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.