What do I tell my friends?

What do I tell my friends?

(This blog was originally written for the Young Minds website – if you don’t follow them, please do)

This is one of the most common issues raised in my therapy group for adolescents with mental health problems.  Not only do they have to try to overcome their difficulties which have led to them being admitted to hospital but they also have the worry of what their friends will say or think when they leave hospital.  The stigma associated with terms such as psychosis, depressive disorder and even emergent personality disorder concerns them.  They worry that their friends won’t understand.

Another fascinating discussion which we regularly have is that of what they expected when they came to hospital.  These are some responses I’ve received over the years: “I expected people in padded cells”, “I thought there’d be people waving their hands about gibbering”, “I thought the nurses would all be in uniform and we’d be in rows of beds”, “I thought it’d be full of psycho’s”.

The reality is, thankfully different.  We don’t have padded cells and the stereotypical view of a person with an acute mental health problem which the young people above voiced is a rarity.  Many wards don’t have uniformed nurses and many wards have en-suite bedrooms for young people. But what about the psycho’s? – When asked young people assume psycho to mean the same as the descriptions above, or like that but violent.

What young people say when I ask them what the reality is, is this “the people here are just like me, but some of their problems are different”. The other interesting note is that when I invite new professionals into the group and I’m talking about how I view young people with mental health problems, I ask them to tell me what they think the young people’s diagnoses are. They never can.  This does not surprise me at all.

But what’s the point here?  The point is this, mental health problems, of all kinds, exist on a continuum, on which we all lie.  It is not the same as physical health.  You either have a broken leg or you don’t.  Mental health is different. If we are to address the stigma which is such a huge problem we must review how we conceptualise and talk about mental health.

The current, dominant model of mental health stipulates that you either have a mental illness or not.  You have a diagnosis or not, it’s called a categorical system.  This perpetuates a belief in society (in my humble opinion), that people with mental health problems are fundamentally different to those who do not have mental health problems.  This helps stigma to remain.  It becomes ‘them and us’.

It isn’t, it’s us.

Putting people in boxes does not help society understand mental health, it leads them to try to understand the box.  There are no boxes.

I have never diagnosed a young person in acute mental health and I have never been asked for a diagnosis by a young person.  I have worked with them on developing a collaborative understanding, which makes sense where they are now, where they have come from and where they want to go to.  It examines their experiences and why they have got to the point where an admission to hospital is the only option.  The young people I work with want to understand why they have got to this point (a regular issue in our groups) much more rarely do want to know what this point is called.  The language we use in our collaborations is not that of a medical Doctor or Psychologist (we too have ridiculous terms which keep others from understanding) it’s in the language and terms of the young person, after all, that’s surely what is most important?

Validating someone’s distress and/or difficulties is not the same as putting a label on them.

Imagine you have a horrendous start to life, people that ought to have offered a high level of care to you did not and you were hurt by people who you trusted, you struggle to relate to people, your emotions run wild and to try to cope with this you try all kinds of strategies such as hurting yourself deliberately and one day you reach a point where you think ‘enough is enough, there’s only one way out of this’ and you take an overdose of tablets.   Then people tell you that you have a disorder!  I think that’s grossly unfair.

Mental health awareness doesn’t seem to be taught routinely in schools, it should be.  But what are we to teach?  Should we teach an approach which tells us that people with mental health problems are categorically different to us? Will this help to end the stigma? I doubt it.

I believe we should teach the psychological model of well being, the model that we all exist on the continuum and sometimes, life has a way of pushing us further up the scale or things happen which push us up and we experience difficulties. How those difficulties appear can be different for different people.  Some people when highly stressed can get very anxious and agitated, some can retreat into themselves more and seem quite low in mood, other people can hear voices.  We’re all on this spectrum somewhere.

The pros and cons of diagnosis are a regular battleground between disciplines in mental health services. But do we need it?  I don’t think we do and moreover, I don’t think society needs it either.  It’s not the forum for prolonged debate on this hot topic here but I genuinely think that offering a collaborative formulation, or joint understanding as I prefer to call it, is a very viable alternative.  It’s clinically useful and guides intervention and risk management far more effectively than a label does but more importantly it does not stigmatise young people and seeks to communicate that although at times mental health difficulties can seem overwhelming, they are understandable and from this understanding improvements can be made.

How we view people with mental health problems in mental health services impacts on how society views mental health problems.  Maybe it’s time for us to start the ball rolling.

Dr Gordon J Milson

Clinical Psychologist


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