Transcript Dr. Jan Wallcraft    I began my thesis seeking an alternative to biomedical discourse to look at how people go into a.

Dr. Jan Wallcraft
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I began my thesis seeking an alternative to biomedical
discourse to look at how people go into a crisis or
breakdown in the first place – often when young – and
because they are unable to cope they are forced to seek
help – or others seek help for them.
This was my own experience at age 22 when I was
admitted to psychiatric hospital after a breakdown. I spent
6 months in hospital, and it was enough to ensure I never
wanted to go back, and somehow I managed to avoid
hospitalisation ever since
Later, I met many people, through the service user
/survivor movement, who had got into psychiatry in a
similar way, but who had been caught up in it for far
longer. I had struggled to cope in my life but I realised I
was probably fortunate in managing not to have a longterm involvement in the mental health system
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In my thesis I wanted to set aside the assumption that
psychiatric hospitals and diagnoses were inevitable, and
pose the question – what was going on for people when
they found themselves in crisis, how did they experience
psychiatric intervention, and what happened during and
after the crisis? I looked for an analytic framework which
was not medical, which did not assume people had been
‘ill’ or ‘diseased’. I used Gerald Caplan’s crisis theory as a
model. It is a theory of systems, and looks at how people
respond to their internal and external environment, how
mostly we cope with life by trial and error, learning and
developing, but sometimes things can get beyond our
control, and our normal coping mechanisms become
overwhelmed. We seek help, with ever greater urgency,
until at some point we can no longer cope at all, and that
is when institutions step in and take over.
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Caplan created his crisis model to show how there are turning
points in this process, where people move sharply towards
greater disintegration or towards positive outcomes,
If communities were more aware of the process of psychological
crisis, suitable help could be provided at the right times, not at
all necessarily by doctors, perhaps better in fact not, ordinary,
non-medical professionals who encountered a person needing
help and recognised the signs of life-crisis.
If societies had the confidence to intervene, in many cases, the
person in crisis might never need to become a mental patient.
Caplan was a psychiatrist, but he wanted communities to learn
the mental health skills they needed to maintain people in the
community rather than handing them over to psychiatry, which
he believed often caused deterioration and institutionalisation,
and revolving door patients.
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CAPLAN CRISIS MODEL
Phase 1: Initial rise in tension from the impact of the
stimulus calls forth habitual problem-solving responses.
Phase 2. Lack of success and continuation of the stimulus
leads to a further rise in tension, with feelings of upset,
helplessness and ineffectuality.
Phase 3. Tension rises past a third threshold, stimulating
the individual to mobilize internal and external resources,
reserves of strength and emergency problem-solving
mechanisms.
Phase 4. If the problem cannot be solved satisfactorily nor
avoided, the tension mounts beyond a further threshold or
increases over time to a breaking point. Major
disorganization of the individual then occurs with drastic
results.
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I asked 26 people about their first experience
of a crisis which had led to hospitalisation.
I sought people whose first experience was in
the last 5-10 years.
A number of them described breakdowns
when they were young.
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Michael, a young Irish man with a visual disability,
was devastated by his mother’s death during his ‘A’
level year, and became steadily more depressed
during his first year at University. He had also
become aware that he was gay and was afraid to tell
his parents about this. He stayed at a friend’s house
for Easter that year and ended up taking an overdose
and being admitted to hospital.
I’d been getting more and more distressed and trying
to hold it in…in the middle of the night I was pacing
up and down and, feeling very very wound up, feeling
that I couldn't actually handle it any more..I found
several tablets, um and I sort of took the bottle (26:7)
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I remember…waiting in casualty…it wasn’t
long, they were er pumping my stomach (p)
and I I wanted [my friend] to stay with me all
the time but he wasn’t allowed (p) while that
was going on and I remember, (p) all the
horrible …feeling you get when um, when
they do that… you’re awake, you’ve got to
keep it [water] down while they get it all
out…its just horrible, I couldn’t believe [it]
could be that painful
◦ they put me in a bed
and I was crying and
stuff…I remember this
nurse saying ‘If you
can’t make it with your
life, um, don’t bother
us with it’ and
‘everybody’s got to
carry on sometime,
some way’…I said ‘I
cant cope’ but she said
‘oh we’ve all got to
cope’, and then just
went away…that was in
the early morning and I
don’t think I saw a
nurse all day…When I
did finally see one and
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asked what was going
to happen they said,
‘oh well, the chief
psychiatrist will be here
to see you shortly’
Michael spoke to one of
his sisters on the phone
during this stay:
◦ When I’d finished that
[phone call] I remember
crying buckets and
buckets of tears and
nobody, absolutely
nobody coming to see
how I was
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Eventually Michael saw a psychiatrist
◦ he said to me, ‘ do you believe that
people are talking about you’ and I
said ‘yeah, I do’ …I thought that
people were laughing at me in the
street, which, it turns out they
were…he said, ‘so, you’re hearing
voices then’ and I said, ‘no, I didn’t
say that’…he said ‘have you always
been sensitive?’…
◦ I said, ‘I don’t know, I spose so’ …he said, ’and
what about, your love life, have you got a
girlfriend?’…I said, ‘no, I I m gay, I think’…he said
‘oh well, are you the active or the passive partner?’
