Mental health is already political
Be in the world, try and make good happen, don’t be a dick: an address to fledgling clinical psychologists
The following is an address given to newly qualified clinical psychologists at Salomons Centre for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells on Friday 15th September 2017
I spend a fair amount of time thinking about the interaction between politics and mental health. Mental health doesn’t exist in a vacuum because people don’t exist in a vacuum.
Today, I’m going to talk to you about your role as clinical psychologists in this amazing, disturbing, dazzling and discomforting place we call the real world. I’m speaking to you as a person who writes and speaks and does a lot in and around mental health and also thinks a lot about what it means to do mental health things. I’m going to be talking to you about a number of different Ps aside from psychology: politics; people; professionalism; presence; the public sphere; privilege; prospects.
Politics
In many ways, you are passing out into this new phase of professional life at one of the most terrifying moments in world history for at least a generation. It is a long time since it was more unclear what the future might hold. In western democracies misogyny, racism, homo and transphobia and reductive nationalism are on the offensive, quite literally. New nationalist aggression and the geopolitics or climate change and resource wars are edging the world closer to conflicts that we hoped might have ended. We as a country have decided to take a massive leap into the political and economic unknown with brexit and it is becoming increasingly clear that second industrial revolution wrought by the ever increasing speed of computational and technological advances will not leave any area of modern life untouched.
You have been trained for a world which is disappearing. It is not guaranteed that we will have an NHS in two decades time. It is not clear that work will look the way it looks to most people at present. New forms of social organisation and community may replace what we see as most normal now. Human beings will remain amazing, perplexing, damaged and transcendent as they always have been, but it is not guaranteed that the world to come will look much like the one we see now.
Far from the machines making your jobs obsolete; it’s likely that the role you occupy as understanders and helpers of human potential and happiness will be more vital than ever, even if the jobs you occupy begin to change out of all recognition.
I say this to make the point that even if you keep your heads down and don’t cause a fuss; the world is changing around you. This gives you a responsibility as professionals to help the best possible future to happen in the face of what might be a worse one.
The seeds of the future are always present right now, so what is this world you are taking your skills out into? What is to be done?
Nearly a decade of concerted work, much of it funded by the coalition government and beyond through national campaigns like Time to Change, has driven mental health up the agenda as a social concern. The message that people with mental health difficulties should not be discriminated against has stuck. This is what creates a particular political opportunity for those wishing to be seen to be doing a very public good. Although people with mental health difficulties actually tend to be poorer, more unhealthy and to rely upon public services more, the general public, by and large, has accepted mental health difficulty does not respect demographic boundaries and that doing something to help people with mental health difficulties is ‘a good thing’.
Once the go-to group for governments wishing to earn humanity points was people with cancer; but it’s difficult to make policy pledges about cancer without it costing the Treasury a lot of money. Mental health, on the other hand, is often embarrassingly grateful for even the smallest of crumbs from the top table.
This gap between public goodwill and detailed knowledge makes mental health the perfect area for a politician who wishes to be seen to be doing unequivocal good. People with mental health difficulties are the new innocent and untainted victims. Or at least the right sort of people with mental health difficulties are. Where once we may have judged the goodness of our society by our behaviour toward recent migrants or to those with whom we did not share political or religious ideas, now in this age of polarisation it has been harder to find victims to help that do not tread on the political sensibilities of one regressive group or another. Once we might have helped refugees, now we lock them up. Where once we might have looked to help homeless people, now we destroy their tents. So adept have we become at demonising minorities, or in allowing our right wing press to do so, that it has become more and more difficult to find anyone that the majority of the population will agree should be given a hand.
The challenges in the lives of people who experience mental health difficulties are not usually accompanied by mass demonstrations, burning police cars and emergency Whitehall meetings. No barricades are built; no baton charges captured by shaky-handed amateur media makers. People with mental health difficulties don’t talk back, or get bolshy or seem ungrateful.
The idealised vision of people with mental health difficulties; quiet tragic figures wilting for want of a course of CBT or a mental health first aid course in their school has created a kind of victorian urchin analogue; a group of people you can offer a tiny sliver of comfort to and then bask in the glow of their ‘god bless you sir’’s; convinced in your heart that you are both caring and kind.
Conservative social ideas have often been uncomfortable about disruptive or ungrateful beneficiaries. While those who are born with disabilities, or who are unwell from childhood often win the hearts of conservative policy makers; those who acquire their challenges later in life are often considered to be more suspect; somehow less pure in their neediness. Adults with severe mental health difficulties are often people who have had and currently have complicated lives where they are not so obviously victims. This often means that they are treated with a lack of care, subject to control rather than nurturance and made to carry with them a sense that somehow society does not know how to fit them in. People with intense needs who also have autonomy and agency often attract sanction and criticism — witness the current situation with social security benefits in the UK — rather than care and support.
