A shorter version of this paper was presented at the INTAR (International Network Toward Alternatives and Recovery) international conference, University of Liverpool, UK (25-27 06 2014), Power to Communities: Healing Through Social Justice, on Day 1 (25 06 2014).
- The ‘disappearing’ of gender as structural dis/advantage
- The impact of feminist methodology and women’s peer process
- Power, politics and casualties: gender, mental health and academic practice
- Neoliberal fallout
- A necessary chorus of dissent and co-creativity.
In response to the publication of Thomas Piketty’s latest book,[ii] Sean Baine, Chair of the Equality Trust writes:
Evidence of the devastating social and economic consequences of inequality has been growing for years. What we now need is for the corridors of power to take the issue of inequality much more seriously. As such, the Equality Trust is calling on all political parties to adopt our inequality test – an explicit commitment in their manifestos that the net impact of their policies will be to reduce the gap between the richest and the rest.[iii] Emphasis added.
Other Guardian letters on the same day refer to: “the problem of rising inequality and declining social mobility”; the ethical assumptions involved in economics (as suggested previously by Ha-Joon Chang,[iv] as well as “psychological expressions of differing beliefs about what constitutes human nature (sic)”; and one letter writer declares that “Equality is not the ‘natural’ state of man (sic); inequality is the persistent state of man (sic)”.
“Inequality”, “social mobility”, human nature”, “man” – my feminist heart sinks, my brain boils.
The ‘disappearing’ of gender as structural dis/advantage.
’The Spirit Level[v] evidence on inequality is encouraging many men on the Left (academics, politicians, journalists, activists) to define inequality as economic disadvantage or poverty.[vi] This position has historical and theoretical roots in C19 Marxism. In 2014, however, this stance can be seen to ‘disappear’ structural disadvantage consequent upon power differentials rooted in racism, homophobia and misogyny, which are patently not explained by social class and/or poverty.[vii]
In the public domain, masculinity and male identity are too often glossed within/by aggregated data and ‘generic’ media reporting, for example in relation to knife crime,[viii] drug-related gun crime,[ix] criminalization, incarceration, social conflict, ‘riots’, terrorism and war.[x] ‘People’, ‘spectators’, ‘demonstrators’, ‘hooligans’, ’criminals’, ‘terrorists’, are actually labels used to report on men’s behaviour and actions (usually in all-male groups, crowds, gangs), on the street, in other public spaces, and in organisational or institutional settings. [xi]
This gender-neutral language leaves the evidential role of gender un(re)marked. This removes gender and masculinity from scrutiny, understanding and critique; and by extension from intellectual (e.g. sociological) and political analysis. This is the default position: normative practice across most of the media, politics, and other areas of professional and business practice, including much academic practice.[xii]
The position of academia as part of this ‘consensus’ is significant, as the prevailing culture provides more than the backdrop to mental health discourses and practices, not least because it both straddles and attempts to theorise the boundary between academia and society; between academics, psychiatrists, psychiatric nurses, social workers, other health practitioners and specialists, as well as service users in the mental health field. It attempts to constitute as well as critique what is complex and contentious, as lived experience, not simply abstractions or speculation. There are apparent and hidden elements of power struggle in these relations, which can have material consequences for clients (a point I will return to).
It is therefore not surprising that there is evidence of cognitive and intellectual continuity with aspects of these wider social and cultural contexts, pressures and practices in recent descriptions and analysis of psychological and social approaches to ‘psychosis’, even as critical and oppositional discourses and practices promote their academic credibility and professional status (while – like aging rock stars? – practitioners simultaneously hold on to their ‘radical’ / alternative / anti-authoritarian identity).
Causes of depression are listed as:
- family, relationship, loss, isolation, childhood and work.[xiii]
- psycho-social factors include “unusual or traumatic experiences” and “childhood adversity”.[xiv]
“Stressors” are identified as:
- “major unpleasant emotional experiences” (USA 1987)
- “family conflicts”
- “unusual or traumatic experiences” (London)
- “psychosocial stress” (West Germany and East Germany)
- “problems in interpersonal relationships” (Japan)
- “childhood events” (East London)
- and “psychological traumas” (Italy).[xv]
- “Childhood adversities are associated with maladaptive functioning, such as parental illness, child abuse and neglect”.[xvi]
- “The causal role of childhood adversity” is highlighted,[xvii] as is “childhood trauma”.[xviii]
This is gender-neutral language that serves to mask the realities of girls’ and women’s lives and the impact of those lives on their mental health and wellbeing. Even when “belonging to a disempowered group”[xix] is mentioned as a factor, it is linked to poverty and racism, with no mention of gender and the positioning of girls and women. And the generic term “social causation”[xx] gives no indication it might encompass gender issues or racism. Gender differences may be mentioned as ignored, but there is no gender analysis; the issue of gender / gender power relations is not simply a matter of noting / assuming gender differences. Highlighting the putative role of life experience “in shaping brain structure and function” produces another list:
- “including attachment relationships
- varieties of trauma and adverse social experience
- social isolation and defeat
- poverty and urban living”.[xxi]
Whether mainstream or specialist, language such as victim, survivor, criminal, patient, spectator, demonstrator, skiver, perpetrator, people; abuse, childhood adversity, social disadvantage, trauma and power, is gender-neutral, and needs contextualizing to serve women, rather than rendering us invisible within its discourses.[xxii]
The impact of feminist methodology and women’s peer process.
