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Outrage at compulsory treatment because they got the 'wrong man'

Fri, 28 Dec 2012 03:14:27 +0100

On Boxing Day the West Australian reported that a man fitting the description of an escaped patient from Graylands Hospital in Perth was detained at the hospital, given antipsychotic drugs and suffered an adverse reaction which landed him in the general hospital. Click here to see the report. The return of an escaped psychiatric patient or an adverse drug reaction do not usually make the news, except that this time the authorities got the wrong man. The state’s Minister of Mental Health expressed her apologies for the ‘dreadful mistake’ and the Shadow Attorney General described the incident as ‘unlawful assault’.

Most readers would agree with the politicians’ assessments but their words of concern uncover an implicit consensus that the ‘assault’ would have been justified on the ‘right’ man. That’s because the ‘right’ man had a diagnosis of mental illness and had been placed under the Mental Health Act. We should always be very suspicious when the state applies different standards to the treatment of different classes of citizen. In this case people believed that the wrong man ought to have been protected from detention and the compulsory administration of potentially harmful drugs but their outrage also underlined that they think these assaults were justified for the ‘right’ man. It doesn't matter to them that the right man may never have committed a crime and obviously did not want to be in the hospital or to take the drugs.

I await the day when our politicians and professional bodies apologise to all people who have experienced psychiatric ‘assault’ without making the distinction between lawful assault and unlawful assault or between people diagnosed with mental illness and others. The report on this incident is a depressing reminder that I may be waiting a long time.

Democratising Psychiatry

Thu, 02 Dec 2010 18:35:19 +0100

Twitter delivered an announcement this week from the Royal Australian and New Zealand College of Psychiatrists (RNZAP) proudly stating it had appointed a ‘consumer and carer representative’ to its governing body. The Australians have the irritating habit of tethering consumers and carers with each other in the same way that the song proclaims, ‘love and marriage go together like horse and carriage’. We all know ‘consumers’ and ‘carers’ are two distinct stakeholder groups whose interests and perspectives do not always align.

I read further down the announcement, curious to know the identity of the ‘consumer and carer representative’. As I expected, the new member is a well known ‘carer’ advocate, a good man, but less likely to ruffle the feathers of psychiatry’s leaders than many ‘consumer’ advocates.

I visited the RNZAP website to see who and how many sit on its governing body but found I had to be a member to find out. Not a good sign. I then looked at their constitution and discovered that the governing board has about as many members as a platoon or your average school class. I don’t envy anyone who has been selected to be a minority of one in such a crowded unwieldy arrangement.

If I wasn’t such a cynic I would probably congratulate the College on taking a very small step away from being a closed club to an open democracy. And I really should congratulate them, except I’ve seen modest incremental changes flicker and die too many times to believe they herald better things to come. I guess at heart I’m a revolutionary.

So, what would a revolution inside the world’s psychiatric colleges and associations look like?

I hadn’t really asked myself this question, but recently I read an interesting chapter on democracy in psychiatry, by US psychiatrist Bradley Lewis, in a book called ‘Liberatory Psychiatry’. Click here to find out more about the book.

Lewis starts off by writing there have been many liberatory efforts in psychiatry, starting with Pinel, and followed by the likes of Tuke, Freud, Liang and Szasz. He then makes the sobering observation that all these efforts at various kinds of liberation were crafted by psychiatrists, without the active involvement of people who use their services or of other stakeholders. He concludes that the systems these liberators devised ended up ‘skewed in rough proportion to the relative input and power of those involved’.

New liberation efforts within psychiatry should not be expert driven, according to Lewis. Key stakeholders, especially service users need to be involved, not just at the point of service but all the way up the system, to our psychiatric colleges and associations. In short, psychiatry needs to become democratised.

The main barrier to democratisation is the privileged place science has within psychiatry over other forms of knowledge. But science, writes Lewis, is a human activity like any other – driven by biases, interests, power relations and blind spots. Psychiatrists often fail to see this but if they did, science would be demoted to the same status as other forms of knowledge. An inevitable consequence would be the democratisation of psychiatry, away from ‘internal elitism’ where only those who know the science make all the key decisions.