It still isn’t clear how a Labour approach might differ significantly.
As such, the interaction between who is considered important and what help is available is one of the prime questions for clinical psychology. Potentially, you will spend your life seeing people at the hard end of public policy. How you understand that will influence where you position yourself. As I said to a room full of clinical psychologists in 2015:
“In mental health I’ve met many people who battle on a daily basis with the gap between their politics and the practice. Often in mental health our head tells us one thing but our gut tells us another. I’ve always been surprised by the amount of people who have told me that they’ve never been able to reconcile their political beliefs with what they do or have experienced in mental health. In mental health I often see a lot of assertions about how the world ‘should’ work which are met with equally emphatic responses about how the world ‘does’ work. Often this obscures how something could be made to work.
“We can often find our discussion agreeably taking flight to the realm of principles and abstractions, taking refuge in debating room victories and bracing academic bunfights while out in the real world people try to live decent lives in a world of broken systems, ever increasing pressures and real unmet needs. It’s easy to win an argument in abstract and easy to fail someone in real life.”
This week I wrote a piece for The Guardian about the recent ONS publication of annual suicide statistics. In contrast to the comments on a piece I published the previous week for them on antidepressants, the comments were full of compassionate and reasonable discussion. One comment made me cry proper wet fat tears because it brought home to me why we do this stuff and why it matters. It was written by a train driver who had been the unwitting agent of someone else’s suicide:
“Perhaps I shouldn’t write this,” the driver wrote,”I don’t know. But I will anyhow.
“Having hit someone as a train driver and killing them. What I found hardest to deal with was the inquest. I won’t go into details, there is no need. But my anger is funnelled at the complete way this chap was let down by society. He was let down, his family were let down. I gave his wife a little hug at the end. It is heartbreaking.
“I swore one thing that day. If I ever hear anyone call someone who commits suicide a coward again, I’ll knock them into the middle of next week.”
This is the effect we can have by talking reasonably and knowledgeably about the realities of people’s lives and using our knowledge and understanding to shape public debate. We can bring light to debate where often only the darkest, bleakest voices are loudest. We can help to make a space where a better, more useful conversation can happen.
And those conversations are getting bleaker and darker for all of the light in the change of public attitude. As I said in a speech in 2015: “We live in a country that is increasingly keen to use psychological techniques but not keen to measure the psychological implications of those techniques. Travelling through the worlds of disruptive innovation and public policy as I’ve been doing for the last twenty years, first as a recipient of support then as someone who has been striving to make things happen, it’s been impossible to move for dubious applications of psychological principles and ideas. It often seems that once you belong to category of person who is considered to be a social problem, you are fair game for the deployment of a range of dubious and potentially damaging psychological tricks and schemes.
We’ve seen the weaponisation of shame as a means of reducing A+E visits. We’ve seen the process of helping find work increasingly absorb the worst of elements of the coaching world. We’ve seen nudges and gamification and activation all seen as technologies for the promotion of particular behaviours. We seen the rise of interventions, projects, programmes and products that are only measuring their positive effects; the extent to which they are proving successful or unsuccessful in achieving their stated aims but are failing to record or consider the collateral damage to individuals and to communities that results from such activities. The old medical joke about the procedure being a complete success apart from the patient not surviving rings true too often.
Psychology still has a lot of power if it picks its battles well. It’s been fascinating to see the how much coverage and credence has been given to Lynne Friedli and Robert Stearn’s “Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes” Coupled with the British Psychological Society’s call for the reform of the Work Capability Assessment this article has gone some way to legitimising the concerns and experiences of many who are involved in attempting to claim social security benefits and who are not having the best of times interacting with a harsh back to work regime.
We need psychology to act not just as an advocate for itself but as an advocate for a better world altogether.
In 2013 The World Health Organisation (WHO) published ‘Investing in mental health: Evidence for action’, an excellent paper which in their own description examines: “potential reasons for apparent contradiction between cherished human values and observed social actions.” The paper examines the case for governments across the world to invest in mental health by acting upon avoidable risks, providing essential care and enforcing fundamental rights. It also examines why governments do not make these investments despite convincing evidence to encourage them. As the report has it; there are a “number of barriers that continue to influence collective values and decision-making — including negative cultural attitudes towards mental illness and a predominant emphasis on the creation or retention of wealth (rather than the promotion of societal well-being).”