By contrast with these generic discourses, the executive summary of the Women’s National Commission report in 2010, on the health aspects of violence against women and girls, states:
Since 2003 the Department of Health (DG) has acknowledged that women’s experiences of domestic violence and other forms of abuse are linked to long-term mental illness (sic) and with physical and sexual health problems.[xxiii] In 2007, the cross-governmental sexual violence action plan recognized that the impact of recent and historic sexual abuse includes anxiety and panic attacks; depression; problematic substance use; eating disorders; post traumatic stress; self harm and suicide.[xxiv]
Here, mental health issues are explicitly linked to women’s lives and experience of sexual violence and abuse, and ‘symptoms’ are understood as consequences of those experiences.[xxv]
In 2014, 11 years after the Department of Health statement, 7 years after the cross-governmental sexual violence action plan, and 4 years after the publication of both the Women’s National Commission’s A Bitter Pill To Swallow and Southall Black Sisters’ Safe and Sane document, Liverpool’s What Women Want Group set up a Task & Finish Group to produce an evidence-based report, with recommendations for local, voluntary and statutory mental health services, based on national research findings and local women’s experiences of domestic abuse and use of mental health services”.[xxvi] It was produced via a peer group process that brought together women from different backgrounds, with various combinations of relevant experience and expertise (as service providers, service users, researchers, academics, activists, etc.). Findings include:
- Women described various forms of psychological, emotional, financial, sexual and physical control used by partners to subordinate, threaten and isolate them.
- Psychological control and emotional abuse were experienced as the worst aspects of the abusive relationship, with the lasting psychological impact of that abuse being a loss of identity, confidence and self esteem, anxiety, depression, social isolation, eating problems, harmful use of alcohol and substances, self-harm and suicidal ideation.[xxvii]
These experiences could be seen to fall within several of the categories already mentioned, such as:
- major unpleasant emotional experience
- family conflict
- traumatic experience
- psychological trauma
- psychosocial stress.
Or these four psychosocial causal beliefs:
- problems from childhood
- day-to-day problems
- death of someone close
- traumatic event.[xxviii]
These summative categories demonstrate the significance of the questions researchers or practitioners actually ask; i.e. the categories their questionnaires and/or focus groups implicitly construct, and by default, the experiences they exclude, suppress or marginalise.
By contrast, Liverpool’s Domestic Violence and Mental Health report, is explicitly rooted in the lives and experiences of actual women, and acknowledges at the outset that gender-based violence against women, such as partner abuse (the most prevalent form of abuse) has its roots in unequal power relations between women and men.[xxix] While vital to the development of functional and empowering processes for both service users and service providers, this stand nonetheless understates the significance of the nature and role of heterosexism, homophobia and misogyny in societies, and within women’s relations with conventional / traditional heterosexual men and their own families.[xxx]
Women’s experience of domestic abuse irrefutably re-iterates the significance of a predatory, unequal heterosexual relationship, in which the woman is subordinated, controlled, coerced and isolated, and by extension, exploited, violated and terrorised. This is not every woman’s experience, but it is too common, too widespread, and apparently spreading. The impact of “conservative attitudes and value systems which justify violence against women and are unsympathetic towards mental illness generally” and the pressure to conform to “traditional gender roles as good and dutiful wives, sisters, mothers, daughters and daughters-in-law” are still significant, and explicitly inform and frame the interventionist work of Southall Black Sisters, for example.[xxxi]
Research over three decades consistently found that Asian women, particularly those aged 15-34, are up to three times more likely to kill themselves than women in the general population.[xxxii]
SBS counsellor, Shahrukh Husain, has developed a new ‘hybrid’ model of psychotherapy that “combines established humanistic, cognitive-behaviourist and psychodynamic therapies in a fluid way. . . using when necessary, some directional elements drawn from Life Coaching”.[xxxiii] SBS have found this model effective in the treatment of Post Traumatic Stress Disorder (PTSD) and recommend that domestic violence as experienced by BME women should be added to the DSM-IV-TR diagnostic criteria for PTSD, either as a sub category within the Battered Women’s Syndrome (sic) or in a category of its own, “so that the impact of religious and cultural pressures such as notions of ‘shame’ and ‘honour’, and of racism, are taken into account.[xxxiv]
The Southall Black Sisters (SBS) model provides holistic specialist services for abused BME women by combining advice, advocacy and support services with counselling and psychotherapy. “It helps prevent the medicalisation or over-medication of BME women by recognizing and eradicating or reducing the social causes of their mental health problems.”[xxxv]
Women’s focus group testimony forms the powerful heart of the Liverpool report, and “the direct, causal connection between the abuse they had experienced and their symptoms of mental distress was a strong, recurring theme throughout the discussions.[xxxvi]
But women report that many health practitioners, including GPs (women or men), ignored, negated, minimised or played down the impact of abuse, referring, for example, to “relationship problems”. As one woman commented: “I do not have ‘relationship problems’. I am not in a relationship. It was domestic abuse.”[xxxvii] Too often, ”GPs, even when made aware of domestic abuse, did not offer support other than medication.”[xxxviii] This suggests a level of denial rooted in ignorance and bordering on contempt, which in turn, I suggest, implicates heterosexist and misogynist values and attitudes.
The problem evidently goes deep. There is alarming testimony in all three of these reports about women’s experiences at the hands of mental health practitioners, in particular GPs and psychiatrists:
- their lack of understanding of gender issues, domestic abuse and all forms of violence against women, and the social causes of women’s distress
- the emphasis on medication
- unhelpful and judgemental attitudes.[xxxix]
- “And psychiatrists are always men.”[xl]
The women in the [Liverpool] focus groups spoke of:
- not being listened to or believed by family courts, police, social services and health professionals.[xli]
- Above all, services did not ask the question about domestic abuse. And as one woman commented: “It’s not something you bring up without the question being asked.”[xlii]
- Another woman reflected: “We have all (here) experienced horrendous things. My personal experience is that I had to be raped for the relevant agencies to kick in.”[xliii]
- And only 2 out of 42 of the women we engaged with had been given information about or directly referred to a specialist domestic abuse support service by a health professional.[xliv]
The disconnect between services and different health practitioners, perhaps reflecting power differentials and unhelpful power relations and status conflicts, clearly presents obstacles to responsive and effective support and care. It seems to reflect, not just a lack of professional contact, co-ordination and mutual respect, but the gender ignorance / prejudice noted at the beginning of this paper: internalized sexism, and the fruits of a society increasingly saturated with pornographic, heterosexist and misogynist values and assumptions, which constitute not just disadvantage or inequality for girls and women, but real and (ever) present danger. A stifling, not just of opportunities, but of being and breathing.