…I said. ‘What do you mean exactly?’, because I was
actually a virgin then, about 18
◦ He said ‘well do behave like a man or a woman in
bed’ [adopts abrupt tone] …well, I lost it then I said
‘I don’t’ know what the hell you’re talking about,
and how’s this helping me?’ I said, ‘me mother’s
died, I’m lonely, I can’t cope and you’re asking me
how I behave in bed’ I said , ‘I’ve never even been
to bed with anybody.’
◦ He said, ‘well (p) I m
going to give you
these tablets and, I
want you to take
them and I m going
to refer you to a
clinical
psychologist, and
I’m going to send a
CPN [community
psychiatric nurse]
to see you’.
◦ I got these tablets
and I remember
these, was Melleril,
Ludiomil and
Temazepam.
◦ Anyway I got them
on the Friday and
on the Saturday I
took them all with a
nice bottle of wine
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Michael’s treatment by professionals was experienced by him
as insensitive and dismissive, particularly in the response to
his sexuality issues. He tried to spell out what he saw as his
problem, which was related to his loss of his mother and his
loneliness at college.
The doctor did offer a clinical psychologist and a CPN, but
perhaps this did not substitute for Michael’s immediate need
for acceptance and understanding from the doctor himself.
The doctor’s questions about Michael’s sexual behaviour
seemed completely unnecessary and inappropriate to him. The
overdose may have been partly an angry response to this
treatment. There is a clue to this in his next statement:
◦ I didn’t take all the sleeping tablets because I realised, in the middle of
it that I was, well I thought I was going to die…I was so confused
because I didn’t know whether I wanted to die or not.
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If Michael was taking the overdose partly out of anger, this
might account for his confusion about whether he really
wanted to die. He may have needed to show the doctor how
hurtful and unhelpful his behaviour had been.
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I got away from my parents who I never (p)
felt understood me…I was quite naive
because all the problems followed me, and …
they seem to have got worse (Sarah, 19:16)
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It was just horrendous, in terms of the treatment…I went
with a friend to A & E, and, nobody, would really talk to
me, none of the staff would really talk to me…or if they
did they would ask me rather….philosophical questions
[such as] ‘do you want to die?’…I said ‘well, you know, its
not as simple as that [laugh] I mean, how long have you
got, I could discuss it with you’
I actually said that to one young bloke and he just looked
terrified and literally shot off and I didn’t see him again…
[the nurses] would look, um, not impressed with what I’d
done …their expressions on their face showed it - they
didn’t say anything…they would give me the old potions, a
mix to make me throw up…they’d look at me as if …this is
like a punishment
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Sarah saw the psychiatrist the day after her admission, and
was asked why she had taken an overdose, and when she
explained, he simply told her not to do it again and
referred her back to her GP. She also saw a social worker
who said ‘you look like a strong lass…..things should work
itself out’, which she says she found ‘so patronising and
unhelpful’ (19:87). Sarah explains what she had hoped for:
I suppose I wanted someone to talk to, to listen to me, and
not to be treated in these….in some ways barbaric
way…heartless and callous way…I suppose I did expect a
lot more from them, but it was just like a conveyor belt,
we just want to…pump all the rubbish out of you …but
we’ll still make assumptions about you at the end of the
day…and when I left…I felt really empty…I’d lost a lot of
emotion and feelings, I just felt they’d taken all that away
as well, its hard to explain, its, everything’s gone
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Sarah’s experience, like Michael’s, was of basic
medical care following her attempted suicide,
coupled with critical and dismissive attitudes from
staff which she found distressing. She was asked
questions, but in a manner that suggested that the
questioner was not willing to take the time to listen
and understand without judgement.
I interpret her description of having had her emotions
taken away along with the overdose as a statement
that she had needed the opportunity to feel and
express her pain, and had been denied this because
of the cold and impersonal treatment she had
received. This had left her feeling that the
opportunity of the crisis had been wasted.