The UK, even with our currently falling level of investment, still has one of the best funded systems of social support for people with mental health difficulties in the world. The report states: “ there is ample international evidence that mental disorders are disproportionately present among the poor, either as a result of a drift by those with mental health problems towards more socially disadvantaged circumstances (due to impaired levels of psychological or social functioning) or because of greater exposure to adverse life events among the poor.”
The WHO feel there are a number of key actions, not limited to treatment, requiring state intervention to promote mental health:
-provide better information, awareness and education about mental health and illness;
-provide better (and more) health and social care services for currently underserved populations with unmet needs;
-provide better social and financial protection for persons with mental disorders, particularly those in socially disadvantaged groups;
-provide better legislative protection and social support for persons, families and communities adversely affected by mental disorders.
Democratic governments maintain their position by remaining popular. UK government maintains its ability to make things happen by gaining the support of the electorate and by gaining agreement of elected representatives to make, amend or remove laws; set taxes; and decide budgets. Centrally controlled spending can be centrally controlled. Devolved spending, such as spending within the current NHS and Local Government budgets can be mandated or incentivised.
But, at a basic level governments do not invest in mental health because there is always something more important to spend money on.
From a policy perspective mental health difficulties are not leading causes of mortality in populations. People do not usually die from mental health difficulties in large, definite numbers in a way that pricks the public conscience and the ways in which mental health difficulty and other problems which may result from them interact is obscured. If someone loses their job as a result of a mental health difficulty and becomes homeless that is seen as a housing problem. If someone with mental health difficulties becomes involved in crime this becomes a criminal justice problem. If you don’t meet people’s mental health needs they drift into other services and thus out of the mental health budget entirely and as such the investment in mental health can always be put off to address the more direct demands placed by reactive services. In this way reactive spending always trumps other forms of spending. This is particularly problematic in mental health as reactive spending is often a response to people’s needs after their wellbeing has been destroyed, undermined or otherwise lost to them.
The WHO paper also suggests that while governments may be fully aware of the individual and community costs of unmet mental health need, they are also aware that to pay for meeting that need would mean removing funds from another potentially more valued activity. In essence, the moving of funds from one or more things to mental health is considered to be too much of an electoral risk. In the UK at present, for example, it has been argued that the decision to attempt to cut spending on social security benefits and reduce government spending has been at the cost of the mental health and wellbeing of many people involved in the claiming or receipt of those benefits.
The WHO also identify the fact that “persons with a wide range of health conditions currently lack access to appropriate health care” as a potential barrier to greater investment in public mental health. In other words: why should mental health come top of the list when there are a number of other competing claims on public funds? Governments, and commissioners in turn, choose where to direct their funds based on evaluating competing demands.
The WHO suggest that negative perceptions of mental illness (stigma) influences decisions as well as “low expressed demand/advocacy for better services”. There is, in other words, a lack of political will and political pressure to spend on mental health.
While England is is investing historically unprecedented yet still modest amounts of funds in combating mental health stigma it’s arguable that this is not creating a demand for better services. While it is true that there has been a recognition of underfunding, there has yet to be a clear, strong, coherent and attractive vision for where the lives of people with mental health difficulties should be in the UK.
If there is no vision of what a psychologically healthy country would be like, there will never be one.
And that’s where a coalition of people who experience mental health difficulties and professionals who are prepared to be their allies might come in. If the world is going to shit, and people’s lives are following suit, it’s folks like clinical psychologists who might be well placed to help make the arguments for how the world might be better. Because you do have power even if you don’t feel like it. You already have professional power over the lives of individuals, some of you will have the power to deny people their freedom or their rights, which may or may not make you feel uncomfortable. But you also have the power of knowledge and standing. You do have power, whether you like it or not, and how you find and use that power is of paramount importance.
Presence
As newly minted professionals you will be excited to dive in and make use of the skills and knowledge directly to try to make the world a better place. You’ll be pressured to see yourself as a cog in a machine. But you’re more than that. You might just be a mechanic of the human soul; but human souls exist in relation to each other. This gives you a potential role in public life as well as the private work that happens between patient and psychologist or reseacher and subject. Mental health is political because politics is the means by which competing human demands are managed. This means, whether you like it or not, you and your actions play out on a wider stage.
I hope that you all remain idealistic and feel that change is possible. For change on a wider scale to happen you must consider your presence in the world and what you mean to people.
This is a speech I gave to a slightly surprised audience at NHS Expo back in 2014. In a lot of ways that was the beginning of my process of getting more and more opportunities to speak. The slot I had was probably primarily understood to be that of a ‘service user’ so the expectation was that I’d say something about how much I like social media personally. Instead, I took the opportunity to make the case for NHS employees as ‘public professionals’; people who belong to a profession who also help the public to understand what that profession is and the difficulties, issues and challenges it faces. Imagine a room full of faces at Expo suddenly looking up from their glossy brochures and thinking ‘bloody hell, I didn’t expect those things to come out of that face.’:
“At a time when the NHS is experiencing its biggest challenges for at least a generation, I want to talk to you about the way in which social media can help to root the NHS in the fabric of communities. I want to talk to you about the ways that social media creates an opportunity for a whole new generation of ‘public professionals’, professionals doing their jobs while maintaining social media enabled relationships with a whole range of people..
