Monthly Archives: March 2009

Hard to reach groups? Try drawing nearer. Guest post by Deborah Living

Today’s guest post is by Deborah Living who is project manager of the Connect through Art Project with Full Potential Arts, she is also a freelance arts in health facilitator and a mental health service survivor. Deborah wants us to consider the role of arts in working with mental health service users.
Art making
Difficult to engage?

What do you think of when you hear the term ‘hard to reach’ groups? 
The term is generally used to describe members of society that service providers, organisations and institutions find ‘difficult to engage’.  You may have seen the term in a local council report, your strategic management document or a care plan – or even heard it in conversation with your colleagues.
As a survivor of the mental health system and a project manager within the field of the arts and mental health, I hear the term applied to people diagnosed with personality disorder, psychosis and complex needs and have also heard it in relation to young people, older people and those from black and minority ethnic backgrounds.  It is also often used to describe people with disabilities, homeless people, drug and alcohol dependants, religious and faith groups and those who are lesbian, gay, bisexual and transgender.


Does the term ‘difficult to engage’ say more about the methods being used than the people it is used to describe?  Do those who use the term stop to ask “what helps?” and “what doesn’t help?”, or do they rely on using prescriptions and procedures, medications and methodology that all too often fall short in addressing the individuals’ fundamental needs?

“What helps . . . and what doesn’t help?” was the focus of a recent mental health event at The Centre of Excellence in Interdisciplinary Mental Health in Edgbaston.  Organised by Sue Imlack of the West Midlands Personality Disorder Service User Network, and designed for users of the mental health service recently given the diagnosis of Personality Disorder, or who think it may apply to them, I facilitated an arts in health workshop during the event.

I asked the delegate group, comprising more than thirty users of the mental health service, to consider the question “What helps . . . and what doesn’t help?” in relation to mental health service providers and within other meaningful relationships.  The delegates were asked to respond to a selection of images with both positive and negative words and then form into groups to create collective collages inspired by their responses. 

I asked the groups to feedback to their fellow delegates at the end of the exercise.  The images produced were both emotionally articulate and visually literate.  Within just one and a half hours of creative activity the participants had shared complex thoughts, touched upon pre-verbal emotions and undergone a group process with people they had never met before.

These complex experiences were depicted and verbalised in striking ways – 

• An image of a baby was described as “dreaming of the time when it was in the womb”
 and spoke of safety, security and peace.

• An image of a cow in the desert was described as “negative – because the cow does not have  any grass” and spoke of lack, neglect and unmet needs. 


My experience of those who took part in the workshop was not of people who were difficult to engage.  On the contrary, my experience was of people engaging with one another – and reaching back to me – through a simple yet effective creative activity designed to encourage self-expression and communication.

I wonder, then, if everyone who uses the terms ‘hard to reach’ and ‘difficult to engage’ questioned their own practice a little more, whether the term would disappear from our language altogether.

Deborah Living is project manager of the Connect Through Art project with Full Potential Arts and is a freelance arts in health facilitator.  The views expressed by Deborah in this article do not represent those of either Full Potential Arts or the West Midlands Personality Disorder Service User Network.


Inequality, health & the credit crunch.

“life expectancy here in London falls by one year for every underground station you stop at from Westminster to Canning Town”

(Gordon Brown 2008)

I am looking forward to reading “The Spirit Level: Why More Equal Societies Almost Always Do Better” by Richard Wilkinson and Kate Pickett which was published at the start of March. Wilkinson has a long track record of studying and drawing attention to the effect that inequalities may have on public health.  Most famously, Wilkinson’s work played an important role in the development of the report into health inequalities that came to be known as the Black report. This link has a good account of the history behind the Black report as well as the then government’s rather un-enthusiastic reaction to it’s conclusions. 

Despite the fact that we have long had good evidence suggesting that inequality has a powerful effect upon health I would argue that usually, nothing very much is done about it. Usually the most prominent Public health messsage is of the “take care of yourself” variety i.e. Five portions fruit & veg, don’t smoke, drink too much, get fat etc etc.  Whilst there is nothing wrong in suggesting that people look after themselves the argument has always been that this “look after yourself” message is pushed by Governments in preference to actually doing anything concrete about structural inequalities in society. I wonder what difference our recent economic woes & the credit crunch will make to this argument?

We have seen an awful lot of argument and anger over executive pay and bonuses for bank bosses. Whilst I think it is a bit simplistic to blame everything upon these people, I do think it is good that some light has been shone onto this sort of thing & that debate has been started about greed in society. 

Am I being naive in wondering whether some good might eventually come out of this current crisis? – Wilkinson’s book (above) is one of a few things (or this) I have noticed recently that are trying to discuss this issue. I predict that this forthcoming report by Micheal Marmot into health inequalities  which is due in December will get quite a lot of attention. I suppose we will have to wait and see what difference any of this makes.

In the meantime, I will answer my own question – I suspect it is naive to imagine that anything will change – the economy will eventually pick up, the rich will continue to get rich & the poor become poorer & all this will get forgotten about again? – or will it- what do you think?
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Mental Health Nursing – Time to flex our muscles?