Lewis quotes the American Psychiatric Association (APA) motto: ‘Member driven. Science based. Patient focused’. How can an association with 36,000 members who are all psychiatrists be patient focused he asks. The APA can only achieve genuine ‘patient’ focus if it becomes democracy-based rather than science-based. Science is a tool; it should not be the foundation.

Lewis suggests we need to open the membership of psychiatric colleges and associations to other stakeholders, whose power through representation should be based on how much psychiatry affects them. Therefore, the membership structure would be weighted towards the people who use services, followed by their families. Citizens and other stakeholders should also be represented. This diverse membership would have the power to make decisions about psychiatric guidelines, training requirements, journals, research, infrastructure and finances. How would decisions ever be made with such as diverse membership? Lewis suggests that proposals not supported by the majority but with over 20% support could be considered legitimate knowledge, with the caveat that it is controversial and needs further investigation.

Thank you Bradley Lewis for giving us a glimpse of what a revolution in the powerhouses of psychiatry might look like. The RNZAP has taken the first step on what could be a long journey into unknown territory. My fear is that the College will stumble and lurch back to the safety of the home plate before they take another step forward. That step would be the inclusion of a ‘consumer’ advocate on its governing body.

Two Accounts of Mental Distress

Thu, 18 Nov 2010 03:29:01 +0100

Many years ago, soon after I got out of the mental health system I applied to see my hospital notes. They arrived, two inches thick, inside some tidy brown folders.

I was shocked. I knew that the psychiatrists’ main interest in me was my psychopathology. I knew they found me frustrating, because their treatments didn’t work and I kept coming back. I knew they were irritated when I questioned their expertise. But what I don’t know until I read my notes is how little regard they had for me as a human being in a desperate existential struggle. I was to them, directionless, schizoid, disordered, immature, inadequate, inappropriate, histrionic, colourless, overactive, withdrawn, and psychotic. Inside the big brown folders, nothing was written about my suffering or despair. No-one wrote a positive word about me. No-one described me as competent or strong, or even as an ordinary human being who was a conglomerate of good, bad and indifferent qualities.

I kept checking to see if they’d got the right name on the covers of the folders. The files were all about me but I couldn’t see me in them. Worse still, there was no process that gave me a right of reply or allowed me to add my version to them. I started feeling more and more alienated.

Then it suddenly occurred to me that my right of reply was sitting in my box of journals under my bed. While the hospital staff were writing their version of my madness I would sometimes write mine while crouching in my bed or the hiding in the toilets.

I dragged the box into the daylight, grabbed a pair of scissors and started to match my journal entries with the hospital notes by date. Over the next few hours I created a linear collage of my journals interspersed with their notes, lined up from one end of the room to the other.

I was astonished at what I saw; two parallel accounts of my madness that could never meet, just like the sun and the moon can never shine brightly in the same sky. When the staff wrote about me they did it in the course of an ordinary day’s work. They wrote about what they saw on the outside through the thick lens of psychopathology. I wrote about what I felt on the inside, unfiltered by professionalism or pretensions of objectivity.

With some deletions, a little bit of editing and a lot of typing, the collage was transformed into words on clean paper. I called it 'Two Accounts of Mental Distress' and it spanned a hospital admission for an episode of depression. Later, at conferences and training sessions I read it out loud, with someone else reading out the clinical notes. It became a chapter in a British book called 'Speaking Our Minds' about people's experiences of mental health services that was published in 1996, and in a 2009 British publication called ‘Mental Health Still Matters’. You can download the full paper here. Here is an extract from it. My journal entries are in italics. The psychiatrist and nursing notes are in plain text.

Today I wanted to die. Everything was hurting. My body was screaming. I saw the doctor. I wanted to collapse against the wall and cry out and show him how I feel about things but I said nothing. Now I feel terrible. Nothing seems good and nothing good seems possible.

I am stuck in this twilight mood where I go down like the setting sun into a lonely black hole where there is room for only one.