“But first I want to take you on a little journey…
“It’s Sunday evening. The house is filled with the smell of ironing and leftovers and the sound of grumbling kids and grumbling adults all counting down the hours to Monday morning. You and the family settle down to watch something comforting and gentle on the television.
“It’ll be set in some time between about 1920 and about 1963-ish. If it isn’t set then it’ll be set in a rural community somewhere as if it were 1920 to 1963-ish. It’ll feature an affable public servant. It might be a police officer. Or a doctor. Or a midwife. Or a district nurse. Or a coastguard. They’ll spend each episode doing their job but also being involved in a whole variety of shenanigans. The message will be they are a valued part of this particular, peculiar community of people. Occasionally they’ll come to blows with someone from The Ministry or similar, someone who represents the far-distant bureaucracy ‘who don’t understand our local ways’.
“What these Sunday night comforts all share is the nostalgic appeal of a world where public services were explicable, knowable and human sized. It’s the fantasy of the local GP having a few pints in the snug of the local pub or the beat bobby who slurps tea in the local cafe. Its a yearning for the days when public services felt like they grew from communities, rather than being distant, complex structures that lurk at the edges of everyday life. It’s the c wish to feel like there’s someone who is part of our world that can also help to understand the world of public services.
“Social media is in some ways the latest village square or local cafe. It’s a place where people check in to hear the latest news, catch up with friends, debate, flirt, ferment revolution and/or swap dirty jokes. In short, it’s a place where people do people stuff. Social media is where people are.
“It’s very easy to underestimate how much of how the NHS works is opaque to the public. It’s like a big castle with high walls. It’s very easy to underestimate how much of how the NHS works and what the NHS does is opaque to the people actually working for the NHS.
“There’s a difference between giving health advice and discussing health issues, just as there is a vast difference between individual treatments and the service which delivers them. The NHS isn’t staffed by robots. In fact we’re so scared that the NHS might be losing its human touch that we’re talking about training people in compassion and empathy.
“So, what’s this got to do with public professionals and social media?
“Public professionals talk about their job via social media. They combine two things: they appear in the public realm talking about their job in way that used to only be possible if a journalist thought you interesting enough to interview. They talk about the pleasures, they talk about the joys, they talk about the difficulties, they talk about the issues that arise from doing it. They put a human face and a human voice to what otherwise might seem a semi-robotic function. They help the public to understand the process, the practice and the limitations of healthcare.
“Public professionals inform the public of their practice and in turn have their practice informed by the public. This is the second thing public professionals do: Public professionals talk to each other, they talk to non-professionals, they carry information into areas where it isn’t usually found. Using social media they get ‘out and about’. Public professionals learn from the blogs, tweets, videos and discussions that they find themselves in and carry this understanding into their work. It’s easy to forget just how much taxpayer funded knowledge and wisdom is currently sitting within the staff of the NHS. It’s awesome but it also ends up hidden from the people who paid for it. Public professionals jailbreak that knowledge and carry it out into the community via social media.
“It’s hilarious to me that the NHS has a challenge with engagement and involvement. Public professionals mix with people via social media (and often in real life too): they’re the person you talk to who is also a nurse, or a the person whose blog you read who is also a doctor. Public professionals are engagers and connectors by nature. You can’t do social media well without connecting with people. For people like me, who aren’t in the NHS, public professionals are a point of entry, a way into understanding it better and a guide to navigating the complicated flows of information, misinformation, spin and rumour.
“If we trust people to make life or death decisions over others we can trust them to have opinions. If we’re battling for hearts and minds, which I think we are with the NHS, then public professionals are the best ambassadors there are.
“Public professionals are a two-way conduit. They take information out of its NHS castle and while they’re outside, in the bustling town square of social media they learn, and talk, and listen and they take information back into the castle, too.
“The rules for being a public professional via social media are really the rules for any healthcare professional: Listen, speak with respect and care, know your subject, don’t talk about the benefits of your work without discussing its limitations, don’t think you know everything, be proud of your job but not blind to its failings and be an advocate for the best of possible worlds by understanding where things are worst.
“While social media isn’t the be all and end all of things: The public sector sometimes only gets the urge to engage with people when it wants something. How do you expect to engage the community, care for the community and be supported by the community if you’re not part of the community? That’s what public professionals do. And that’s why I love ‘em.”