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Eight of the interviewees spoke about early
abuse or trauma that they linked to their
crisis:
◦ It started off I think very, very early in my childhood
I was, I suppose, physically abused by my parents
then, sexually abused by a friend of the family
(Mark - young man)
◦ my father had killed himself, that’s really the root
of my problem…I’d been planning this for a long
time, like years, I’d dabbled in the idea of trying to
kill myself (Lucy - young woman)
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I was abused from the start, I was physically
abused by my father, not sexually as far as I
know, but he, um. He beat us up, yeah, he
was given to uncontrollable rages and he
would just smack us around and he had, we
were powerless and he had all the authority,
and he had the authority to smash us up any
time he wanted, and for years any time
anybody made a movement (Alice - upper
class woman)
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There was the childhood…I was abused, off me
dad, and he damaged one of me testicles…and I
went away to boarding schools…locked away in
boarding schools…they was very cruel to me at
one of the schools…they used to tie me to beds
and that….[later] the school got closed
down…boarding school for backward people or
something (Donald – man with learning
disabilities)
I couldn’t accept it [bereavement] because I never
had any brothers and sisters…my mother …died
at 30 crossing the road (Martin - middle-class
man who broke down when his wife died)
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some of my mental health stuff goes back to my
childhood, which my dad was an alcoholic, I
actually watched my dad beat my mum up
…when you try and talk about it hurts …it’s easy
to think you’ve forgotten about it, but it’s still
like there in the back of your mind… I’ve tried
suicide ten times since the age of 13 and I've
actually done self-harm (Philip, young gay man)
I’d just come out of an orphanage, to be abused
by me dad…when you told people about it,
nobody believed you, in the 60s…I told the
priests, cos that’s all I know of then, and I got a
hiding…from the priest, he slapped me (Irish
woman)
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I didn’t learn all the social skills and how to be with
people and how to interact…because I was locked up
as a youngster, I’m suffering from sort of low self
esteem now, and my parents are very good at making
me feel inadequate, because of the way they’ve been
brought up…I realise that, so I know why they do
what they do, but I can’t forgive them (Bina, young
Asian woman)
Well, when I was 16 I started feeling hellish anxiety.
My father’d been going on for a few years he was
going to chuck me out when I was 16. … so when I
turned 16 I got all this anxiety stuff… my mother
packed her bags and left…father started chucking me
out of the house (Roger, white man)
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Philip describes a reluctance to ask his mother
for help
my mum’s already had a breakdown previously,
before I had mine, so…maybe I didn’t want to
upset her any more…I didn’t want to depress her
and make her worse, so I just bottled it all up for
a whole year
Lucy mentioned an ultimately unsuccessful
search for help from friends:
I suppose it was a build up of complete anger
that no one was helping me and I was going to
different friends trying to get help and they had
no understanding.
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The problems experienced by people seeking
help from friends were similar to the problems in
seeking help from family
However willing to help the friends were, the
person going into crisis found problems of
communicating the need for help, or perhaps
their needs were too great.
Perhaps during the crisis, the person needed to
talk in a way with which they and their friends
were unfamiliar.
For many, the next step was to seek professional
help from their family doctor or other
community services.
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People had varying relationships with their GPs, but
the consistent factor is that GPs seemed to have little
to offer beyond medication and referral to a
psychiatrist.
This does not seem to have coincided with what the
interviewees felt they wanted and needed at this
stage, though the evidence suggests they may not
have been clear about what they were asking for.
Medication was not found helpful and was considered
to have contributed to the worsening crisis in some
cases.
Some of the interviewees were clear that they wanted
to be listened to or given therapy or social support of
some kind
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Sarah became a day patient at the psychiatric
hospital. This treatment, she considers in retrospect,
made things worse
unfortunately, it didn’t help, all I got from the
psychiatrist was, lots of drugs…Antidepressants,
Amitryptiline and sleeping tablets, tranquillisers, just
one big cocktail which seemed to turn me into a bit
of a zombie…
I just couldn’t think or feel or anything, everything
just seemed to, be detached from, everything…[my
partner] seeing me in vulnerable powerless state he
could abuse me in any way he wanted to…because of
the drugs, and because of the way the psychiatric
system deals….I felt even more disempowered, I felt I
couldn’t think for myself
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Philip
◦ I went to the Accident and Emergency and asked to
see the Emergency Psychiatrist…he kept saying ‘are
you hearing voices’…it was really getting to me,
‘I’m not hearing voices, I’m depressed, can’t you
understand that?’ what do you have to do, to make
these people see that…there’s mental health that’s
not just hearing voices and schizophrenia, and
there’s so many other different forms of mental
health
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Philip’s doctor was insistent that Philip’s problems were
related to his homosexuality and tried to convince him to
‘go straight’.