Flat, lacking motivation, sleep and appetite good. Discussed aetiology. Cont. Li Carb. 250 mg qid. Levels next time.

I am lying face down behind a chair in the waiting room of the hospital.

I am a long piercing scream. All screaming on the inside of me and out of the pores of my skin. My screaming and my self are one. This is pure pain.

The doctor comes along and snaps at me to get up. He tells a nurse to put me to bed. I have never ever been in so much shame.

Guilt swoops down on me and pecks my sense of being good to bits, as I lie here snared between my sheets like a whimpering animal.

I am full of red hot blame at myself for everything. I cannot bear being so thoroughly bad. I am carrying hell around inside me.

On arriving on the ward - spent the entire day curled up on the waiting room floor behind a chair. Could not talk. Impression of over dramatisation but with underlying gross psychological turmoil. She is difficult to engage and to that effect I have admitted her for a period of two weeks in order to consolidate her working relationship with us.

I am locked in here alone in this black box. I used to hide its blackness with colourful decorations. On its walls I painted windows with pleasing views on them. Now I have been stripped right back to the bare boards of my mind.

My world has been emptied out, as if burglars broke into my mind and stole all my power. On their way out they pulled down my blinds. Now, I cannot see the world and the world cannot see me.

Poor eye contact, slow speech and movements. Stated her head felt empty and fuzzy; vision disordered, things appearing very ugly. Mentioned need to find meaning in her depression - not just a wasteful experience.

Download Two Accounts of Mental Distress here.

The end of compulsory treatment

Thu, 04 Nov 2010 08:14:01 +0100

Western culture places a high value on freedom of the individual. We only justify the removal of freedoms when citizens transgress or are regarded as not fully human. Since the eighteenth century enlightenment, rationality has become the pinnacle of full humanity. People seen to lack rationality are easily denied full human status and full human freedoms; among them are slaves, women and mad people.

There is a growing international movement to abolish special legislation allowing compulsory interventions on mad people. But in my own part of the world (Australia and New Zealand) compulsory interventions are a long way down the human rights agenda. Very few people worry about them or think to imagine a world without them. To them, compulsory interventions are inevitable and necessary – just like slavery and the disenfranchisement of women were once seen as inevitable and necessary.

When progressive people began to challenge slavery and the disenfranchisement of women the establishment responded with arguments that are often laughable in hindsight. Today’s arguments in favour of compulsory interventions could also become tomorrow’s quaint historical baggage. In fact the arguments for restricting the freedoms of all three groups tend to echo each other within at least four distinct but interlocking themes.

Firstly, the people are better off without their freedom. The people who supported slavery claimed that slaves needed to be protected from the world because they were not capable of living independently in the countries they had been brought to. And the people who believed women shouldn’t vote argued that women were suited to the domestic sphere and that involvement in politics was far too aggressive for them. One of the major arguments for compulsory interventions in mental health is that mad people need treatment, far more than they need freedom. Even if slaves, women and mad people wanted their freedom, the ‘benevolent’ authorities know better.

Secondly, some people who have lost their freedom prefer it that way. It appears that some slaves were afraid of freedom and others were ‘Uncle Toms’ who were subservient and loyal to their masters. Similarly, when suffragette activity was at its height in England the majority of women didn’t agree they should have the vote. According to some research, a significant number of people receiving compulsory treatment either like it or feel ambivalent about it. This must bring additional certainty to authorities responsible for these restrictions in freedoms, who conveniently fail to see this concurrence as a feature of internalised oppression.

Thirdly, removing people’s freedoms is necessary for social, economic or political order. The pro-slavery people, for instance, argued vehemently that the abolition of slavery would collapse the new world economies that had grown up on slave labour, with a ripple effect on the old world. Many people in the Victorian era thought the vote for women would undermine women’s and men’s separate roles in society – women occupied the domestic sphere while men occupied the public sphere. Advocates for compulsory treatment often claim that it is necessary for public safety. They believe that even if the consequences of freedom are good for some individuals, they would be bad for society.