Writing that, I had in mind some prominent public health professionals who did much to further my understanding of healthcare while also helping me to understand the impact on health of wider social, economic and political forces. They were people who were both highly principled professionals who were good at their jobs and people who went beyond that to take that knowledge and apply it to trying to influence the world beyond their day-to-day contracted work. 2014 was before we’d really seen the power of social media to change the direction of world events, which, to my mind at least, makes the role of public professionals in a world of ‘fake news’ an even more pressing issue.
Of course, social media isn’t the only way to influence and interact. Any time you stop seeing your job as only nine to five and any time where you widen your circle of interactions beyond your immediate colleagues or workload you have a chance to influence events and to take knowledge, understanding and compassion to places it may not otherwise live.
In the years since that talk I’ve had the opportunity to think and speak a bit more deeply on the role of mental health professionals in the public realm. The following year I gave a speech to a room full of clinical psychologists and clinical psychology students about such public interaction. This was just after the 2015 general election, when it became clear that there wasn’t going to be a huge change in direction for government policy on public spending but before the brexit referendum of 2016, the change of government and the confusing, shambolic hung parliament we find ourselves in now. At that point the potential upheaval of a yes vote in the referendum to leave the European Union hadn’t crossed my mind. In the speech I focused on the responsibility of clinical psychologists and other mental health professionals to use themselves as tools to make a better world. I still think that there is much in the speech that remains relevant.
In the speech I was keen to warn people against the seductive, messianic belief that all the world needs is more clinical psychologists. I think discussions in mental health often get stuck like that, as fights for more resources for your profession to do the things it thinks are vital. But professions are bodies of knowledge,too. Your profession can be a lens to help understand and, through understanding, change things for which you are not directly responsible. That takes stepping out into public and engaging with the world around you: ““There is nothing that doesn’t have a bearing on mental health and wellbeing. For clinical psychology; the entire world is outside of the therapy room. But what should you do? The therapy room is safe. People pay you money to do a job and you do it. But you want more. Your conscience tells you that there is more that can be done. But what?”
As I told the room “Clinical psychology is not just a field of work; it’s also a field of knowledge and experience and skills. All of you who can describe yourself as clinical psychologists have tied up in you a huge pile of different resources that can be put to uses other than the thing you get your pay cheque for at the end of the month.
“There’s an interesting thing that happens in every single discussion of the future of mental health. Regardless of the tone, regardless of the context, the conclusion is the same: what we need is more people from our profession doing more of the job our profession does.
“Through the work we have been trained for, and the work we feel confident in carrying out, we shall redeem the world from its fallen state. If we just had more clinical psychologists, then eventually we wouldn’t need clinical psychologists because everyone would be better. Eventually. While it’s entirely understandable to feel that the work we do is indispensable and to champion its role in the world, it’s not correct to see that as being the only way that we can use our skills to make change happen. In part this way of thinking comes from being unable to see what clinical psychology might contribute beyond staying in the therapy room where it’s comfortable.
“But to what other ends should we put those resources to? How would you decide? I think there’s a number of things we need to think about. Clinical psychology, and the wellbeing of people both collectively and individually do not happen in a vacuum.
“More than ever we need people who can bring understanding into the mainstream of trauma, of difficulty, of sadness, of frustration, of despair, of prejudice and marginalisation and being thwarted at every turn in the attempt to have a better life. We need people who help people with power to understand not just the positive effects of their actions but also the negative. We need people to put the humanity back into the understanding of the effects of policy and practice.”
We need a new generation of public professionals and a resurgence of older ones. We need people powered by psychological knowledge who can hold the world to account and say ‘hang on, stop acting like utter dicks’. In a country that seems to many to either be becoming more polarised or more unequal depending on who you talk to; we need people who can speak up for people’s wellbeing.
We need, more than ever, public professionals who can help us to understand and public professionals who can help support the legitimacy of the problems raised with society from those with least power and least influence.”
Privilege
Whenever I talk to mental health professionals I warn about how seductive it can be to be certain that you are on the ‘side of the angels’; that by definition your works are good works because you have a good heart. It is possible with the best of intentions and the greatest desire to help to do things that are injurious and dangerous for others without even realising
As a group of people you are now privileged to have knowledge that others do not. You have worked hard for that knowledge, you’ve passed your initiation into the secret society. You have proved that you’ve got what it takes to join the honourable order.
This now gives you something that other people don’t have: deep knowledge of psychology and ways to apply that knowledge. Whether you like it or not, this sets you aside from other people. You now possess a privilege. a special right, advantage, or immunity granted or available only to a particular person or group.