As women’s activism and feminist theory have confirmed over the years, ‘context constantly threatens to make emotional and behavioural problems intelligible’:[xlv] thereby open to critical scrutiny and political engagement.[xlvi] The three reports drawn on here were all produced by mixed teams of women variously working in the field of women’s mental health. The WNC Report recommends support for women via “empowerment towards recovery” (rather than medicalization and medication), and that:
Mental health professionals should be required to be trained in the social model of mental ill- health and in women’s mental health needs, using the experience from specialist violence against women services to inform its development and delivery.[xlvii]
Southall Black Sisters stress the importance of:
- minimum standards, guidance and compulsory training (being) developed by the NHS and other health and social care bodies in consultation with specialist, secular BME women’s organisations
- the implementation of policies and practices which meet human rights standards, such as those required by CEDAW, within the health and social care services”[xlviii]
- and the importance of “culturally competent” staff, capable of addressing issues of gender as well as race inequality.[xlix]
This last point clarifies how a social model of mental health in a diverse society that prioritises respect for difference, attention to social justice issues and a human rights framework,[l] requires health practitioners with a multi-disciplinary background, together with relevant expertise by experience. In 2014, social, cultural and political awareness and sensitivity are professionally vital.
These 30+ neoliberal years, with their heterosexist, hyper-sexualised, consumerist, competitive and violent culture, have rendered girls and women more vulnerable in both the private and the public domains, as media and business have intensified and exploited gender differences and divisions for power and profit. A recent product of this culture, British-born American student, Elliot Rodger, went on You Tube and “raged that he was a virgin and would exact vengeance.”[li]
I don’t know why you girls haven’t been attracted to me, but I will punish you, for it is an injustice. I’ll take great pleasure in slaughtering all of you. You will finally see that I am the superior one, the true alpha male.[lii]
This case will stir up old debates about male perpetrators as “mad” or “bad”. The ‘lone male’ boast of misogyny as justification for premeditated femicide is a reminder that:
There is no such thing as a lone misogynist. They are created by our culture, and by communities that tell men that their hatred is both commonplace and justified.[liii]
But perhaps in 2014 this debate is better served by the greater prominence of feminist commentators and activists of all ages, particularly in the wake of the virulent misogynist attacks on women in the public domain in the UK in 2012/13/14, such as academic Mary Beard, MP Stella Creasey and feminist campaigner and journalist, Caroline Criado-Perez, and the continuing stream of historic abuse cases going through the UK courts since the death of Jimmy Savile.[liv]
If VAWG (including domestic abuse, partner abuse, and rape) is now the single most significant social determinant / causal factor for women’s mental distress, psychological chaos and ill health, should we not expect it to be more prominent in contemporary mental health discourses and practices? More embedded within current critiques and theories. Less marginalized.
Power, politics and casualties: gender, mental health and academic practice.
Mental health critique of the medical model recognises that service users are not just bodies, to be done to, in a process that amounts to objectification and commodification. Yet, as has been shown above, the problematic nature of the generic language and assumptions of psychosocial discourses and the testimony of women survivors of abuse / service users, as well as women service providers, suggest there remain serious, largely unacknowledged, gender issues within the profession that serve to compromise progressive mental health philosophy and practice.[lv]
The declared “focus on recovery not pathology”,[lvi] and on “a human rights and social model”[lvii] is welcome, but needs to demonstrate awareness of and action on the gender issues raised by women’s concerns and evidence, as well as critical self reflexivity regarding structural issues attendant on the profession’s current and longstanding demographic: its gender imbalance and the consequences of this for appropriate, good service provision for girls and women clients.
I return to a question I asked 10 years ago of a plenary speaker at a mental health conference, an ‘innovative’ psychiatrist running a mixed residential mental health service: “Given that we know that the biggest factor in women’s mental ill health derives from their negative (and abusive) experiences within heterosexual relationships, involving power and control, how could their recovery be effected within a mixed ward or environment?” [lviii] He observed, with a smile, that it was a very good question, but that he “pre-dated political correctness”. He declined to respond, and handed over to two service users / residents he had brought with him.
In the intervening years, women’s specialist, women-only services have established their expertise and effectiveness in the field of women’s mental health.[lix] These projects emerged from the culture created by women’s activism from the 1970s: and they were grassroots, feminist-inspired and community-based. The result in 2014, is a sort of parallel universe with regard to mental health service provision: male (overwhelmingly white?) psychiatrists on the one hand, and diverse (in terms of age, ethnicity, social class, sexual preference, for example) women activist practitioners on the other. This separation and disconnect comes through in the testimony of women victims and survivors.
The only reason I’m still alive is because I got out of the mental health system. It is a dangerous place for abused women to be. (FGN)[lx] Emphasis added.
If you complain or ask to see a woman they write on your notes ‘aggressive non-compliant patient!’ You learn as a kid to shut up and not complain and you’re treated the same by the NHS. (FGN) [lxi] Emphasis added.
Psychiatry does nothing but harm women who have been abused in a profession where they are supposed to alleviate distress. In my experience, they have no understanding of violence against women, of child sexual abuse, and of the impact this has on women. (FGN)[lxii] Emphasis added.
I think psychiatry today is an essentially patriarchal institution that reproduces situations of lack of dignity and powerlessness contained in the original abuse. (FGN)[lxiii] Emphasis added.
And, as in society at large, older women[lxiv] and disabled women[lxv] can find themselves particularly disadvantaged and ill served by mental health services and practitioners. The misogyny and ageism encountered in society are too often intensified away from the public gaze, within institutional settings meant to support and assist recovery.[lxvi]
I just can’t believe the things that I just was not taught. As a qualified nurse the social model of disability was never even mentioned in my training. (FGK)[lxvii]
Is this also a hierarchy? Salaried professionals on secure contracts v the insecure and uncertain funding of women-only services over these many years, despite the specialist services proving their value to their client group: women damaged and derailed by their relationships with traditional heterosexual men. The material conditions of their lives, supposedly central to the social model of mental health.
