The Elephant in the Room

…or perhaps the ‘PDtoOT’ in the room?

I’ve just returned to university to start my second year. I began the week looking forward to a year that might suit my learning style better as it’s more focused on critical thinking and appraisal of information. I’ve also had my first experience of mental health specific lectures, which have given me a lot to reflect on and are the catalyst for this post.

Before I begin I must state that I don’t believe my university is intentionally causing stigma, nor is every lecturer/workshop leader ‘guilty’ of what I’m about to describe, but I do feel that my experience this week highlights problems. I also am conscious that the topic of stigma in mental health is such a giant topic, and many of the questions floating around my head of ‘WHY are we (society) so scared of talking frankly about this?’ are too big to be considered entirely in this post, so I shall stick to my university experience.

What happened? (Albeit, in my subjective experience)

My university, thankfully, is normally very good at challenging use of language that encourages stigma. Terms like ‘Mrs X suffers with bipolar’ and ‘Mr Y was a schizophrenic man I saw on placement’ will usually be noticed and corrected. That said, I’ve heard it be said and remain unchallenged in several sessions this week. I did challenge a friend on the matter and it was met with a response of ‘Oh’. I’m not sure if, when these issues were mentioned in our first year, people sufficiently understood the effect of this use of language. I suspect some felt they weren’t allowed to use the terms without understanding why it is reductionist and encourages a victim-projection into the client.

‘Them and us’ – I was very relieved, after the majority of a lecture had been spent referring to ‘them’ (as shorthand for people with severe and enduring mental health problems), when another student raised the point of the challenge of considering vocational rehabilitation for ‘them’ when it would contain so many people with different life experiences, never mind varying severe/enduring mental illnesses. The lecturer did validate this point, however I don’t feel it was sufficient after a whole morning where I felt this client group were being considered as a very separate group, that had to be handled with kid gloves and the therapist must have very low expectations of achievement. It felt like the client-centredness approach was entirely absent. For some people a successful OT intervention may result in a small period of voluntary activity each week, but for others this would be significant failure of the rehabilitation for that client. If the lecture had been discussing physical conditions I think the expectations of what an individual can achieve would be much higher. Of course, I am aware that for some mental health problems will prohibit a return to work, but unless we are brave enough to imagine people recovering enough to lead ‘lives worth living’ I fear the profession will not help people achieve the full extent of recovery that is possible for them.

I was glad that we were encouraged to share preconceptions about mental health problems and, for those that had been on a mental health placement, how they had changed after placement. As I discuss below I value an open and frank discussion, but this all felt one-sided. Yes, the point that fears that people with mental health problems were violent was discussed as unfair, but the point was not elaborated on to increase understanding about what the reality is. For those in the room that have this preconception all they now have to go on is the knowledge that one student doesn’t believe this is true, but no understanding as to the reasons violence may happen, or about clients that would only ever inflict violent acts on themselves, or even the many clients who will have significant mental health problems, none of which involve violent behaviour of any sort. This is a point I feel can only be delivered by service-users, to truly impart understanding of the reality of mental illness and how it influences behaviour.

My final issue relates to the ‘them and us’ issue raised above. The times I felt myself cringeing most in the lectures were when I felt that people with mental health problems were being patronised, either by staff or students. I’m not sure why anyone feels this is appropriate or helpful, but comments like ‘x struggled with ;, bless him’ are not ok and actively encourage stigma. If a soldier who had recently had a limb amputated was finding a self-care task challenging I seriously doubt they would be patted on the head and told, ‘ah, bless you’. I also sincerely hope if they were finding the same task difficult due to Post-Traumatic Stress Disorder they wouldn’t be treated in this way, but after this week I’m not entirely confident of this. Again, it feels like validation of the capability, resilience and skills of clients with mental health problems is not sufficiently present.

Am I more sensitive as an ex-service-user?