Your privilege is knowledge of how humans work and how they interact with their environments and how their environments interact with them and access to a body of knowledge that can both cast light on understanding those things and also influence them.
Basically, you are now have a position where you are allowed to look at people and their behaviour and pass a variety of judgements. You will now get jobs and receive praise based upon not how you are the same as the rest of the population, but based on your difference.
No profession can fully guard its members from being dicks. Clinical psychology is no exception. Despite intense ethical and professional guidelines it is still remarkably easy to be a dick to others; often in a way that your colleagues might not pick up. The combination of special knowledge, license to use it and a sense of moral and personal purpose and passion can be the thing that makes you amazing but also the thing that can make you be a dick. The hallmark of being a dick based on your privileged position is saying or doing something that seems entirely reasonable, kind even, but which does not take into account the power imbalance between you and another person or group of people.
One that I see often, which is often said with the best of intentions, is someone standing up at a conference about things that concern patients and saying, with their privilege and power, that ‘we are all patients’. While this is true, we are all patients at one time or another, in the context of the issue at hand some of us are professionals with power and standing and the rest of us are patients who may be struggling to be heard or given respect. That’s a well meaning example of not recognising your own privilege.
In Ian McEwan’s novel ‘Saturday’ there is a far less benign example of the use of medical privilege. It’s a novel that is often ignored because it’s about middle class smugness. In it, a neurosurgeon spends the Saturday of the massive anti war march in the run up to the Iraq war in 2003 in London getting ready for a family dinner. He is rerouted from his usual route because of the marchers and has a run in with a violent and angry man. On reflecting on the man and his behaviour he surmises that he has a very particular kind of neurological condition. Later, the man turns up at his family gathering and threatens violence against the neurosurgeon’s family. Despite having spent the day musing about how impotent in the face of world affairs he is as a neurosurgeon and member of the chattering classes, the neurosurgeon uses his specialist knowledge to tell the violent angry man that he has a terrible condition and uses that knowledge to gain the upper hand and guarantee the safety of his family. When it came to it, and the things that he knows and loves comes under threat; the neurosurgeon uses his privileged knowledge to win the day. And he did it very, very smugly.
In mental health that temptation will always be there, especially when you take yourself as a vessel of knowledge and experience out into the world, to rise above and put on your special cloak of professional knowledge. Understanding someone’s motives or being able to analyse why they behave the way they behave is not the same as paying that person respect or indeed being supportive or trying to make change happen.
I live my life in social media. Social media is where people of wildly different situations and worldviews rub up against each other. It’s where I can see the lines of power and discomfort and possibility for the future of mental health by watching the way different people interact with each other.
Over the past five years social media has rung with calls for others to check their privilege to the extent that it almost became a running joke for some. As with many things, this derision has sought to hollow out the original meaning of the idea and reduce it to caricature. At it’s heart the call to check your privilege is about being aware of the ways in which your experience, knowledge and conclusions draw from a particular set of economic, political and social conditions which you may have profited more from than someone else. It’s an assertion that some people are listened to more than other people because of their status. It’s pointing out that there is not equal access to resources, learning, opportunities and to voice. It has most commonly arisen when some groups of people have been seen to speak on behalf of other groups of people and where there has been doubt that their advocacy has been true and not involved a degree of self-serving. This is most often recognised when the person doing the advocacy by accident or design ends up using the attention that they get because of their position to talk about ways that other might understand or respond to the experiences of a third party, in turn claiming greater knowledge or insight into the situation of that third party than the third party themselves. It can also happen where people’s wish to claim solidarity with the experience of others causes them to jump from empathy and identification to claiming that the struggles they face are the same as others, or that they have a special insight into those struggles that those experiencing them don’t face. Saying ‘we are all patients’ is an example of this, of using your power and authority to try and level out difference when difference of experience and outcome is exactly the nub of the issue that those with less standing than you are trying to discuss.
Another interesting and vexatious example is the decision of the American Psychoanalytic Association to do away with the Goldwater Rule in relation to the angry ‘grab ’em in the pussy’ relaxed about white supremacists late night tweeter and belligerent wall builder currently the leader of the free world.
The Goldwater Rule is named after presidential candidate Barry Goldwater, whom a small minority of psychiatrists when sent a questionnaire proclaimed to be mentally unwell allowing Fact magazine to run the headline “1,189 Psychiatrists Say Goldwater is Psychologically Unfit to Be President!” In 1973 the American Psychiatric Association (APA)created the Goldwater Rule, explicitly forbidding members from diagnosing public figure they have not themselves examined with mental health conditions.