Asking a woman client, ”What has happened to you?” serves to expand the category of trauma beyond the gender-neutral lists cited earlier. Girls’ and women’s trauma-induced distress, disintegration and psychological chaos are gender issues, feminist issues. Trauma-informed service provision and trauma-sensitive therapeutic practices are necessarily feminist practices, tailored to girls’ and women’s needs and aspirations. Depression and anxiety, for example, are not attributed the status of first causes, but consequences.[lxviii]
For conventional male academics, politicians and psychiatrists (i.e. the majority), the basic fact of the role of VAWG for women’s mental health is presumably indigestible, because it implicates them as (heterosexual) men. It muddies, even threatens to undermine, their professional status. Ignorance and resistance is still deep rooted and widespread, for example amongst male police officers, GPs, psychiatrists and judges: in some cases a woman has to be dead before agencies take notice, and are willing to consider the man as perpetrator, a risk to a woman or child’s life.[lxix] The charisma of being another heterosexual man seems to act like a built-in protection. But the heterosexual frame can also make women service providers complicit with this resistance and denial. They too have a vested interest in seeing all heterosexual men as basically good guys. But, as feminist blogger, Melissa McEwan tweeted:
Dismissing violent misogynists as “crazy” is a neat way of saying that violent misogyny is an individual problem, not a cultural one.[lxx]
For male practitioners, confronting the issue of VAWG and misogyny as at the core of women’s mental distress and psychological disarray, could dilute their professional credentials, purpose and capabilities, rendering them less powerful, even unemployable. After all, within this gendered dyad, with his masculinity a potential disadvantage, what possible roles and relational possibilities are open to (or to be avoided by) the conventional, male mental health practitioner (Counsellor? Mentor? Father figure? ‘Romantic’ interest? Predator?). All of these ‘positions’ echo the heterosexist relationship at the root of the girl, woman or trans person’s [lxxi] dis-ease / mental health crisis after sexual violence and/or domestic abuse. It is likely to be experienced (on both sides?) as an unsustainable, ‘inappropriate’ relationship, with scant therapeutic value. And the Nursing and Midwifery Council are likely to be less forgiving than the Liberal Democrat Party.[lxxii]
At the same time, some mental health practitioners already feel the heat of service-led movements for change, which they fear could derail their professional identity and status, as this psychiatrist’s outburst reveals:
“I get sick and tired of being attacked all the time – from clients, families, professionals. So you would get rid of all psychiatrists would you?”[lxxiii]
In these circumstances, to be asked to critically reflect on the nature and consequences of their own masculinity and sexual identity for their professional practice could presumably be a ‘last straw’, triggering identity crisis. Like academics, in the wake of years of neoliberal advances and their impact on the university sector (less secure contracts, erosion of tenure, increasing uncertainty around career paths, increasingly unsustainable workloads, and authoritarian, managerialist regimes), they are becoming newly vulnerable anyway: potential clients for their own services.
Neoliberal fallout.
Dr Clare Gerada, former president of the Royal College of General Practitioners, made it clear in interview that:
- The number of doctors becoming affected by mental illness or addiction is a frontline issue that could have catastrophic consequences.
- NHS occupational health services have been drastically cut in recent years, which coincides with increased workloads and stress.
- For GPs, it’s the pressure of the workload, the denigration of what they are trying to do. For others, it is the loss of team structure.
- An atmosphere of fear and uncertainty pervades the NHS, adding to doctors’ anxiety about being perceived as weak or unwell.
- (Doctors’) problems are deep-rooted, psychological and social, part of a stigma in the NHS attached to weakness, addiction or mental illness.
- There is absolutely no pastoral support, no help for doctors with mental illness, no post-traumatic stress counselling.[lxxiv]
A “50 year old consultant at the top of his profession, . . recently diagnosed with bipolar II disorder” who reckons he has had it for 20 years of his career, revealed the intense pressure on him not “to be found out”.[lxxv]
I lose a child, I lose a 20-year-old, and I go round the back of the hospital and have a fag and then it’s straight back to work. There’s no debrief, no pastoral support.[lxxvi]
At the other extreme, unpaid carers (mostly women), who have been in role for many years, and who have no union, agency or support group to mitigate mental health crises or represent their interests, are themselves succumbing to ill health, desperation and collapse.[lxxvii]
Compare these examples of overload, isolation and lack of institutional care and support, with another expanding cohort with mental health issues in 2014. Combat Stress, the charity set up to provide for the mental health needs of war veterans, has recorded a 57% surge in those seeking help in 2013, its current caseload of 5,400 comprising veterans from Iraq, Afghanistan and Northern Ireland.[lxxviii] General Sir Richard Dannatt comments:
The Ministry of Defence will always try to talk the figure down for budgetary and compensation reasons. But psychiatric injuries should be widely recognized and talked about.[lxxix]
He said that former soldiers were often caught up in a “culture of coping alone” and that it needed to be recognised that there were too many former combatants who ended up in jail as murderers, or as suicide victims.[lxxx] Meanwhile, it appears that more and more medics (salaried professionals) and carers (unpaid ‘volunteers’), both devoted to providing the very best care, struggle to survive and cope in their own private ‘combat zones’, and remain largely abandoned: invisible, unless identified (scapegoated?) as being culpable (for a ‘mistake’ or ‘failure’).
