Person-centred approaches to adult mental health

[Introduction]

Katy: Welcome to this Research in Practice for Adults podcast. I'm really pleased to be here with Lydia Guthrie who has written a recent front-line briefing for us called Person-Centred Approaches to Adult Mental Health. Would you like to just say a little bit about yourself and how you came to be here?

Lydia: Yes, thanks, Katy, hello. I'm pleased to be here too, so I qualified as a social worker in 1998, which is 20 years ago now, and worked in the Probation Service for 11 years, so I had a wide experience of working alongside people who had experienced different kinds of mental health diagnoses and people who had experienced all kinds of very difficult life events. After leaving the Probation Service, I started to work as a trainer and supervisor and I'm really delighted to be an associate for Research in Practice for Adults. I'm also training as a systemic family therapist, so I should probably declare from the start that systemic models, theories and approaches are close to my heart and I tend to think in a very systemic way. So, just to be upfront that that's my bias.

[Diagnoses of mental health conditions]

Katy: I think that certainly enriched the publication as well, certainly from my point of view. I mean, I had a background in psychology, and so I think it was only when we were delving into the evidence and the different viewpoints when we were researching this publication that I started to realise my own assumptions and expectations around what diagnosis is, what a mental health system is there to do, and how people engage within it. So, it was a really enlightening experience for me to be involved in this publication. So, I was interested in how aware you were of the different viewpoints around the debate around diagnosis in mental health at the moment and the medical model vs the person-centred approaches to mental health.

Lydia: Yes, it's a great question, Katy. I think I can answer that question on a range of different levels. I think as a professional, one of the areas where I work a lot is around attachment theory, and I've done lots of multi-agency training around attachment theory which has been attended by people from all kinds of different professions, so psychology, psychiatry, occupational therapy, social work and others. So, I'm very accustomed to having conversations with other professionals where we might conceive of people's situations or the challenges they're facing in very different ways and use very different language. So, I think on a professional level I'm, kind of, quite aware of the things that divide us and also the things that bring us together. On a personal level, within my extended family, I have a couple of relatives who've received diagnoses of mental health conditions that affect their daily lives and they both have a different relationship with the diagnosis. So, from spending time with my relatives and speaking with them and supporting them, that's really helped me to tune into the idea that individuals might have very different relationships with a diagnosis and how to support them in that.

Katy: The very different viewpoints and the debate that's going on, so, for example, there's a big debate on Twitter and the Power Threat Meaning Framework was released fairly recently before we started writing on it. Did those kinds of debates have an impact on how you felt about writing?

Lydia: Yes, they did, Katy, that's another great question. I did, when I first started doing, kind of, early exploratory reading in preparation for writing this briefing, I did spend a few hours on Twitter following the reaction from different people to the publication of the Power Threat Meaning Framework and noticing how quickly those debates become polarised. Also, how precious people's viewpoints are to them, be they somebody with personal experience of receiving a diagnosis or be they somebody with professional experience, or be they someone with both because, of course, those groups aren't mutually exclusive. So, I noticed how quickly people adopt positions that are incompatible with each other, and also how emotionally charged the discussions can become because these things really matter. The discussion can become very heated, which is a reflection of how important it is to people and how quickly we become very connected to our way of seeing the world, and having that challenged can feel very, very uncomfortable. So, I did spend a few hours reading Twitter threads and becoming increasingly anxious at the idea that I was going to write something which would have my name on it as well as under the RiPfA (Research in Practice for Adults_ umbrella that would be a reflection of my views. So, I did become quite mindful of how high stakes this discussions is for people, and rightly so.

Katy: Definitely. So, I guess, what did you do about that when you were feeling that responsibility for this huge diversity of different views and opinions around an issue? Did you do anything in particular to try and mitigate your anxiety or concern around that?

Lydia: Responsibility is a really good word for that, I did feel very responsible. Well, we had some conversations about it, and I certainly felt that your support was a real anchor. We were able to talk through what's the purpose of this document, what are the aims and the values that we want to espouse in the preparation and the writing of this document? Who will we seek peer review from? It was really important to both of us that there was a very wide range of peer reviewers coming from very different and diverse viewpoints, so that was very important to us. I also made sure that I had lots of time because I realised that in order to do the kind of job I wanted to do, it was going to take a lot of time and reflection, and lots of rewriting of versions. Then, I think I just reminded myself what the purpose was. I thought back to my own experiences of being a student social worker and arriving in a community mental health team, which was very much dominated by a medical viewpoint, very much rooted in the practice of diagnosis, and mostly medication-based treatment. I thought back to that experience and thought how useful I would have found it to have a resource that summarised different alternatives in an even-handed way and offered a critique of each of the different approaches. So, I reminded myself that I would have found that really useful, and that gave me some motivation to crack on with it.