Fourthly, if the freedoms are granted the people will misuse them. During the debates on the abolition of slavery people worried that freed slaves could go on a rampage against their white masters. People who opposed the vote for women were concerned that enfranchised women might leave their domestic duties and go on to become members of parliament, opening up the possibility that a woman could be the Minister for War, roles which were beyond women’s capabilities. Advocates for compulsory treatment assume that mad people would kill themselves or harm others at a much increased rate. The establishment, fearing a backlash, claim that the people cannot be trusted to use their new freedoms constructively.

What happened when slaves were freed and women got the vote? Certainly, none of the things that people feared. The African American population survived well with their freedom, slave owners were not slaughtered, economies did not collapse, men and women continued to coexist, and women succeeded in public life. Instead, the new freedoms for slaves and women raised their status and opportunities and created a more just and open society. While the social, economic or political order was changed, the fabric of society remained in one piece.

Imagine a world without Mental Health Acts and other legislation that restricts the freedoms of people on the basis of their ‘mental disorder’. Imagine how it would raise the status and opportunities of mad people, how it would create a more just and open mental health system and society, how it would force services and society to find non-coercive ways to reduce harm and preserve personal, family and social order.

My prediction is that the people in favour of compulsory interventions are on the wrong side of history, and the people against them are on the right side. Where would you rather be? As the playwright Henrick Ibsen once wrote: the person in the right is the person who is in league with the future.

The values of peer support

Sat, 23 Oct 2010 06:54:58 +0100

In the last two years I’ve been involved in two reviews of peer support and peer led responses in Canada – one for Ontario (click to download) and the other for the whole of Canada (which has yet to be released by the Mental Health Commission of Canada).

Services run by and for ‘mad’ people have been a small but growing part of the landscape since the 1970s. Peers have supported each other informally since they were first thrown together into the lunatic asylums, and probably even before then. In the last few decades formal, funded peer support services have provided people with a huge variety of supports, information, work opportunities and advocacy. There’s huge potential for peer led responses but they are still few and far between in the mental health landscape, amounting to less than one percent of total mental health expenditure in most countries or jurisdictions.

Peer led services and responses will probably use more of the mental health dollar in the future. But a threat lurks on the flipside of this opportunity. Peer support is at risk of being corrupted by the powerful and controlling system that funds it. This is already happening in some places in the world. To counteract this risk, we urgently need to reach an international consensus on what defines peer support and peer led responses. To start we need to define our values.

When we asked people about the values of peer support for our two reviews in Canada, they told us that peer led responses apply values that differ from those applied in mainstream services. This is hardly surprising, since the drive to develop peer led services arose out of experiences of oppression, harm and lack of responsiveness from the mental health system. The values people talked about to us revolved around three themes:

Equal power relationships

(Described by respondents as egalitarian, reciprocal, autonomy, self-determination, empowerment, choice, voice, social justice).

“We don’t have to fake it at a peer service”

“We can say what we need after years of being told what’s good for us”

These equal and empowering power relationships show up in a number of ways: Consumer/survivor members control the organization, they are free to choose their supports, and there is a commitment to social justice in many peer groups. In contrast, respondents often described the power relationships operating in mental health services as controlling, directing, hierarchical, patronising or authoritarian.

Identification with each other

(Described by respondents as reciprocity, mutuality, camaraderie, empathy, acceptance, no discrimination, community).

“In peer support we can see what professionals can’t see.”

“I want to be listened to and validated in my pain, not shut up and locked up.”

Identification with each other is reflected in the relationships inside peer led services. Peer support involves reciprocal roles of helping, learning and responsibility. There is also less role distinction between peer staff and clients or members than there is between professionals and clients. In contrast, people often described mental health services as trying to do things to people rather than do things with them, and as valuing book learning over lived experience.

Holistic understanding of madness

(Described by respondents as holistic, recovery, hope, different language).

“Peer support is not about how ill we are but how well we are”

“Professionals forget we know how to live with mental illness as we do it each day”

Peer support emphasises whole of life issues, our strengths, and the validity of personal experience. The value of personal narrative is elevated, particularly one that moves people away from an illness and victim identity. A belief in hope and recovery enables people to believe in each other, feel better about themselves and their future, and to make positive changes to their lives. In contrast, many people criticised the mental health system’s reductionism, pessimism and the dominance of a narrow biological approach.