In 2014, the mental health movement also finds echoes in critique by beleaguered academics (‘exhausted, stressed, overloaded, suffering insomnia, feeling anxious, experiencing feelings of shame, aggression, hurt, guilt and out-of-placeness’[lxxxi]) of the impact of neoliberalism on the university sector.[lxxxii] The ‘disciplinary technologies’[lxxxiii] of neoliberalism, New Public Management practices and audit culture have been described as inducing ‘psychosis’ in modern public universities:[lxxxiv] an institutional exemplar of the social determinants of mental health: ‘Bad things happen and can drive you crazy.[lxxxv] And all this because, like other former public sector services (such as the NHS, social work, probation, socal care), “the university has become a place of work rather than a vocation”.[lxxxvi]
The diminution or loss of a working environment in which academics, medics, and others, experienced personal / professional agency and efficacy; could practise critical enquiry; and exercise co-creativity without fear or caution, has been replaced by heightened risks and surveillance, as a consequence of top down managerialist controls and government Cuts; and a loss of self esteem and status.[lxxxvii] None of these should count as privilege, rather as human rights. Professor Ronald Barnett, an acknowledged expert worldwide on higher education systems, reflects on the changes to the character of academic life in C21:
There is much to be pessimistic about . . . . Its super-saturated character, being dense with tasks and expectations; its extending into the life-world and so affecting the life-world balance; its audit and surveillance regimes; the ‘commodification’ of student learning; and its sheer instrumentalism, as every activity in academic life is required to have an outcome or impact beyond itself: these are just some of the sources of pessimism.[lxxxviii]
The public sector post 1945 created a wide range of opportunities (e.g. education, training, travel) and jobs that provided many people with not just a secure income and career path, but with job satisfaction: personal and professional purpose, daily meaningfulness and social conviviality in the workplace. Women especially benefitted from these changes. This is what has been under political attack in these long neoliberal years, and it has been experienced as a violation of the person, with integrity as a casualty; see Andrew Sparkes and Mary O’Reilly (16 05 2013).[lxxxix]
It is clear that mental health is not just ‘a whole population issue’,[xc] but in the wake of 30+ years of neoliberal coercion and control, a whole society crisis, as we stare down ravaging inequalities and consequential personal and social damage.[xci] We have a common enemy and it is not each other. Together we can pool skills and expertise, bear witness across difference, and build alliances that will effect the paradigm change, not just in mental health services, but in society, that will foster human dignity, equality and environmental sustainability.
A necessary chorus of dissent and co-creativity.
These further examples of the social determinants of mental distress and the evidence of widespread injury and damage (to students, workers of all kinds, creatives and professionals alike), lend urgency to the critique of mental health services:
- that decontextualize the individual[xcii] and human distress;[xciii]
- that identify ‘control by the powerful, for their own self-interests, of the relatively powerless’;[xciv]
- a model of ‘control and coercion, not support and care’.[xcv]
The politics of health implicates and has consequences for us all. As has knowledge production: What counts as evidence? Who gets to speak? Who listens? Like academic critiques of neoliberalism, mental health activism, theory and critique go beyond identifying the needs and aspirations of a specific constituency. For example, the recent draft SWAN Mental Health Charter[xcvi] highlights values as well as practices, and implicitly addresses the question of power relations and responsibility, thereby engendering a vital conversation about what counts as good practice. In contrast to psychosocial practices that can (unavoidably?) serve to individualise misery and damage, it is part of a movement that advocates greater service user participation[xcvii] (i.e. partnership and collectivity), as well as self-advocacy,[xcviii] and collaboration, for example involving trade unions.
Moving away from demarcation and divergence, and the tensions and conflicts these have engendered within mental health services in the UK, the service-led group reVision[xcix] facilitates mutuality and reciprocity, beginning to establish a convergence of interests and values between service users, service providers, academics and activists, for example, without loss of face or individual identity. This is peer group process in action beyond the medical environment, and counters entrenched white western, masculinist cultural assumptions about the primacy of the autonomous individual (historically non disabled, white and male), and the virtue of hierarchy.[c] Mutuality, reciprocity, sociability, conviviality are no mere add-ons. Neoliberalism discounts and ridicules these values as beyond and irrelevant to the scope of market consumerism and corporatism.
It is clear that experiencing disadvantage as a function of racism, homophobia, misogyny, bullying, mental health issues, for example, is not simply a function of social class or poverty, although both these are likely to exacerbate mental health crises. Racism, homophobia, sexism, misogyny, social class prejudice, have been politicizing experiences for many of those at their sharp end, moving us beyond victim status and identity politics, to offer critiques of power in society: organizational, cultural, political and economic. Equality, human rights, sustainability and democracy are entwined projects.
Since 2010 and the ConDem onslaught, many single issue campaigns have sprung up, for example against the bedroom tax, the council tax, benefits cuts, NHS privatization, etc.. These have involved many older and/or vulnerable people unaccustomed to public speaking or action, who have no experience of political campaigning (discourse, language, strategy and communication). In the wake of the Con Dem Cuts and break up of public sector services and values, inexperienced activists may resist identifying their actions as ‘political’. They just want “better services”.
Moving suddenly from a position of social and experiential powerlessness and subjugation, into collective action, personal participation, and self advocacy is a steep learning curve, exposing differences and inequalities between the least and the most experienced activists, that can result in tensions and conflict, arising out of feelings of inferiority on the one side, and superiority on the other. But pain, anguish, anger do not suffice as political heft. Sharing experiences, testifying to disadvantage, bemoaning misery, venting anger, while important features of rising awareness, will not on their own effect the change campaigners need and want.
If you are to build effective alliances with other victims and enemies of the neoliberal project; if you are not to continue to be represented and done to by others / ‘experts’, a process of consciousness raising and politicization is vital. This is a hard call if you feel isolated and without hope or energy, as a result of mental health issues. And as with the claims of previous subjugated constituencies or uprisings, there is the inbuilt paradox of simultaneously claiming disadvantage (specialness, victim status) and agency (the ability to function ‘normally’, to be ‘hardworking’, contribute to other lives and to society). So wanting recognition of how debilitating depression or PTSD is, for example, accompanies the desire to be accorded full human rights and status. And it’s not an either/or.
Political awareness comes on the back of subjugation and injustice, and its endurance. The development of resistance follows. And in turn, we build collectivity and alliances. This process of politicisation is a movement outwards, from privacy into the public domain, from silence to voice, from fear to agency and co-creativity / co-production.[ci] A well-worn, historical path.