I actually feel that when mental health matters are discussed in an open and frank matter, without any trace of ‘tip-toeing’ around the subject, I am no more sensitive than any other person (and possibly far less than many people). I don’t mind if people ‘get it wrong’, I also don’t mind if people have strong opinions or judgements, so long as both they and I are able to have a discussion in which both parties can express their opinion and attempt to listen to, and understand, each other. I have delivered teaching to psychologists and counsellors in which I was asked directly if my self-harm had been manipulative or attention-seeking. This did not upset or offend me, it simply pleased me that people felt able to ask directly and listen to my response.

I struggle more when I feel lectures are delivered in a way that encourages stigma and misunderstanding, due to an overly sensitive and patronising delivery. I tend to go quiet rather than offer an alternative opinion, perhaps indicative of how unhelpful and silencing such an approach would be with clients.

I am mindful of the fact that I do find myself slipping into criticism of my university regarding a somewhat incongruent approach on their behalf. I have attended lectures that highlight the poor statistics for return to work for people with mental health problems after long period of sick-leave, and discussed intervention strategies that highlight the employer’s role in allowing an adjusted return to work. This is the first point in my life where I have been able to consider full-time work for 9 years, and the area of my life that still limits my performance is a very poor sleep pattern due to re-experiencing of traumatic events. Despite this I am about to embark on my second placement that involves a significant commute. While I function very well during the day I tend to have a few hours in the morning where I feel more vulnerable, almost like an emotional hangover from the night before. I have had several discussions with my university about these matters and feel slightly ‘not listened to’. It’s not my style to make a fuss and I’m also aware that I have internalised stigma and feel desperate to ‘just cope like everyone else’, but the reality is that it hurts to feel dismissed after taking steps to admit vulnerability.

Do I have a perspective that could help my fellow students?

One thing I am very clear on is that I have no experience of what it feels like to be an OT student that is nervous about working with people with mental health problems due to lack of experience, and for that reason this is the area I need to listen to those peers who are brave enough to admit the preconceptions and fears they have, to increase my own understanding of the issue.

I’m very conscious that my experience is just one of many people who have had mental health problems. Even if my peers all knew my views and experience this would simply give them insight into one person’s experience. That said, I feel the ‘power’ of my story is that these people know me primarily as a student, most people I know struggle to imagine me as the sectioned, destructive, despairing girl that spent several years in hospital. And that is my point, both those things are true. I am the person I am today AND I’ve had significant mental health problems that I almost didn’t survive, with many professionals feeling I’d always be detained in secure facilities.

What could be done to improve matters?

It’s very early days in the semester and I’m not sure if our teaching involves service-user involvement. If it doesn’t I think this is a significant oversight and will not challenge perspectives sufficiently. I know we have some lectures and workshops in the next few weeks delivered by people who I am confident will not teach in the manner that I feel silenced by, so perhaps I will contribute more of my perspective then.

Part of me would love to deliver a session, one that discusses the experience of a young woman with BPD who is intently suicidal and ends up sectioned and on 24hr-observations with all professionals at a loss of how to help, who eventually recovered due to treatment at a therapeutic community involving intensive psychotherapy, DBT and OT, and finally reveal that person is in fact standing in the room with them. I’m sure that at some point in my career I’ll be able to challenge views in this way. However, the time isn’t now, my priority is my own learning but I can’t help feeling my learning would be much less frustrating with a teaching programme that was less ‘fearful’ of upsetting the people with experience of mental health problems.

 

 

11/10/12 Update

I considered editing this post in light of recent developments at university, but I feel it’s better to leave it as is, with this update. I’m really pleased to say the second and third weeks of term have included some fantastic teaching on a variety of psychosocial issues for occupational therapy practice. That doesn’t make my frustrations with the first week any less valid but I am grateful that the issues I raised did not continue. I’ve also had a lot of support from my tutor and placement coordinator to resolve my worries about placement, and used my own therapy sessions to explore why I find communicating my needs so difficult.

