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.


8 thoughts on “The Elephant in the Room

  1. Such an interesting blog post, thank you for sharing your reflections.

    You’ve hit upon several issues that I think are very important, and that will no doubt prompt reflections for the rest of your course and into your career. Sadly, there is a lot of stigma about mental health, and I’m sad to say that it exists in OT students, OTs, and other members of the health professions, as you have already discovered. So what is to be done abou it? Do you share your experiences, and “out” yourself? Do you stay silent and risk the aggregation of impacts on your own recovery of not standing up for yourself? No one has these answers for you, everyone must find their own road, but I would like to share some of my reflections about this.

    I’m sure that there will be sessions on your course when people come in and discuss their own recovery journeys. I think this will be very helpful for students without direct experience of mental health issues. I am concerned that we expect service users to contribute to teaching by re-living their experiences at their worst, without the accompanying support to help them achieve their best. I had an interesting discussion yesterday with @MarkOneInFour and @ShirleyAyres about this- how people can be “trapped” into their own narrative of illness through continuous invitations to re-share their experiences.

    Ultimately, I’m not sure that this addresses the issue that you identify about our low expectations for people in mental health recovery, which I believe to be of huge importance in mental health practice. Actually, the most successful interventions lead to people having “an ordinary life”, where they are busy with work, family, leisure activities and therefore unable to come in and talk to a cohort of students about their experiences.

    We run the risk, in practice, that because we see people return for further treatment when they are struggling, we don’t appreciate just how many people do recover completely. I remember some junior doctors being very surprised to hear that 1/3 of people who have an episode of psychosis go on to live a perfectly “normal” life, and never have a second episode. 1/3 of people go on to have occasional episodes, and might need to spend time working on their recovery again in future. 1/3 of people go on to have a chronic mental health issue, requiring many appointments and lots of support. The last group is the group we see in mental health practice most often. So, we infer that they are representative of the whole group of people experiencing psychosis- and they’re not.

    Thank you for sharing this post and giving me the opportunity to reflect on this, too.

    • Thanks for your comments/reflections, Claire. You’ve made some very interesting points that have given me more to think about! I’ll reply in more depth when I’ve done that.

  2. I can identify a lot with what you’ve written about. As a second year OT student studying a mental health unit this semester, I’ve struggled with the “us and them” aspect of it. I still identify myself as a mental health consumer, as well as an OT student obviously but it’s something that to some extent I’ve hidden, even though I have a lot I opinions when it comes to mental health.

    I too would love to share my story about being a patient in the mental health system and numerous psych wards, especially to challenge the “us and them” view as I’m just an ordinary OT student for the most part.

  3. As a fellow OT student with a background of physical health problems I also notice the use of “them and us” in some lectures surrounding physical health. In some cases this has prompted me to not volunteer an experience, which I often do, hidden as a question or an idea, because I’ve seen it as a challenge to have some original ideas or to think about how the service user may be feeling; to develop feelings of empathy. I have chosen to ignore this “them and us” label but, on reflection, wonder whether this is something I should have challenged more in the formal lecture environment.

    Then again I wonder sometimes whether the number of times I challenge opinions and experiences gets me a bad reputation!

    You talk about people’s fears of working in mental health, I’ll admit to those fears myself. For me it is a twofold fear. The first fear is perhaps the obvious one. A fear of the unknown. I’ve delivered sessions as an independent provider in medium secure settings and enjoyed every second of it. The difference here is that I’ve been surrounded by “people who know what they’re doing”. Whether this is true or not has been debatable on some occasions but the thought has quelled my inner demons.

    The second fear, which, if people are honest with themselves, with that 1 in 4 statistic ringing in their ears, is I’m sure one which more than I hold, is a lack of confidence in my own mental health. In a cohort of 40 doesn’t that mean 10 of “us” will become “them” at some point? At this point I usually give myself a bit of a shake and remind myself that, as with physical health conditions, mental health conditions lie on a continuum. That not all mental health service users will be the psychotic scary axe wielding murderer favoured of the horror script writer, but can include many relatively benign conditions.

    I feel that like anything else a bit of background knowledge and ensuring that the service user is the one who guides meaningful goal setting will get both me and the service user through with a step towards that perfect outcome. All helped along by an ounce of hubris in accepting that I don’t and can’t know everything but I can learn from the lived experiences of those around me.

    • Further thoughts…

      Following a lecture today about a health condition which has similar associated functional difficulties as I experience though is a different condition I again heard “them” and “normal” and thought about it with this blog post in mind.

      The lecturer was/is aware of those functional difficulties, I use equipment in the session which raises questions from those who don’t know me very well and knowing grins and direct musings form those who do especially when that same equipment is being discussed.

      This, in this context, and with this conversation in mind, actually felt like an attempt to preserve some confidentiality for me and left me controlling what, if any, information I felt able to share. This changes depending on subject matter and those around me so it was nice to have that control rather than being “outed” to use the same term Claire used above. Especially given we touched on both toileting and intimacy in today’s lecture!

  4. Hi. I’m a final year OT student who has been living with severe anxiety and depression triggered by traumatic events in my life. I am struggling to cope, with final year assessments, the stress and anxiety of graduation, with life in general. OT is my one and only passion. If I didn’t have this, I’d have nothing. It’s the only thing that keeps me getting up in the morning…
    Anyway, what I struggle with is how I’m urged by staff to keep my condition secret, to “protect my reputation” and “privacy”… What I don’t understand is why I should have to? While I’m far from accepting my diagnosis (long story), i almost feel that the stigma is perpetuated by my having to hide this from everyone…
    Perhaps I’m just over sensitive though… =(

  5. Pingback: Does being pd2ot make me less competent? | pd2ot

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