But Thatcherism and neoliberalism stigmatised and criminalized protest and political organisations, such as the unions. Neoliberal culture also had its sights on democracy itself, and has worked hard to convince people that politics was for ‘élites’ or ‘losers’, and that political debate was old-fashioned, unfashionable (unless packaged for BBC1’s Question Time) and pointless.
I have long argued that agency and creativity function for humans as both self-care and politics. This understanding has particular resonance in 2014 for the mental health movement. It has been claimed that:
Fighting for the rights of people deemed mad, who have already suffered more than enough, is the last great civil rights movement.[cii]
This bold (over)statement implies, not just self-advocacy, but alliance and representation; a dissolution of boundaries as well as hostilities and prejudice, in recognition that previous liberation and sustainability movements have never been simply rooted in vested interests, but brought together diverse and hybrid individuals and communities of interest, to identify and address broad human rights, social justice and environmental issues. Vested interest politics, after all, belongs to the Right.
Acknowledging our shared “somatic crisis”[ciii] and the need to move from bullying and authoritarianism, control and coercion; from psychiatry (like universities) identified by women service users as an ‘essentially patriarchal institution’,[civ] towards ‘nurturing mental capital and wellbeing’,[cv] returning empathy and compassion to the public domain, on the basis of a human rights framework,[cvi] and a commitment to social justice, is the necessary, collective undoing of the neoliberal project, for all our sakes/souls. Common ground for urgent but long term cultivation.
val walsh / 25 06 2014
[i] See Andrew C. Sparkes (2013) Qualitative research in sport, exercise and health in the era of neoliberalism, audit and New Public Management: understanding the conditions for the (im)possibilties of a new paradigm dialogue. Qualitative Research in Sport, Exercise and Health: 13.
[ii] Thomas Piketty (2014) Capital.
[iii] Sean Baine (02 05 2014) letter to The Guardian.
[iv] Ha-Joon Chang (01 05 2014) Article in The Guardian. Also (2011) 23 Things They Don’t Tell You About Capitalism.
[v] Richard Wilkinson & Kate Pickett (2010) The Spirit Level. Why Equality is Better for Everyone. London: Penguin Books.
[vi] See CLASS, For a qualitative, nuanced analysis of inequality, see Danny Dorling (2011) Injustice: Why Social Inequality Persists.
[vii] As Derry Hunter’s gendered autobiographical narrative of sexual violence, oppression and psychosis testifies (18 11 2013): Madness and uncivilisation. ISP UK event, Liverpool Quaker Meeting House.
[viii] teacher killed in classroom
[ix] See Val Walsh (15 01 2014) ‘Picking up the pieces: men and masculinity in an outsourced world’. LJMU. In category ‘Conference papers 2014’. togetherfornow.wordpress.com
[x] Fergal Keene talk 2013. University of Liverpool.
[xi] See Owen Gibson (12 05 2014) Premier League chief under fire for sexist emails. The Guardian. And Rani Abraham (21 05 2014) Why I blew the whistle. The Guardian.
[xii] See Val Walsh, selection of unpublished letters to The Guardian at togetherfornow.wordpress.com: (02 07 2010) Opening a dialogue on rape, violence and gender [posted 19 09 2013]; (06 07 2011) Rape, violence and gender: the new normal? (posted 19 09 2013]; (07 04 2013) The Philpott case and the media: sensationalism, denial, obfuscation, irresponsibility. [posted 19 09 2013]; (17 05 2013) Daniel Cohn-Bendit: children of the ‘revolution’ [posted 19 09 2013]; (02 06 2013) Gender, violence and the media: free speech or irresponsible speech [posted 19 09 2013]; Anachronistic conduct [posted 21 01 2014]; Gender-neutral language ‘disappears’ men and masculinity [posted 20 04 2014]; Murder in a UK classroom [posted 02 05 2014].
[xiii] John Read & Jacqui Dillon (eds, 2nd edition) (2013) Models of Madness: Psychological, Social and Biological Approaches to Psychosis. London & New York, Routledge, published for ISPS (The International Society for Psychological and Social Approaches to Psychosis: 3.
[xiv] Ibid.: 2.
[xv] John Read (05 04 2014) University of Liverpool handout. 196
[xvi] Judi Clements & Emma Davies (2013) Prevention of psychosis. Creating societies where more people flourish. Read & Dillon (eds.): 296
[xvii] Judi Clements & Emma Davies (2013) Prevention of psychosis. Creating societies where more people flourish. Read & Dillon (eds.): 300/3002.
[xviii] John Read & Jacqui Dillon (2013) Creating Evidence-based, effective and humane mental health services. Overcoming barroers to a paradigm shift. Read & Dillon (eds.): 400.
[xix] John Read, Lucy Johnstone & Melissa Taitimu (2013) Psychosis, poverty and ethnicity. Read & Dillon (eds.): 191.
[xx] John Read, Lucy Johnstone & Melissa Taitimu (2013) Psychosis, poverty and ethnicity. Read & Dillon (eds): 200.
[xxi] Bryan Koehler, Ann-Louise Silver & Bertram Karon (2013) Psychodynamic approaches to understanding psychosis. Defences against terror. Read & Dillon (eds): 243
[xxii] Department of Health (2003) Women’s Mental Health: Into the Mainstream, Strategic Development of Mental Health Care for Women. Cited Women’s National Commission (January 2010) A Bitter Pill to Swallow: Report from WNC Focus Groups to inform the Department of Health Taskforce on the Health Aspects of Violence Against Women and Girls: 4.
[xxiii] Women’s National Commission (01 2010) A Bitter Pill to Swallow: Report from WNC Focus Groups to inform the Department of Health Taskforce on the Health Aspects of Violence Against Women and Girls: 4.
[xxiv] HM Government (2007) Cross Governmeånt Action Plan on Sexual Violence and Abuse. Home Office: London. Cited WNC (2010) A Bitter Pill To Swallow : 4.