I told the doctor I’d been raped at the age of 13…and now
he’s saying, I’m gay because I got raped…..so I was trying
to like, say ‘look, my sexuality’s got nothing to do with
what happened there, in that moment of time
This made matters worse, confirming his experience that
people would not really listen to him and respect his
beliefs and his sexuality:
You can’t seem to get the help you want without
somebody else criticising you…you get more and more
frustrated and more and more depressed, cos you’re
bottling it all up…its like being in a corner, like as if
people were literally strangling you, not a good condition
for me to get into
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I….was really desperate and I went to see the student
counsellor there…
I said to her, [aggressive tone] yknow, ‘you can't tell
me not to kill myself can you cos that's not your job
you're not allowed to say things like that are you?’
…I wanted someone to care, but not that it was
really her, but I was so desperate that I thought it
could be her….
I said to her, well I'm gonna kill myself, and that was
the end of the session…straight after that I bought
some razor blades
the next morning…. I decided that I was gonna kill
myself, and I spent approximately 2 hours cutting my
wrists
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I considered that Lucy was testing the therapist by her verbal
challenge, and put this to her at my second meeting with her.
She agreed:
I said to her ‘you are not going to tell me not to, if I say I am
going to kill myself. You are a counsellor, and you can’t tell
people not to do or to do anything’, and what I was implying was
that she didn’t care…she was crap, I mean universities are
notorious for people killing themselves and I was practically
asking her to intervene without getting down on my hands and
knees and I was also throwing it in her face and I was being
manipulative, but if she had cared a bit more about another
human’s life…I was being nasty because I was on a death path,
but even so it must have been obvious that I wasn’t a really
horrible person inside. When people are angry it’s usually
because they are really really sad, everyone knows that, so why
don’t people act upon it and find out why people are feeling sad?
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The point she made about her challenging
behaviour to the therapist was a general one that
might apply to a number of the interviewees. It
helps to explain why people often sought help
but were unable to communicate the problem in
a way that others could easily respond to, and
why people are not always able to use help that is
offered. Lucy wanted help from someone who
was more mature, more knowledgeable and
stronger than her. She wanted someone who
could see the real person inside, which she was
unable to show.
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I went up to the top of the roof, of the hospital… and
this porter came and got me down and if I’d have
jumped then I would have been dead…They took me
back and they didn’t do anything
….so the next day, I dressed up, in my best
clothes…and I ran out of the hospital, ran up a fire
escape and jumped, from the 5th floor…
I was taken to intensive care, and I woke up, and my
whole body was in a plaster…I just couldn’t believe it
, I was so angry…that time I think was the most time
that I’ve ever meant it, cos I was so, off my head
Lucy’s determination to jump from the hospital roof
seems like an increasingly desperate attempt to be
taken seriously even if this was only to happen after
her death
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When Lucy had been brought back down from the
roof the first time a nurse spoke to her in a sarcastic
manner:
‘You don’t wanna be doing anything like that, Lucy,
you don’t wanna get sectioned, it wouldn’t be good
for your career’
I asked her at the second interview if this comment
had had an effect on her and she said:
yes she was **** *horrible. and it was like it was
blackmail. They should have sectioned me. I’ve got a
right to be sectioned. I am desperately saying to them
I’m ***** wanting to kill myself. I am 21. Had I been
31 it might have been different but at the age of 21
everybody's got the right to get a bit of support
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She believes that she should have been sectioned
at that time for her own safety, and that she
needed medication:
‘as a mental and emotional pain killer …I needed
professional care. my friends and my family
weren’t enough. Or they weren’t what I needed at
that time…I was immature. I wanted to be a baby
again. I wanted to be reborn. I think that was part
of my thing about suicide, it was trying to rebirth
myself. I felt a sense of relief after I cut my wrist.
because I thought then they were going to do
something’
For Lucy during her crisis period, death seems to
have been preferable to being ignored.
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Lucy, miraculously survived her jump from roof and was taken to
intensive care:
I was ….given loads of morphine and that was great, yknow,
when you’re feeling shit, I mean morphine does make you feel
good [laugh]…
then they took me down to the orthopaedic ward after about
eleven days, and um, I was in a room on my own…I had 24 hr
nurse [laugh] obviously they were getting worried by that
time…they hadn’t taken me seriously when I’d sort of said to
them before that I felt really shit and I felt like killing myself and
stuff…
I got a different psychiatrist, and they gave me some
medication…I gradually got better and I think that was to do with
being in a normal environment, partly…being in a general ward,
with, yknow, normal people…there was more activity on that
ward…there was a routine, and the nurses..spoke to you more…
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Many of the interviewees had turned to
professionals hoping to find knowledgeable and
skilled help, based on good listening and
genuine caring.