[The peer review process]

Katy: Great, yes, and it will be of value, I'm sure. I think, because I can remember having a conversation when we were just about to put it out to peer review and we were wondering what it is that we were going to get back, and I was certainly less worried about it. I'd read your draft and I knew that it was balanced and I knew that the evidence and the research behind what we were talking about was sound, but I guess I didn't have the personal investment in being the author that perhaps you had in it. So, when you did get the peer review feedback and the comments back, how did that feel for you?

Lydia: Yes, it was a really interesting process and it caused me to reflect. The comments were broadly really positive and there were some very constructive ideas for things to include or reword or different perspectives to add, and they were all framed in extremely constructive ways. So, thank you, peer reviewers, if any of you are out there, for your hard work and your thoughtfulness. And the peer review process really improved the document. Reflecting on it, it made me consider my own relationship with wanting to get things right, not wanting to cause offence, and wanting to be liked. It really made me think about how important those things are to me, and am I okay with that? Is it okay to sometimes get something wrong? Is it okay to cause unintentional offence? Reflecting on that discussion that I was having in my head made me think that these themes are really important when we think about emotional distress, how people cope with traumatic events, how people cope with pain and despair and anger, and how people experience emotional distress that may lead to a diagnosis as a mental health condition. When we talk about these things, often we are really concerned to say the right thing. I don't want to say anything that might make it worse. I don't want to say something that causes offences, and then people won't like me and I'll be excluded from that group of people because I've got it wrong or put my foot in it.

So, it really made me reflect on how important it is to be able to have safe, respectful conversations about issues to do with trauma and emotional distress and mental health diagnoses, and giving each other the benefit of the doubt and being gracious to each other. If somebody says something a bit clumsily, not rushing to a conclusion that they're a terrible person and shouldn't ever be allowed to comment again, but being gracious and generous with each other because most people are trying to convey something that's very important to them. So, yes, those were the reflections that I had.

Katy: I guess those were reflections from you as an author writing and responding to peer review feedback, but probably you could draw parallels, kind of, between that and a practitioner working with an individual across and within a system. I think, you know, one of the key messages and conclusions that comes out of the report is acknowledging that complexity and recognising individual perception and choice as being at the forefront and foundation of then how support or services are then taken forward together. So, yes, it was just interesting hearing you talk about your experiences, and also in how that could be translated into practice as well as a piece of learning.

Lydia: Yes, very much so, very much so, practice between professionals and also practice between professionals and the people who are working alongside and with, I would very much agree that. In my current role, I'm fortunate enough to work with representatives of many different professions, so from psychiatry, psychology, social work, occupational therapy, and it's really interesting how often I have a conversation with someone who says, 'Oh, the members of that particular profession, they're so narrow-minded and they always think they're right.' I've heard members of every profession say that about members of every other profession, so I think there's a real message there that it's very easy to think, 'I'm really broad-minded, it's everybody else who needs to lighten up.' It's easy to think that intolerance is something that only belongs to other people.

Katy: Yes, so everything and every viewpoint has got something to offer.

Lydia: Absolutely.

Katy: Listening, and listening is the important thing.

Lydia: Yes, listening with an attitude of, 'What can I learn from this?' and with a respect that whether we're hearing a professional talk about a professional lens that maybe they've invested many, many years of training in, or whether we're listening to somebody who has experienced mental emotional distress and maybe has been diagnosed with a mental health, a psychiatric diagnosis. So, whether we're listening to a professional or to somebody with lived experience, not that they're mutually exclusive, we need to extend an understanding and a respect about how that perspective might mean a great deal to them. So, we listen with the intention to understand and to learn rather than the listening with cynicism or listening so that I can confirm that I'm actually right and you're wrong. That kind of listening narrows down the debate and entrenches people's positions and I think, at the end of the day, is less useful.