Last I looked at the NMC statistics there were over 100,000 Registered Mental Health nurses in the UK, Isn’t it time that we flexed our muscles and got our voices heard?

Mental Health Nursing in the UK is beginning to adapt to the 21st century. As a professional group we are facing some fascinating opportunities and challenges. Increasingly we are required to consider Human Rights v Responsibilities v Risk. This is interwoven with the Mental Capacity Act, the reviewed Mental Health Act alongside Nursing & Midwifery Council changes to pre-registration and post-registration education, New Ways of Working, The Darzi Review, Nurse prescribing, The National Dementia Strategy and greater demands for evidence based practice just to identify a small selection of the policy drivers in mental health nursing and services.

As a mental health nurse educator of many years I would contend that not only do we need high quality initial and continuing education but Mental Health nurses need to demonstrate their worth and value and expertise to mental health service users, carers and services through recognised research processes. We need to engage with high quality, large, random controlled trials (these are the Department of Health Gold Standard) which examine and specifies what we do, how, why and when we are effective in practice.

Looking over the pond to the example of our American colleagues in the American Psychiatric Nursing Association provides some useful strategies that mental health nurses in the UK could employ to enhance our practice. An effective national organisation for mental health nurses might be a start alongside a commitment to promoting rigorous doctoral level programmes for mental health nurses into their practice – too ambitious, I would welcome responses.

Laughing at the lunatic and distracted – it wouldn't happen these days?

I have always found William Hogarth’s engravings fascinating – detailing both the trivia and the drama of ordinary lives in 18thCentury England. Many of them offer commentary on the problems of the day and perhaps also our own times?

In 1735 Hogarth completed a popular series of engravings entitled the “Rakes Progress”. These depicted a young mans debauched journey from a privileged start in life to his death in the infamous London Asylum called Bedlam. This name of this institution has passed into our speech as a term for a fearful and chaotic place. 

The Rake in Bedlam
Hogarth: The Rake in Bedlam

In the foreground of this picture we see the attendants removing the Rake’s chains (although I have read some saying that the chains are just being put on?). In death he is mourned only by the sweetheart he abandoned to pursue a life of drinking, gambling and womanising. As is typical of Hogarth’s work the rest of the picture is full of incident.

The cell on the left shows a “religious maniac”. His face contorts as he sees the shafts of sunlight coming through the bars which he sees as a spiritual visitation. In another cell a man who believes himself to be a king adopts a regal pose – harder to see is the pot he is pissing into. If you remember Dava Sobells book Longitude you will know about the struggle to figure out how to navigate around the world, the man with the telescope has lost his mind in the attempt. Other figures depict depression, a man who thinks he is the Pope and a mad tailor, a reminder of the tailor who measures him for a suit at the start of his progress. Two fashionably dressed women stand out from amongst the inmates.

These ladies have paid to tour Bedlam, this was a popular diversion of the day and a practice that was allowed until 1770 ( See thiswebsite for more details) . One of them is holding a fan to her face and is thought to be either trying to waft the stench from her face or possibly trying to hide the fact that she is laughing at the inmates. It is thought likely that Hogarth himself had toured this institution as it is said that architectural details (such as the bars which divide the “curables” from the “incurables”) are correct. Hogarth was closely involved in the foundation a few years later of the Foundling hospital – which cared for abandoned children. It seems reasonable to me to assume that he would have had a good reason to visit other institutions and didn’t go to Bedlam just to laugh? Whatever his reason to visit though we can be grateful that ideas have changed since Hogarth’s day – or have they?

Everyone is familiar with the experience of meeting a stranger at a party and going through the “what do you for a living” routine. Nowadays I say that  I am a University Lecturer, but previously the revelation that I was a mental health nurse would often prompt a response such as “gosh you must be brave” or a request to talk about the sights I must have seen. If you are a mental health nurse – reflect on this yourself, do people have much idea of what mental health care is like or would their ideas more accurately fit Hogarths image?

Partly this may be due to media portrayals – try entering “schizophrenia” and “murder” into Google or recall the treatment Frank Bruno got from the Sun newspaper in the now infamous “Bonkers Bruno” headline. It is easy to question the press over some of this coverage, especially when the truth is that people with mental health problems are much more likely to be the victims than the perpetrators of violent crime (See MIND information for more details). It would be too easy (if not a little lazy?) to simply blame the press. Perhaps we all enjoy laughing at people who are perceived as different?

For example, I have laughed at some of the X factor auditions – there is an element of slapstick humour when things go horribly wrong but at the same time, being asked to join the laughter at films like this makes me uncomfortable. I have also come across this a few times as well – (whether this film is a fake or not) it is interesting to read the comments underneath.


What do you think? – I think we need to ask ourselves some questions: 

  What do we communicate to people about our work?

  •  What responsibility do we have in promoting understanding about mental health issues?
  •  Are we part of the solution?

…or sometimes part of the problem?