In conclusion, these peer support values should permeate the whole mental health system, but it is more likely that they will be diluted as more peer run initiatives are funded by the mental health system and delivered within mainstream mental health services. We need to act now to preserve the integrity of the biggest hope we have of ensuring that future generations of mad people get a better deal than we have.

(Download the Ontario report here)

User/survivor leadership

Thu, 14 Oct 2010 22:34:55 +0100

Click here to find the full article.

The international mental health user/survivor movement has been around for nearly 40 years. It started as a protest movement but it has over time become more absorbed into the mental health system. The movement has created leadership opportunities in its independent activities, and the idea of leadership in one’s own recovery, but the policy of service user participation in mental health services has failed to deliver consistent participation, let alone service user leadership.

Part of the problem lies with the unequal distribution of power and resources, which is reflected in the lack of an infrastructure to develop peer-run initiatives and the failure to provide users and survivors with tailored training and development, career pathways, standards of practice and so on. Part of the problem also lies with the concept of participation itself. To participate people have to rely on the invitation of others. In the last decade some users and survivors have used a stronger concept of leadership. Unlike participation, leadership assumes people with mental health problems have the power to set the agenda, make major decisions and control resources.

The user/survivor movement arose from the oppressive treatment of people diagnosed with severe mental illnesses. This includes forced interventions, damaging treatments, segregation in institutions and social exclusion. In response, the user/survivor movement was founded on the principle of self-determination - in other words the equal distribution of power at a collective level and ‘empowerment’ at an individual level. These values apply to power and relationships within the movement, but the movement also advocates for their application in mental health services and in the position people with lived experience have in society.

The mental health system was founded on values that are the antithesis to empowerment and equality. Therefore, user/survivor leadership will only thrive with some seismic shifts in the mental health arena on every level.

Firstly, there needs to be a philosophical shift in the way people view madness from the deficits-based pathology view to the view that madness is a crisis of being that value and meaning can be derived from. This is essential because the root of all forms of discrimination is the denial that madness is a legitimate human experience; the deficits-based view perpetuates inequality and disempowerment, despite its benign intent.

Secondly, there needs to be a psychological shift within users and survivors themselves from a marginalised disempowered identity to empowered identity. Similarly, people in the mental health workforce need to change their identities from expert authorities to expert advisors.

Thirdly, there needs to be a political shift from power and resources dominated by professionals and managers to at least an equal power sharing with users and survivors. This is more likely to happen if users and survivors are in leadership roles at all levels of the system – as bureaucrats, managers, academics and in their professions. We need position power.

Fourthly, there needs to be a practical shift that enables services, systems, users and survivors to:

- Create opportunities for users and survivors to collaborate in clinical decisions.

- Define peer run initiatives, their competencies, ethical standards and new practices.

- Plan and fund peer run initiatives.

- Develop the peer workforce.

- Democratise decision making in services and systems.

- Hand over more resources, decision making and responsibility to users and survivors.

- Encourage users and survivors to enter into mental health training and employment.

- Continue to develop recovery-based services that promote hope, self-determination, a broader range of options, and equality for users and survivors in services and in society.

These seismic shifts have rumbled for two decades in western mental health systems but in New Zealand they have been eerily quiet over the last few years. The big shake may be decades away, but it will come, and the mental health landscape will be changed forever.

Click here to find the full article.

The beliefs that drive services

Wed, 06 Oct 2010 07:03:29 +0100

The mental health sector, like any other, is crowded with bureaucracy, politics, standards, indicators, jargon, gossip and other day-to-day diversions. In this atmosphere it’s difficult to disentangle oneself enough to burrow down and explore the bedrock of beliefs the mental health system is based upon. These beliefs drive our thoughts and feelings, our behaviour and our systems, but we are often barely aware of them.