Katy: Thank you. So, just before we go off the peer review process, I just want to put a bit of a shout out to everyone who is listening. Here at RiPfA, we're always looking for people to peer review the publications that are in draft. Whether you're a practitioner or a strategic leader or, kind of, anywhere working across social care or allied health professionals, we're always interested in your viewpoints.

Lydia: Yes, I can second that as a peer reviewer. I've learnt a lot from peer reviewing other people's writings because you get to read what they've written, also you get to learn yourself, and RIPFA are really grateful as well, so they're always really nice about your comments too. So, if you're thinking about giving it a go, then do.

[The key messages of the publication]

Katy: As the author of this publication, do you have anything you want to say in terms of an overarching message from the publication, both in terms of the topic area, but also in terms of a practitioner or an author, or anyone working where they might be coming across an incongruence between a personal perception and a system perception?

Lydia: I think it's really important to be able to name discourses that are about power and hierarchy. That one of the things that leapt out at me from the reading and peer review process was that if an individual wishes to define their experiences of emotional distress using the language of psychiatric diagnosis and medication, then there will be a lot more support for them in organisations and in structures than there is if they want to define or describe their experiences through the lens of trauma or through the lens of attachment relationships, or through another person-centred lens. And it's really important to have that discussion because if we don't, then we're only entrenching the… if we don't name it, then the work that we do serves to entrench it, in my view, or to reinforce it. So, I think starting from that discussion about power is really important. It's also important to pay attention, I think, to other dimensions of unequal power in society. So, the lenses of gender, of race, of sexuality, of ability or disability, these are all very relevant lenses because your chance of being detained under the Mental Health Act varies according to ethnicity. Once detained, your chance of experiencing forceful measures such as restrained or forceful injection of medication, they all differ according to your ethnicity or your gender.

So, we also need to use those lenses to make sense of people's experiences as well, that's really important. Also, I think I became more humble in my views. I went into this with a bias towards thinking about trauma, thinking about attachment, thinking about relationships, thinking about people's social context. I think, personally, I have felt usefully challenged by people who feel that the experience of receiving a psychiatric diagnosis was a useful experience to them, so I read personal accounts from people who talked about the relief at receiving a diagnosis, the relief at having a name that they felt captured something important about their experiences. So, reading those accounts I found usefully challenging because it reminded me that if I'm going to espouse the view that it's okay for there to be multiple views, I have to accept that the view I feel closest to might not be correct, or might not be useful in all situations. So, I think writing this really helped me to move away from the question of what's right and to start adopting the question of what's useful, that different people find different lenses useful or less useful ways of describing or capturing their experiences, and that's okay.

So, for us as practitioners, the question is, what's the most useful framework in this moment of time with this person, with this family, with this professional, for example? And that the lenses we adopt might vary from conversation to conversation, and from person to person, and that's okay. That might be about working in the most person-centred way we can and adapting, but I think also we need to be able to name it so that we can name the fluidity and don't feel that we need to nail our colours to the mast and say, 'This is where I stand.' It's okay if people want to do that, and people might have very strong views for doing that, and that's okay. I think in writing this briefing, I tried quite hard to adopt as open and non-biased an approach as I possibly could, so I look forward to readers telling me how I did.

Katy: Yes, and please do read Person-Centred Approaches to Adult Mental Health which is on the Research in Practice website. Thank you very much for that, Lydia. Is there anything else you wanted to add?

Lydia: Thanks, Katy. I think I really enjoyed writing it and I think, if anything, writing this briefing made me more passionate about wanting to be respectful towards the right of every individual to describe their experiences of emotional distress in a way that makes sense to them and is useful to them. It also made me more passionate about discourses about power and oppression, whether that's unequal power within the professional system or unequal power that people experience in wider social system, so, I hope I've managed to capture some of that.

Katy: Thank you very much for your time today, Lydia.

Lydia: Thank you.

Katy: And I hope you all enjoy reading Person-Centred Approaches to Adult Mental Health and have enjoyed listening to this podcast, yes.

Lydia: Thanks very much.

Katy: Thank you very much.

[Outro]

You've been listening to the Research in Practice for Adults podcast, and we hope you enjoyed it. Why not share with your colleagues, and share your thoughts on Twitter? Tweet us @ripfa [please note @ripfa is not in use, please contact us @researchIP]. Thanks for listening.