To quote Time magazine: “That is precisely the position another professional group, the American Psychoanalytic Association (APsaA), has now taken. In an internal email, the association urged its 3,500 members to speak their minds on the matter of presidential mental health, and if they consider Trump unwell, to say so. According to the health and medicine website STAT, some members of the group have gone so far as to conclude that not only is it alright to weigh in on the matter of Presidential sanity, but that doctors have an affirmative “duty to warn.””
Trump may well be a huge threat, but is it fair for psychoanalysts to risk the reputation of their profession and potentially the safety of their clients, by using their position to make such statements? I know that I don’t want Trump to be president, and that it is well within the equal opportunities policy of my company to oppose his policies, but is using the privilege conferred by a professional status the way to oppose him? Many people across the world have been slinging ideas about Trump’s mental health about and no one is listening to them. If the APA’s members were to be listened to it would be precisely because of their privileged professional status? We generally have looked to work for greater acceptance of mental health difficulties and neurodivergence, but the actions of the APA suggest that it’s OK to throw that out of the window if the noble higher goal is important enough. Quite reasonably, people ask: ‘what gives you the right to decide your political aims, which I might well agree with, are more important than our fight for acceptance and freedom from the use of mental illness as a pejorative term used to judge people? Can’t Trump’s bad judgement and bad decisions and existing objectionable track record be enough?’
Some people with mental health difficulties and disabilities see this as throwing them ‘under the bus’ in the effort to achieve a bigger goal. If you aren’t familiar with the phrase, wikipedia says: “To throw (someone) under the bus” is an idiomatic phrase in American English meaning to sacrifice a friend or ally for selfish reasons.”
It may well be that the motives of the APA members in question are of the highest and loftiest virtue, but it is their privilege that allows them to decide when to cast aside the concerns of others and their privilege conversely that means they might be listened to.
As mental health professionals, this is the territory you are now entering. And it’s an issue that will face you each and every day. How will you use your knowledge and your position to amplify the voice of others and help them to strengthen their position in a world that might be hostile to them and their needs? How, when part of your job might be to know someone better than they know themselves will you prevent that becoming a way in which you elevate your own position at the cost of others? Now that you have the certificate to prove that you are a special kind of person; how will you make sure that you do not become blind to the ways in which that specialness might make you talk over someone else rather than with them?
By definition you now have a role as a clinical psychologist that might involve deciding what is someone else’s best interest. Stepping out into your new professional identity must be a lifelong process of introspection and sense checking, otherwise it is very easy to be a dick and to never even realise. Your role gives you the power to define what is important and to have others observe it. This is the very definition of a kind of privilege.
People
It is vital then, for you to balance your privilege with your commitment to making the world a better place in whatever way you can. That’s room for table thumpers. There’s also room for smooth influencers. And committed researchers. And people who do any of the tiny day-to-day things that add up to making profound changes happen.
Of course, the first thing we need is for you to be good at your job as clinical psychologists. But you’ve got the certificates to prove it now, so I’m trusting you all. But what does this grander project of psychology in the world require? How do you make change happen and avoid being a dick about it? Indeed, how do you make sure the change you think is right is the one that people actually want? The answer is surprisingly simple: you hang out with the people who have the problems and use them as your colleagues and your peers as well as your patients and subjects.
One of the first things that needs to happen is that clinical psychology needs to be of this world. It needs to be rooted in the actuality of people’s lives. People are glorious, confusing, challenging, infuriating, amazing things. It needs as much as possible to, as we say in design, get out of the office. It needs to hang out with people.
We have a problem in mental health, as we do in society, with the question of who is considered to be legitimate in raising problems. We tend to devalue those who experience suffering when they raise points that challenge both our own position and the ideological position we hold them to occupy. In mental health, some flavours of user opinion are afforded more respect than others. We need clinical psychology wherever to help bring into public discourse the full range of human emotional responses to the profound changes our country is going through, not just the ones that fit a particular ideological position. We need allies; not saviours. We may not be comfortable with it, but the words of clinical psychologists still have power.
We need clinical psychology to help make wellbeing happen, by first always, always, always making sure that it spends enough time with people to be clear of where the problems really are.
At all times, we need clinical psychologists who
Listen,
speak with respect and care,
know their subject,
don’t talk about the benefits of their work without discussing its limitations,
don’t think they know everything,
who are proud of their job but not blind to its failings
and who are advocates for the best of possible worlds by understanding where things are worst.