Occasionally I get the time to dig down into these bedrock beliefs. I doubt if I’ve got to the bottom yet, but I think I’ve hit upon some beliefs worth examining.

One is the belief that madness has no legitimacy. Most people experience major mental health problems as frightening, desolate and even destructive. The pain of madness is probably on a par with major grief, torture, surviving the trenches, or being falsely accused of a serious crime. There’s a big difference though; these other experiences have legitimacy. Society enables a pathway though them towards growth, recovery or justice. Though they are not well understood by the majority, surviving them is often regarded as admirable or heroic. Madness however, is met with pity, fear and reproach. It does not have status as a full human experience, and this has provided justification for cruelty, segregation and control.

No society or mental health system built on this bedrock belief will ever do well for people with major mental distress. The recovery philosophy, if it has not been corrupted by the current system, undoes our traditional beliefs about madness by giving it meaning, full human status and a pathway to a better life. All social justice and anti-discrimination efforts also have a duty to undo traditional beliefs about madness. Too often they don't.

Another bedrock belief I’ve been trying to understand is the community’s abdication of ultimate responsibility for its marginalised citizens to professionals and services. In comparison to a century or more ago, people seek many more answers to human problems from state-authorised professionals and services. In some respects this has been of benefit. But dependence on deficits-oriented professionals and services, with their reputed monopoly on expertise and authority, has disabled communities and individuals. Traditionally the mental health system has perpetuated its power, resources and beliefs about madness by keeping people stuck in services.

People with mental distress as well as their communities need to start believing they hold most of the solutions to human problems, instead of professionals and services. We need to start viewing mental health professionals and services as the carriers of technologies that we may want to use at times, just like architects, plumbers and hairdressers. At the same time the mental health system needs to get real about the harm it has done. It needs to hand over control to people with mental distress and their communities, through fostering service user leadership in recovery and in services, integrating with other sectors, and engaging in community development and social justice work.

Psychiatric Drugs: The two stories

Sat, 25 Sep 2010 23:20:00 +0100

Psychiatric drugs are controversial. There’s the good story and the bad story. In his book ‘Anatomy of an Epidemic’, Robert Whitaker puts it like this: ‘There is a famous optical illusion, and depending how you look at it, you either see a beautiful young woman picture which tells of a revolutionary advance in the treatment of mental disorders. Or you see an old hag picture which tells of a form of care that has led to an epidemic of disabling mental illness.’

When I used mental health services I got a heavy dose the good story from my prescribers. They tried me on just about everything. Some of the drugs made me feel worse, others didn’t make any difference. One drug did make me feel better (though later evidence suggests it was a placebo response). At the time I started to question the good story. Since then I’ve read many authors, mostly psychiatrists, who tell the bad story. At the same time the good story on psychiatric drugs has flourished, through drug company marketing and the revival in biological psychiatry; it’s the story that fuels our current mental health systems.

Here’s my summary of the two stories (which inevitably do not do justice to the complexity of this subject).

THE GOOD STORY	THE BAD STORY
Psychiatric drugs reduce symptoms by correcting a chemical imbalance.	Psychiatric drugs reduce symptoms by creating a chemical imbalance.
Psychiatric drugs help to heal the brain.	Psychiatric drugs can disable or damage the brain.
The use of higher doses or more than one drug can increase the healing.	The use of higher doses or more than one drug can increase the damage.
People should stay on the drugs long term.	People should not stay on the drugs long term.
People often relapse after coming off the drugs, proving that they need them.	People often relapse after coming off the drugs, due to withdrawal effects.
People who keep taking their drugs do better in the long term than people who don’t take them.	People who don’t take drugs do better in the long term than those who do take them.
Psychiatric drugs are effective treatments and improve long terms outcomes for people	Some psychiatric drugs are barely more effective than a placebo and long term outcomes haven’t improved since they were introduced 50 years ago.
Psychiatric drugs are safe treatments.	They can cause serious or life shortening side-effects.

Of course everyone is unique and each drug is unique, so it’s hard to generalise. But I’m much more persuaded by the bad story than the good one, based on my reading, on my personal experiences and on the serious damage I’ve seen some of the drugs do to some people.