Guest Post : Psychiatric theories can be damaging

Today we introduce our first guest poster – Pam Pinder. Pam runs her own website which focuses upon carers issues (see also this link which is relevant to her blog post). In this post, Pam challenges us to consider one possible effect of a well known Psychiatric theory, as usual – we would be interested to hear your views on this.. 


The schizophrenogenic mother is the first one that comes to mind and the psychiatrist that I link this to is R D Laing but there were others that latched onto this theory.

Quote: A cold, dominant, conflict-inducing mother believed to cause schizophrenia in her child.

From the late 1940s to the early 1970s, the concept of the “schizophrenogenic mother” was popular in the psychiatric literature. Research later confirmed that the mother who could cause schizophrenia in her offspring did not exist. Such a blame-levelling concept, which had no basis in scientific fact, may have caused a great deal of harm. Sociocultural factors, coupled with developments in psychiatric theory, contributed to the genesis of the concept. Implications of this episode in the history of psychiatry are discussed. (Arieti 1997, p. 353; Neill 1990).

Even though this theory was alleged to have faded out in the early 70’s this theory of blame towards parents and link to childhood still exist today. Very recently I spoke to a mother whose daughter had been referred for a psychiatric assessment. Her daughter spent just thirty minutes with the psychiatrist, who promptly told her that she did not have a mental illness and he could not help her. Her problems were due to her childhood, consequently the daughter told her mother there was nothing wrong with her it was her parent’s fault she was the way she is.

The mother is left searching for clues as to what she was meant to have done. But this comment didn’t just stop there. This mother had lost a daughter ten years previous; she died of a brain haemorrhage. Her daughter not only blamed her for her mental health problems but constantly tells her mother that she killed her sister. This is coming from someone who as far as the psychiatrist is concerned does not have any psychological problems!

Of course this mother didn’t kill her daughter and there is no evidence that she caused her other daughter’s problems. Could you imagine how something like this would affect you when you are grieving for a child you lost and someone constantly making accusations that you were responsible for their death?


In a court of law you are innocent until proven guilty yet in psychiatry your guilt is based upon someone else’s theory – something that has been read.

Reflection: Such a Beautiful Notion!!

Reflection – “a beautiful notion” may not be how you would describe this term!  

Reflect, reflect, reflect, was all I heard from my tutors during the first three years of my nursing degree. I remember telling my friend ‘if they ask me to reflect one more time I think I am going to scream’. I could not get my head around what I was being asked to do. Why was it so important that every essay I wrote had to be reflective? As a consequence of my ignorance you can perhaps realise that most of my assignments barely scraped a pass and I was perceived as not the brightest of nursing students.


Then I met my last and final clinical assessor as a pre-reg nursing student, who opened my eyes to the wonderful world of reflection. I was fortunate enough to spend my 4th year in the company of a nurse who could see beyond my inability to pass assignments well and saw a student nurse with a brain who really wanted to learn (honestly!).  

Every day after placement we would spend an hour going through the service users we had seen that day. I was asked questions about how I felt in different situations that had presented themselves to me. Not just what was good or bad, but if I was anxious we looked at why I was anxious and where had that anxiety stemmed from. If I felt confident about something we followed the same process. I was asked about why I had chosen a particular course of action, why was I concerned, where was my evidence for that intervention for that particular patient? What could I take away from today that would help me in the future, but importantly what had I learned about myself? During the course of my last year I grew in confidence as a practitioner and as a person. My assignments went from low level passes to A grades.

The difference between my attempts at reflecting on my own for assignments and my reflections with my clinical assessor was remarkable. I now realise that what my assessor was helping me to do was reflect ‘on action’, a retrospective contemplation of practice undertaken in order to uncover the knowledge used in a particular situation, by analysing and interpreting the information recalled, Schon (1983). But not only that my assessor was offering me ‘guided’ reflection.  Johns, (2000), acknowledges that there are limits to reflecting alone and that guided reflection with a second person can allow the reflective process to become more meaningful. Students and practitioners often bring situations of emotional disturbance, grounded in such feelings as guilt, anger, anxiety, distress, conflict and inadequacy to guided reflection. The guide is there to help the student/practitioner to find meaning to the event, in order to understand and learn through and from it. As a consequence I matured and developed as a human being. I got to know myself better and became a healthier and more productive practitioner. 

Burns and Bulman, (2000) suggest self-awareness is the foundation skill upon which reflective practice is built. I am not suggesting that final year taught me everything I needed to know about myself to be the perfect practitioner or human being, but what it did do was open my eyes to the wonderful world of reflection and raise my self awareness to a point that I no longer stumbled through life hitting the same road blocks over and over again.  I still run into things every now again but never the same thing twice! 

I am not sure that self awareness is something that we can teach our students but I do feel that our job as tutors and as clinical assessors is to offer the students the time and process that I was offered to help the student get to know themselves better and develop into good/healthy nurses.

I urge students to not shy away from reflection and to demand more from your personal tutors and clinical assessors.  

I would enjoy hearing your thoughts on this.