[xxv] Recent evidence of numerous historic abuse cases, perpetrated by prominent men in the public domains of entertainment and politics (many carried out over a period of years) have amply demonstrated the lingering mental distress, ill health and damage caused by these violations.
[xxvi] (03 2014) Domestic Abuse & Mental Health.
[xxvii] Ibid.: 4.
[xxviii] Cited J. Read, N. Haslam, L. Sayce & E. Davies (2006) Review article. Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand: 114: 307.
[xxix] See Refuge 2007; Home Office 2010.
[xxx] See Jessica Valenti (25 05 2014) Elliot Rodgers’ California shooting spree: further proof that misogyny kills. The Guardian.
[xxxi] Hannana Siddiqui & Meena Patel (2010) Safe and Sane. A Model of Intervention on Domestic Violence and Mental Health, Suicide and Self-Harm Amongst Black and Minority Ethnic Women. Southall Black Sisters Trust: 12.
[xxxii] Raleigh et al cited Siddiqui & Patel (2010): 9.
[xxxiii] Siddiqui & Patel (2010): 7.
[xxxiv] Ibid.
[xxxv] Siddiqui & Patel (2010): 11.
[xxxvi] What Women Want Group (03 2014) Domestic Abuse & Mental Health: 19.
[xxxvii] What Women Want Group (03 2014): 28.
[xxxviii] Ibid.: 25.
[xxxix] See WNC (2010) Psychiatry and mental health services; and Adult social Care Services for ‘vulnerable adults. A Bitter Pill To Swallow: 86-96.
[xl] Ibid.: 87.
[xli] Ibid.: 31.
[xlii] Ibid.: 40.
[xliii] Ibid.: 34.
[xliv] Ibid.: 42.
[xlv] M. Boyle (2011) in Rapley et al De-Medicalizing Misery, cited Read & Dillon (2013) Creating evidence-based, effective and human health services. Overcoming barriers to a paradigm shift. Ibid: 398. See for example, WNC Report (2010) A Bitter Pill to Swallow, and Hannana Siddiqui & Meena Patel (2010) Safe and Sane. A Model of Intervention on Domestic Violence and Mental Health, Suicide and Self-Harm Amongst Black and Minority Ethnic Women. Southall Black Sisters Trust.
[xlvi] See Val Walsh (2005) ‘Into the sunlight’: Gender, narrative, mental health. Resources for a missing conversation. togetherfornow.wordpress.com
[xlvii] A Bitter Pill To Swallow (01 2010): 14.
[xlviii] Hannana Siddiqui & Meena Patel 2010) Safe and Sane. A Model of Intervention on Domestic Violence and Mental Health, Suicide and Self-harm Amongst Black and Minority Ethnic Women. Southall Black Sisters Trust: 8.
[xlix] Ibid.: 113.
[l] See Human Rights Act 1998; the Beijing Declaration and Platform Action 1995; the Convention for the Eliminaton of All forms of Discrimination against Women (CEDAW) 1979; and the Convention on the Rights of the Child 1989.
[li] Rory Carroll (26 05 2014) US gun culture and mental health system under fresh scrutiny after shooting spree. The Guardian.
[lii] Cited Carroll (26 05 2014).
[liii] Jessica Valenti (25 05 2014) Elliot Rodgers California shooting spree: further proof that misogyny kills. The Guardian.
[liv] Matthew Taylor (02 06 2014) Savile abused 500 children, says report. The Guardian. A study by the NSPCC, commissioned by BBC Panorama in conjunction with The World At One. (02 06 2014) provide the latest evidence.
[lv] See Val Walsh (2005) ‘Into the sunlight’: Gender narrative, (mental) health. Resources for a missing conversation. togetherfornow.wordpress.com
[lvi] John Read & Jacqui Dillon (2014) Creating evidence-based, effective and humane mental health services. Overcoming barriers to a paradigm shift. Read & Dillon (eds.): 405.
[lvii] R. Kogstad (2012) Towards a paradigmatic shift in mental health care? cited ibid.: 404.
[lviii] See Walsh (2005).
[lix] Pat Craven’s The Freedom Programme, first available in Tranmere, on the Wirral, has proved influential and useful as both resource and process for women survivors, and has since been adopted across the country and made available as a book.
[lx] Cited WNC (01 2010) A Bitter Pill To Swallow: 89.
[lxi] Ibid..
[lxii] Ibid.: 90.
[lxiii] Ibid.: 92.
[lxiv] See ibid.: 93.
[lxv] See ibid.: 95.
[lxvi] As shocking secret filming inside institutions has shown.
[lxvii] WNC (01 2010) ibid..
[lxviii] See Boyle (2011) Making the world go away, and how psychology and psychiatry benefit. In M. Rapley et al (eds.) De-Medicalising Misery: cited Read & Dillon (2014) Creating evidence-based, effective and human mental health services. Overcoming barriers to a paradigm shift: 397/8.
[lxix] See for example, press cutting / murder
[lxx] Melissa McEwan, cited Jessica Valenti (25 05 2014).
[lxxi] See Jane Fae (30 05 2014) Is this a trans moment? The Guardian.
[lxxii] In 2009 the Nursing & Midwifery Council struck off a male psychiatric nurse, as a result of his five month “inappropriate sexual relationship” with a much younger female client, whose mental health issues (including suicidal ideation) were consequent on her experience of sexual abuse as a teenager by an older man. Contrast this with the drawn out process of denial and non-enquiry into, for example, the (now admitted) sexual harassment of younger Lib Dem colleagues by Lord Rennard. Fellow Lords are now “glad it’s all over” (Lord Steel, 29 05 2014) and demanding his re-instatement after his suspension from the House. See Rowena Mason (31 05 2014) Party grandees call for Rennard’s return to fold. The Guardian. See also Val Walsh (21 01 2014) Anachronistic conduct. Unpublished letter to The Guardian. Posted in togetherfornow.wordpress.com
[lxxiii] New Zealand nurse, John Clarke, personal communication to JR, 2012, cited Read & Dillon(2014) Creating evidence-based, effective and humane mental health services. Overcoming barriers to a paradigm shift: 398.
