lots of leisure, lots of everything, perfectly balanced’, whereas my own experience was ‘everything I do is torture, I get no pleasure from anything’. And that was the point. Almost a quarter of my day was ‘leisure’, experienced as compulsive exercise I had to do to punish and protect myself, and the same figure of ‘rest’ involved no sleep, but instead anxiety and dissociation. Feeling so misunderstood by these categories prompted me to speak honestly about my engagement in occupations.

Several months later my pie chart looked very different. It was recorded over the 24hr period that had the same structure, and therefore similar productivity, as the first pie. While leisure only made up 13% of my day the difference was significant, it was leisure that I enjoyed and wanted to participate in. My self-care had increased, as I was taking more pride in my appearance and exploring the challenges in living independently as a day-patient and cooking for myself. In those early days cooking an evening meal took several hours and a lot of support and encouragement(both internal and external). I divided ‘rest’ into sleep and ‘activities designed to promote rest’ when I couldn’t sleep. This helped me feel that people could understand how little sleep I got and how hard I was trying to rest and let my body cope.

So, time-use was very important for me. For making me reflect and think about the function of my occupations and for the value of its limitations in providing me with the opportunity to have an emotional reaction to what I felt the theory implied. I still analyse my time-use today and find it a really useful reflective tool, as well as a marker of my progression as I realise how my daily occupations are now largely meaningful and incredibly positive.


Whalley Hammell, K (2009a) Sacred texts: A sceptical exploration of the assumptions underpinnings theories of occupation Canadian Journal of Occupational Therapy 76 (1) 6-13

Whalley Hammell, K (2009b) Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational “categories” Canadian Journal of Occupational Therapy 76 (2) 107-114