Clinical psychology is all about people; but ask yourself: how close do you actually feel to the people your profession is attempting to help? When we don’t feel an authentic connection to the people we are trying to help we are subject to idealisations, to fantasies, about what they might want and how they might be and what they might find helpful. We are subject to our ideologies overtaking our experiences. One of the things I’ve noticed is that often someone will meet a particular group of people who experience mental health difficulty or a particular approach developed slightly outside of the mainstream of standard practice and that, for them, will become their ‘answer’. The wish to do right be these people who initially opened our eyes to suffering or desire grows in fervour. ‘I’ve spoken to service users and this is what they tell me they want,’ the newly converted radical will say. But people get stuck having found their radical path. They change from someone questioning to becoming someone dogmatic. They get stuck with one perspective that they feel replaces their old, authoritarian or inflexible model with a new one. This might be their first exposure to the pain or the enthusiasm of some people who seem closer to the problem than they do. They become fixated on the the truth and rightfulness of this alternative, the ‘user perspective’, forgetting that this is one view amongst many and that people’s views about what is best or what is desirable won’t be fixed over time.
People sometimes want to make change by being the most radical then complaining that the lumpen proletariat is ignoring their avantgarde. I’ve seen clinical psychologists committed to overthrowing the tyranny of diagnosis lecturing people with mental health difficulties about how their diagnosis is made up. I’ve seen clinicians who are convinced that medications are unhelpful flat out arguing with those who take them and find them valuable. I’ve seen those who never have to take meds telling people to tolerate their side effects. I’ve seen people more convinced that winning the argument is important than having the discussion. Let people be your guide. Your knowledge and position are tools, not gifts. Be close to people who actually have the problems and allow them to shape your mission. You can not give up your privilege and power while still holding it; you can only find the best purpose to which to put it that is most equitable and ethical and fair.
In an area of activity that is all about people, we sometimes, for entirely honourable reasons, manage to leave people out of our thinking. In our discomfort with our paternalism, with our authority we seek to salve our conscience by promoting one ‘service user’ cause or another, getting stuck in a position of trying to advocate for what once was a radical idea but which has now been superseded by other ideas.
If our business is people, then we must never leave people out of our business.
Prospects
We could have a better world, if we want one. Writing for the Guardian recently, on Theresa May’s suggestion there might be a replacement for the Mental Health Act, I said:
“If we really wanted change we could aim much higher: imagine a bill of rights for those experiencing mental distress. A future bill could enshrine in law an entitlement to adequate social security benefits for those too unwell to work. No one should experience poverty as a result of mental ill health. Few people have access to someone to fight their corner while in hospital or treatment since true independent advocacy has withered due to cuts. That could change.
Were May serious about reforming mental health care, she could set minimum standards to which all are entitled by law, including both inpatient and outpatient care. A future bill could guarantee that all stays in hospital were safe, free from prejudice and discrimination, and based upon the principle not just of reducing risk to the public but maximising the possibilities of healing and care for those requiring it. If the intention is to reduce admissions, this act could find ways to mitigate the disadvantages that those who are in serious mental health need face in housing, employment and education. The bill could lay out the provisions for those who wished to refuse treatment, and build new models of consent and care.
A new mental health bill could bring us so much more if we were brave. It could be a chance to create a covenant that commits our country to protecting, nurturing and healing those in distress.”
And writing earlier in the year: “We talk about fighting cuts but the money to achieve equality for people with mental health difficulties has never been there. We need to be fighting for a future where supporting and protecting the lives of those experiencing mental distress is not an optional act of kindness but an obligation hard-wired into all of structures and thinking. The man on the street might say that sounds like special treatment, like whining instead of pulling your socks up. But the man on the street will keep saying that until we seize the political initiative. Or until his brain flips over one night and he can’t trust his own thoughts and feelings and suddenly he discovers the world doesn’t work for him any more.
Being in distress hurts. Finding you are treated unequally at such a time even more so.”
Once you get out of the safety of the institution you run into the world in all of its confusing, upsetting, uplifting and beguiling glory. As soon as you leave this university, as soon as you are at the coalface, such high flying dreams of change may well become lost in the every day of being a professional. But hold on. You’re a special body of skills and knowledge in a world that really needs them.
When clinical psychology can’t act directly it must help to bring into sight the suffering and the difficulties of those who are in need without shaping those needs through abstracting ideological prisms. People need help now, not in the next world. We need you to help change the world, not to stand and stroke your chins and study how it is falling apart.
We need you to be engaged. We need your resources. We need ideas and help with ideas. We need clinical Psychology to get out of the office and beyond the therapy room because we need someone to help make the case for those who are losing out. To do that we need a clinical psychology that has political understandings but which also is close enough to people to be able to offer pragmatic support, too.
Mental health is too important to us all to lose its capacity to dream and to aspire and to fight what is wrong.
You can use your power to help make the world that we need for all of our mental health. And if you can avoid becoming a dick about it, people will love you for it, too.
@markoneinfour