It may be that people need one-way help during
a crisis which is free of the backlog of tensions
that is common with family and friends.
The help people sought was rarely available.
The failure of professionals to understand and
provide empathic and appropriate help, and the
ill effects of medication appear to have provided
the final turning point into crisis for a large
number of the interviewees
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I found that most people were seeking appropriate
treatment for problems which they considered to be
related mainly to psychosocial causes.
Hospital services in crisis were valued by a number of
people, but it seemed that their view of what they
needed was a place of refuge and asylum, with
talking treatments offered, rather than to be
sectioned and forced to take medication.
People valued those aspects of hospital that most
closely matched their perceived wants and needs.
In most cases these needs were not fully met, with
the response from psychiatrists and other hospital
staff being primarily based on the discourse of
psychopathology, which does not involve listening to
and believing or respecting patients’ views.
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Some people experienced turning points
towards long term patient-hood because of
poor treatment within the medical model,
while a small number experienced turning
points towards recovery because of finding
respectful listening coupled with practical
support.
Some people did accept the discourse of
psychopathology and believed they needed to
continue taking medication because they had
had a further crisis after discontinuing it.
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This research offers confirmation and validation
of psychosocial theories, including crisis theory
and trauma theory, along with some evidence of
psycho-spiritual aspects to crisis.
It adds substance to these theories by showing
the of how crisis and crisis intervention is
experienced, and why some interventions work
better than others.
It also gives substance to critiques of the
discourse of psychopathology from the
psychosocial and from the self-advocacy
perspectives, by showing exactly how and at
what point people found themselves let down by
professional treatment within the discourse.
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they keep saying ‘take this pill try this pill try this pill’
….I keep saying ‘well its not about pills, it’s other
things’ (Joseph)
I have tried very hard to actually do something, that’s
why I get aggressive with people in authority, or
whatever, because they’ve never given me a chance
(Donald)
I think I needed a lot of confidence-raising, which I
was not getting (Alice)
[we need] user sensitive people working rather than
what we have in the health service at the moment,
they don’t really have any idea (Bina)
I wanted to get back to work….I don’t want to go into
hospital any more….I prefer to become a….respected
citizen again and get on with my life (Mary)
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People found help for
their recovery outside
health and social
services in terms of
◦ increasing selfknowledge
◦ learning to manage their
problems
◦ making their own choices
about medication
◦ mutual support
◦ relationships with their
friends and family
◦ making their own choices
about medication
◦ finding enjoyable
activities and work
◦ exploring spirituality and
culture
◦ Recovery was more
difficult if these factors
were absent, in particular
where people were
isolated.
◦ Lost relationships and
current isolation led to
feelings of anger, hate
and violence in some
people
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Strategies for Living user-led research found that people create
their own coping strategies for on-going survival, crisis or lifesaving, symptom management and healing.
What people find most helpful is acceptance, sharing experience
and identity, emotional support, finding a reason for living,
peace of mind and relaxation, taking control and having choices,
security and safety, and pleasure or enjoyment in life.
Strategies for Living researchers recommended that mental
health professionals, service providers and policy makers
recognise the expertise that service users have to contribute to
mental health, and work with them to look at how services can
support people’s own strategies through Expert Patient
programmes, self-management training and support, and more
investment in healthy living, health education, health promotion
and positive images of people living with mental health
problems.
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Complementary and alternative therapies can be
shown to work for people with mental health
problems
◦ Active therapies such as exercise, yoga and relaxation
can reduce anxiety and depression and help people
reduce medication
◦ Massage helps people feel more positive about
themselves, reduces stress and uplifts mood
◦ Nutritional medicine/therapy can be effective in
schizophrenia and depression, though more research is
needed
◦ Herbal medicine – some herbs can be effective for
depression, anxiety and insomnia
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I have argued strongly that there is a need for
more research to be done on the types of
treatment that service users want, including
talking treatments, complementary therapies
and self-management
The reasons this does not happen more are
financial and political – governments do not
want to offend the pharma industry, and rely
on pharma to fund most psychiatric research
◦ Acupuncture – can be effective in schizophrenia but
more research is needed. Some evidence for its
value in depression.
◦ Complementary therapies such as aromatherapy
and reflexology work well alongside talking
treatments, helping to open up feelings for
exploration in therapy, or helping to calm a person
down after an emotional session.