Multi-Disciplinary Summer School ‘Healthy Ageing: Enjoyment vs. Endurance’

I was fortunate enough to gain a place on The College of Medicine’s (http://collegeofmedicine.org.uk/) Summer School for students of healthcare professions, hosted by the University of Birmingham Medical School in partnership with the Centre for Health Ageing Research at the shiny, new Queen Elizabeth Hospital (left). Approximately 70 delegates gave up 2 precious days of summer holidays or Vital Money-Earning Time to consider the issues surrounding healthy ageing for older adults. The professions of medicine, nursing, podiatry, osteopathy, physiotherapy, psychology, diagnostic radiography, nutrition and dietetics, pharmacy, dentistry, herbal medicine, chiropractic, radiotherapy and of course occupational therapy were all represented by students from around the UK. I think the ‘multi-disciplinary’ label was certainly justified! The event was very well organised and every team member was helpful and friendly throughout the very intense 2-day summer school. This post is simply a personal reflection on the summer-school.

Friday

The first day of summer school was very much the ‘food for thought’. We had seven 30-minute talks, each followed by 15-minutes question and answer time. The topics covered were vast. The most scientific talks included; ‘Ageing, Infection and Immunity’, ‘Nutrition in Healthy Ageing’, ‘Cognitive Health and Ageing’ and ‘Physical Activity to Support Healthy Ageing’, all of which were presented by leading professionals in the areas who were able to share their latest research findings to support their presentation. The more practical and ‘in-practice’ areas were represented by presentations about the ‘Move-it or Lose-it’ exercise classes for older adults (http://www.moveitorloseit.co.uk/) as well as Well UK’s Director presenting the Upstream Project (http://www.upstream-uk.com/) as an example of a ‘Community Based Model for Healthy Ageing’. The latter was the most akin the models I’m familiar with as an OT student and I found it fascinating that the programme was so focused on meaningful (often leisure) occupations as a central point of a social group, despite not having OT involvement. I found it refreshing to listen to presentations concerned with physiological processes of ageing. I found it enhanced my understanding of the process and also allowed me to consider the likely relevance to occupational therapy. The common theme was that moderate activity is vital to limit ‘unhealthy ageing’ and so I found myself wondering how occupational therapists can encourage this, particularly for clients who may not select physical activity as a goal they wish to achieve. Can a balance be achieved between health promotion while remaining person-centred in approach? Another common theme was that ‘connectedness’ and relationships were important determinants of well-being, by limiting social isolation and mental ill-health. This wasn’t ‘news’ to me as both an OT student and someone who has recovered from serious mental health problems, but the key learning was developing awareness that for some professional-students this was a novel idea and reminded me just how ‘medical-model’ some of the other professions are.

Saturday

Day 2 mostly focused on small group workshops facilitated by service-users with an interest in a specific aspect of ‘older-adult-life’. These were; ‘spirituality, religion and ageing’, ‘sexuality in older age: an LGBT perspective’, ‘ethnicity in older age’, ‘mental health in older age’, ‘retirement and well-being’, ‘exercise in older age’. I was grateful to get into a more interactive style of learning after a long, albeit interesting, day yesterday. The facilitators of the sessions were all excellent. My only criticism was that some of the groups might have benefited from a co-facilitator that had a contrasting experience. For example someone who had been a reluctant exerciser, someone who struggled with the transition to retirement and someone who experienced mental health problems for the first-time as an older adult, not a working age adult. The students brought a range of personal experiences and it was all done in a reflective and open-minded manner. I was struck by how some of the topics being discussed were quite obviously ‘new territory’ for many of the students, particularly the workshop on LGBT issues. While I felt glad that at least the participants today may now be aware of their heteronormative use of language with clients, I felt quite sad that this was the first time they had ever considered it. The closing plenary was a summation of everyone’s thoughts and it was nice to hear the different ‘key points’ that people would take away. I was aware of how beneficial the summer school could be to other students, those perhaps who also need to challenge some of their assumptions.

What will I, personally, take away from the summer school learning?

Some of the professionals I work with are going to be very focused on diagnosis and symptoms. While this is not an approach I wish to take, the depth of their understanding of physiological processes is vital and will provide evidence for the interventions being provided by those with a more bio-psycho-social consideration of the person.

The physiological explanations of the ageing process and issues that determine the relative success of ‘healthy ageing’ were very helpful to understand. However, the practical ‘consequences’ mean that the approach for an OT focuses on occupations that support an active lifestyle and reducing social isolation, which would be similar for a working-age adult, adolescent or child. Furthermore, discussions highlighted how clients want to be listened to, not judged and have a clinician that doesn’t make assumptions as well as showing great kindness. Again, this is something I feel is important, irrespective of age.