The chances are that people get more exposure to the good story, so it’s worth looking into the bad story, especially if you prescribe or take psychiatric drugs. These books will tell that story far better than I have here:

Anatomy of an Epidemic by Robert Whitaker

The Myth of the Chemical Cure by Joanna Moncrieff

Psychiatric Drugs Explained by David Healy

The Emperor's New Drugs by Irving Kirsch

Medication Madness by Peter Breggin

Doctoring the Mind by Richard Bentall

Is the mental health system crazy?

Sat, 18 Sep 2010 10:33:28 +0100

People with major mental distress often suffer multiple personal, social and economic losses. Our personal loss of power and self-esteem does not so much derive from the condition itself, but the attitudes we and others have towards it. We may feel shame. Those around us may feel pity and fear. Our paid helpers often reinforce these responses by pathologising our experience. Once our personal losses have taken hold, a cascade of social and economic losses tends to follow, such as isolation, under-education, unemployment, homelessness and poverty.

If the people who ran the mental health system honestly asked themselves, what single intervention would help the most people regain these losses, they wouldn’t have much trouble coming up with the answer. It’s work. Work reduces poverty, increases social contact, improves mental and physical health and increases social status. No other single intervention has so many benefits. Psychiatric drugs alone could never produce these benefits, and they have more dangerous side effects. Nor does a single minded focus on housing produce so many benefits; I’ve seen too many lonely people sitting in good houses leading diminished lives. If I had to put the majority of mental health dollars into one basket, I’d choose services to support people to succeed in education and employment. I’m also mindful that supported employment services have an evidence base that would make most drug companies drool with envy.

Ask most people with ongoing major mental distress and they will tell you that medical interventions only fix a part of their problems if they’re lucky, and make them worse if they’re not lucky. The big problems they face are personal, social and economic. But if you look at where most of the funding for services for them goes in every country, you will find it pouring into clinical services, such as hospitals and community mental health centres where crisis responses and biological treatments dominate.

Everyone who uses mental health services can reliably access psychiatric drugs, often with dubious benefits, and sometimes when they don’t even want them. But only a tiny percentage can access supported employment services. This is despite the undoubted benefits of work, despite the fact that over 90% of people who use services want to work, and despite a scandalous unemployment rate of 70% to 90%.

Allow me to suggest that the system is crazier than those of us it so often fails to serve.

Thinking about suicide

Mon, 13 Sep 2010 22:25:30 +0100

Welcome to my first blog.

David Webb is a friend and colleague as well as a survivor of many suicide attempts. He has recently written 'Thinking About Suicide: Contemplating and comprehending the urge to die.'

The book is based loosely on David's PhD, the world's first PhD on suicide written by someone who has survived it. It is not an academic book, though David does have a cerebral approach to the issue. He writes of the absence of interest in first person accounts in the suicidology literature and he laments the general lack of respect for the intense anguish and 'crisis of self' that leads to the urge to die. Mental health services take little interest in the lived experience of suicidality and often dehumanise it with the rituals of diagnosis, treatment and coercive practices. He also criticises the code of silence around suicide that denies people safe spaces to tell their stories.

David then unravels the mystery of his own suicidality and his breakthrough to a life worth living. No, it wasn't antidepressants, psychotherapy, drug rehab or other mental health interventions that saved him from his own hand, but the insight he gained from his practice of gyan yoga - the yoga of self inquiry. He lost his long held urge to die when he surrendered himself to the silence at the heart of his being, beneath his mind and all thoughts. He suggests later that the silence may also be the black hole of his despair. The difference is that when he saw it as silence he faced it and found peace, but when he saw it as a black hole he ran from it and lost himself in terror.

It's difficult to capture such a deeply introspective work in a few lines. The book will help readers understand suicide from a first person perspective, and compel them to respect the perilous spiritual pathway into and beyond despair.

Buy the book online at http://www.pccs-books.co.uk/product.php?xProd=528&xSec=116. Or visit David's website www.thinkingaboutsuicide.org