[lxxiv] Cited Louise Carpenter (17 05 2014) Bad medicine. The Guardian Weekend: 50.
[lxxv] Ibid..
[lxxvi] Ibid..
[lxxvii] See Judith Varley (08 04 2014) on the crisis of mental health for carers. Merseyside People’s Health Assembly Report: 3-7.
[lxxviii] Nick Hopkins (12 05 2014) Mental illness surges among war veterans. The Guardian. Dr. Nicola Sorfleet (12 05 2014), in charge of psychological therapies at Combat stress’s treatment centre in Leatherhead, Surrey, reported: Veterans are seeking help quickly. This gives us hope. The Guardian.
[lxxix] General Sir Richard Dannatt, chief of the general staff when British forces were fighting in Iran and Afghanistan. Cited Nick Hopkins (12 05 2014).
[lxxx] Ibid..
[lxxxi] R. Burrows (2012) Living with the h-index? Metric assemblages in the contemporary academy. The Sociological Review, 60 (2), 355-372. Cited Sparkes: 4. See also Stephen Ball (2003) The teacher’s soul and the terrors of performativity. Journal of Education Policy Volume, 18 (2), 215-218.
[lxxxii] See Sparkes’ chilling exposition and summary (2013). Mary O’Reilly (16 05 2013) searingly testifies to the current crisis in mental health care in ‘Human cost – Where does personal and professional integrity figure on a spreadsheet?’ BASW conference, London. The parallels between the analyses of Andrew and Mary are telling. As is the underlying (on the one hand) and explicit (on the other) pain, anguish and anger of their testimony. And their courage.
[lxxxiii] R. Craig, J. Amernic & D. Tourish (in press) Perverse audit culture and accountability of the modern public university. Financial Accountability and Management. Cited Sparkes: 7.
[lxxxiv] Ibid.: 8.
[lxxxv] John Read, Lorenza Magliano & Vanessa Beavan (2013) Public beliefs about the causes of ‘schizophrenia’. Bad things happen and can drive you crazy. In Read & Dillon: 143.
[lxxxvi] Ronald Barnett (2014) Conclusion. Academia as workplace: A natural pessimism and a due optimism. Lynne Gornall, Caryn Cook, Lyn Daunton, Jane Salisbury & Brychan Thomas (eds.) Academic Working Lives: Experience, Practice and Change: 302.
[lxxxvii] See Lynne Gornall et al. (2014) Introduction: Starting the day fresh: hidden work and discourse in contemporary academic practice. Gornall et al.: 1-9. Also Rod Kelly & Rebecca Boden (2014) How management accounting shapes academic lives. Gornall et al.: 94-101; Lynne Gornall & Brychan Thomas (2014) Professional work and policy reform agendas in a marketised higher education system. Gornall et al.: 110-118; Sandra Acker & Michelle Webber (2014) Academia as the (comp)promised land of women? Gornall et al.: 199-206.
[lxxxviii] Ronald Barnett (2014) Conclusion. Academia as workplace: A natural pessimism and a due optimism. Lynne Gornall, Caryn Cook, Lyn Daunton, Jane Salisbury & Brychan Thomas (eds.) Academic Working Lives: Experience, Practice and Change: 296.
[lxxxix] refs to Andrew Sparkes, Mary, et al.
[xc] Judi Clements & Emma Davies (2013) Prevention of psychosis. Creating societies where more people flourish. in Read & Dillon: 296.
[xci] See Val Walsh (09 09 2013) ‘Why set up a blog now’ and ‘Democracy in turmoil: Lies, exploitation, corruption, damage, division, conflict, abuse. . . Is that all there is? (With a nod to singer Peggy Lee.)’ togetherfornow.wordpress.com
[xcii] John Read & Jacqui Dillon (eds.) (2013), 2nd edition) Models of Madness: Psychological, social and Biological Approaches to Psychosis. East Sussex, Routledge: 399.
[xciii] John Read & Jacquie Dillon (2013) Creating evidence-based effective and humane mental health services. Overcoming barriers to paradigm shift. In Read & Dillon, ibid: 394.
[xciv] Ibid: 393.
[xcv] Mick McKeown, Fiona Jones & Helen Spandler (2013) Challenging austerity policies: democratic alliances between survivor groups and trade unions. Mental Health Nursing 33(6): XX.
[xcvi] (04 2014) SWAN Mental Health Service Charter.
[xcvii] See Jacqui Dillon, Peter Bullimore, Debra Lampshire & Judi Chamberlin (2014) The work of experience-based experts. Read & Dillon (eds.): 314.
[xcviii] See ibid.: 310.
[xcix] The mental health organisation, reVision, aims to be “an alliance of critically aware thinkers”. Its statement of intent and purpose refers to empowerment through research and education, the connections between individual experiences and structural oppression and disadvantage, facilitating collective empowerment, and speaking out against the medicalization of inequality. For more information: revision.liverpool@hotmail.co.uk
[c] See Boyle cited Read & Dillon: 397.
[ci] See The Resilience Space 2014. Surviving Work: the Activists’ Survival Guide. http://www.survivingwork.org
[cii] Dillon , Bullimore, Lampshire & Chamberlin (2014) ibid.: 315.
[ciii] Cited Andrew Sparkes (2013) ibid.: 13.
[civ] WNC Report (2010) ibid: 92.
[cv] Clements & Davies (2013) ibid: 297.
[cvi] Mary O’Reilly (2013) points out that the NHS constitution, part of the Health Act 2009, makes clear that healthcare and human rights go hand in hand. See also Hannana Siddiqui & Meena Patel (2010) Safe and Sane. A Model of Intervention on Domestic Violence and Mental Health, Suicide and Self-Harm Amongst Black and Minority Ethnic Wome, citing the importance of human rights obligations as a framework for best practice. Southall Black Sisters Trust. And Women’s National Commission Report (January 2010) ibid.
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