Personal ‘Experiences’

As a representative of the OT profession I noticed certain issues repeating throughout the weekend. I anticipated having to answer the question of ‘so what does an OT do?’ but seemingly underestimated the frequency with which I would be trying to define and explain the profession. Fortunately it’s a topic I like discussing and was able to draw on the summer school content to put things into context.

One aspect that left me feeling a little sad was that in several discussions I noticed a marked change in peoples’ attitudes towards me when they discovered I had initially studied another degree at a prestigious institution, compared to when they thought I was ‘just’ an OT student. I am not an OT student because I can’t do any better, but simply because I think it is a profession that can make a real difference to people’s lives, in a way that fits with my own values and even ‘spirituality’.

Occupational Therapy’s Invisibility

The link to occupation was made on numerous occasions throughout the summer school, but never was it suggested that OTs could be crucial clinicians for encouraging healthy ageing. This, combined with the numerous ‘what is occupational therapy?’ questions, reminded me of some of the challenges the profession faces. I can’t help but feel that the answer lies in research and evidence production. There is clearly fantastic medical and physiological research available on this topic but unless this can be linked to the role of occupational therapy in enabling people to make the occupational changes in their lives that support good mental and physical health I feel we will always be invisible and misunderstood.

Areas for Continued Reflection

While a fan of evidence-based practice, I felt very aware that I spent a lot of time thinking that occupational therapy ‘just IS the right approach’. I suspect I need to challenge this and continue to explore the current evidence to evaluate this belief or moderate it accordingly. (For the record, after the numerous discussions with other-discipline students I do feel more content than ever embarking on a career as an OT, and equally I’m conscious of some of the frustrations I will, probably repeatedly, face.)

I’m just working on a summary of the #occhat on Mindfulness and Occupation that I hosted on Twitter last week. For now here is the grab chat of tweets, helpfully generated by @clissa89 .

OTalk

According to the GrabChat, 28 people wrote 520 unique tweets for this week’s #occhat. No wonder it was so fast paced and stimulating! Thanks everyone for contributing to a very interesting chat! :)

Here’s the GrabChat URL: http://grabchat.com/cache/iayx8i – not sure what happened to the table at 19:40. I’ve tried using previous GC version and editing the code several times but same effect. If anyone knows how to fix it, please go ahead! (CS)

Involved …

@clissa89@pd2ot@BillWongOT@HealingFromBPD@kirstyes@Trio33@adiemusfree@BPDFFS@gilliancrossley@allisulli@Helen_otuk@Claire_OT@michelliwelli@Nnikki_Duffy@TeddyMercury@Th00ha@CharOReilly@stairliftscheme@HazelClerkin@complexcase@BPDtainted@MHchat@IthinkIamCarrie@vikproject@OnyxBPD@DebbiiHarrison@living_as_if@bretawarshawsky

Top resources …

https://pd2ot.wordpress.com/2012/08/20/mindfulness-and-occupation/
http://www.ted.com/talks/mihaly_csikszentmihalyi_on_flow.html
http://www.my-borderline-personality-disorder.com/2012/08/one-moment-meditation-how-to-meditate-in-a-moment-dbt-mindfulness-dialectical-behavior-therapy.html
http://twitter.com/kirstyes/status/240527656104386560/photo/1
http://www.pomodorotechnique.com/
http://www.tandfonline.com/doi/abs/10.1080/14427591.2008.9686606
http://individual.utoronto.ca/DTReid/paper/(16)%20Exploring%20the%20relationship%20between%20occupational%20presence%20occupational%20engagment.pdf

Related tags …

#bpd#mindfulness#dbt#bpdchat#anxious#occupationaltherapy#yoga#smallstone#cot2012#mhchat

See Twitter for more tweets, people, videos and photos for #occhat

@Helen_otuk RT @pd2ot : 10 Minutes until we start discussing Mindfulness and Occupation…

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