All posts by Carole

Unconditional positive regard?

I would like to think a little bit about the use of language within mental health. I have struggled for a couple of years with the kind of language that we use on a regular basis, but don’t really give it much more thought. I know we all have words or phrases that when heard, make your hackles rise. Here is a small selection of mine!  How about “therapeutic relationships” for a start, hands up if you can give a definition? I’m sure we all can, but it will mean something different to everyone. Yet we use it often, how many times do we hear people say, “well, first of all I’d build a therapeutic relationship with the person” No! No! No!

Conversation (click to see photographer)

I noticed that even Jim Chapman and Cheryl Chessum struggled with this concept in their chapter in “The fundamentals of mental health nursing”. Their research shows that Aldridge (2006) states that brief definitions of the therapeutic relationships are scarce, giving only one which is, “Building a genuine human alliance that might begin to address the person’s problems with living.” (Barker & Buchanan-Barker, 2005). Jim and Cheryl say that engagement with the client starts the therapeutic relationship. But does it ever get underway? And if it does, where to then?

Maybe it’s on to “Unconditional positive regard”. The good old statement that says I’m not really troubled that you have been violent and aggressive to people in the past, that you beat up your girlfriend so badly she lost her baby, or that you threw your 9 week old puppy down the waste disposal chute, I’ll accept you as you are now because I believe you were lacking “insight” at the time. But what it really means is that I will try and disguise the disgust I feel for your actions because I’m only human and because I’m told you have a mental health problem – but I’m not promising anything.

Speaking of insight…….The Collins English dictionary defines insight as;

“The ability to perceive clearly or deeply”

 And “a penetrating and often sudden understanding, as of a complex situation or problem. There is also, “3. psychol; The capacity for understanding one’s own or another’s mental processes”

“4. Psychia; the ability to understand one’s own problems, sometimes used to distinguish between psychotic and neurotic disorders”.

Now I consider myself to be a fairly rational, responsible and capable human being, but am I always insightful according to the definitions? I don’t think so! So why do we often hear, “Mr Jones, suffering from schizophrenia, lacks insight”. How dare we? A double whammy there – who says that everyone suffers from or with schizophrenia? I know of many people who have and still do enjoy their experiences.

I’m not so stupid as to think we can, or should get rid of this type of language, but I think we need to consider the implications of using it. Are we really being honest in our use of it? Does it exclude people because we as mental health professionals have a shared, common understanding of its meaning and others don’t? Is it a cunningly disguised way of stigmatising and discriminating against “service users/patients/clients” (there’s another area that we should really get sorted!)

What do you think?


(NB Click images to see photographers)

Service losers?

I have just been reading some work written by people looking at issues of stigma and discrimination in mental health, some of the material made me think quite a lot about this subject. Not only did the work state the obvious – things we already know such as people with a mental health issue treated differently to others, but it also examined the role of mental health nurses and I couldn’t help but recognise some of these statements were actually true.

Much is written about stigma and discrimination in mental health, particularly regarding service users, patients clients etc. Erving Goffman, in his book Stigma: Notes on the Management of Spoiled Identity (1963), describes stigma as ‘ a special kind of relationship between attribute and stereotype. An attribute that is deeply discrediting, that reduces the bearer from a whole and usual person to a tainted, discounted one. We believe that a person with stigma is not quite human. We tend to impute a wide range of imperfections on the basis of the original one. We may perceive his defensive response to his situation as a direct expression of his defect’. Goffman goes on to point out that stigma is generated in a social situation. It is a reaction by society that spoils a person’s identity by a set of imposed norms that are brought to bear on an encounter.

There are ‘them and us’ distinctions that underpin prejudice and discrimination and pervade mental heath services. People with mental health problems are devalued and, therefore those who work with them are also devalued by association: this is termed ‘courtesy stigma’ (Goffman 1963) or ‘stigma by association’ ( Neuberg et al 1994) The image of the psychiatric nurse compared to that of busy A&E ‘angel’ or life-giving midwife is seen very differently. Psychiatric nurses receive least recognition, affirmation, acknowledgement and validation from their family and friends (Cronin-Stubbs & Brophy 1985) and the psychiatric system as a whole is downgraded to a ‘Cinderella service’.

In an attempt to preserve our status, it might be tempting for mental health nurses to dissociate themselves from the devalued patients, to amplify differences in order to reduce the perceived threat from ‘out-group’ members (Heatherton et al 2003). When out with clients/patients/service users, it is often clearly demonstrated that you have not chosen to be with this person, that you are not a friend, neighbour, relative, but are with a patient AND are just doing your job!

Does this happen?