NOTE: This post mentions suicidal ideation and thoughts. If this may cause you distress, please do not read on.
I’m looking forward to seeing Bedlam this week on Channel 4. My one hope is that it shows the people, not just the problems they experience. That may just show how it’s part of human nature to be vulnerable to emotional distress, we’re all built that way. It’s what makes us human. Otherwise what happens is we get programmes about ‘people with MH problems’ as if they’re fundamentally different to ‘us’. Some psychological discussions about the development of difficulties may also do this, I hope so.
My previous post looked directly at stigma and the impact of persisting with an approach that seeks to stress the difference between people with and without mental distress/illness/disability.
As people will no doubt know by now, I don’t use that approach clinically, nor do I believe it is an approach that will help us all break down the boundaries and barriers to developing better services and reducing stigma in relation to mental health. Indeed, clinically very often the first step I undertake when working with young people is to get to a point which makes their distress understandable. They often say “there’s no reason for me to think this way” or “I shouldn’t feel/think like this”. I think it’s helpful for them to see that their presentation is understandable in context. Their context.
Despite many agreeing with me at least in principle there does seem to be some concern that “there must be a cut off” for example, feeling a bit down is not the same as ‘having’ depression. Well I think that it’s a spectrum, which encompasses a lot of different aspects of being human and at times responding to adversity. There are extremes in any spectrum so I’m in no way minimising anyone’s difficulties.
Without wanting to reduce Psychology to a sentence, a lot of human functioning can be summarised in three domains: thoughts, feelings, actions. I know it’s simplistic but there is a degree of truth in that.
How we understand distress also reflects these three and people understand or sadly often, don’t understand in terms of these three domains. For example, depression using ICD classification has a few ‘symptoms’ which are thought based, such as: loss of interest, poor concentration or indecisiveness, low self-confidence, suicidal thoughts and guilt or self-blame in Depression.
This is a well accepted view that the thought patterns above are ‘symptoms of depression’ but can that be so? Can a thought be a symptom of a distinct illness? Are there thoughts related to illnesses which are signs that person is ill?
My blogs are pretty much full of writing in blocks so I want to change it up a little. Here is a list of thoughts and impulses expressed by a group of people, they’re from a famous study (details later) examining thinking in people with different clinical presentations, which I use clinically, what I’d like you to do is to guess whether the person is from:
- group one (people presenting with obsessive/compulsive problems)
- group 2 people (presenting with psychosis) or
- group 3 from the non-clinical group (do not present with any clinical difficulty)
Impulse To harm an unknown person
Thought To jump on the rails when a train is approaching
Thought Of violent acts in sex
Impulse To harm a child
Thought Wishing and imagining that someone close to them was hurt or harmed
Thought That they might rob a bank
Impulse To jump from a cliff
Ok what do you think?
They were all from the non-clinical population which I imagine a few people guessed. It’s from a famous study in 1978 – Abnormal and Normal Obsessions by Rachman and De Silva. Just for equity here are some of the thoughts from the clinical (people presenting with obsessive/compulsive difficulties there was no psychosis group I just put that there to put you off).
Impulse To jump out of a window
Thought of ‘disgusting’ sexual acts
Thought That they may harm someone
Thought Of wishing someone near to them to be dead
Thought That he may go insane
Impulse To harm a dog.
Different? No, it doesn’t seem so. Yet this group came for help.
Well, surely psychotic thoughts are different? Psychosis is still viewed by many as the most severe form of mental distress (a term used by professionals more than people who experience psychosis).
Let’s see. A recent study looked at paranoid thinking How many people in the general population do you think report paranoid thoughts?
Answer is d 40%.
That’s a lot more than any prevalence for paranoia based problems by anybody’s reckoning.
More specifically and what I get told fairly often is “you’re talking about minor problems, there is a difference” ok, what about this thought:
“The belief that there is a group of people was currently plotting to cause them serious harm of injury.”
How many in the general population think that?
a) one in a thousand
b) 5 in a thousand
Answer is d, 2% expressed that belief. Again, more than the reported prevalence for paranoia based problems.
Further findings in the study: A sixth of the population (in the study of 8580 people) spent a lot of time wondering whether they could trust their friends or work colleagues.
About 10% of the population sometimes felt that people were watching them, staring at them, deliberately acting to harm them or trying to control their thoughts.
So where’s the cut off? One thing seems clear, using thoughts as a cut off or indicator for mental distress or illness is too simplistic and the utility of this is limited.
One more, what about suicidal thoughts? Stigma in relation to suicide is a massive problem and the public’s understanding of it is still limited, it’s often simplified in the press and misrepresented. The Samaritans Suicide statistics report state the following (http://www.samaritans.org/support-us/why-support-samaritans/facts-and-figures-about-suicide)
“Between 10 and 14 % of people have suicidal thinking throughout their lifetime.”
That is much more than many people would consider.
But what point am I making (albeit in a typical rambling way)?
What is the difference? There doesn’t seem to be thoughts which are unique to depression or unique to paranoid psychosis or OCD. What is different is what Rachman and De Silva indicated in 1978,
“… normal and abnormal obsessions differ in several respects including frequency, duration, intensity and consequences, among others”
It’s not the thoughts it’s how much they dominate our lives. There is more to mental distress than just thoughts and thoughts don’t necessarily indicate mental distress.
Stigma – why emphasise the differences, why not the similarities? What if a campaign said:
“We have all felt low or scared or angry at a time, imagine feeling that way or thinking that way all the time. Imagine your lowest day, imagine that day every day, what would that be like? Mental health problems are not experienced by people who are ‘different’ they’re experienced by us all, to different degrees”
Would that help to combat stigma? Maybe.
Is using systems which denotes thoughts which evidently many people have as being ‘symptoms’ are we pathologising humanity? This is not about denying the existence of distress but how we talk about it and how we understand and teach it (see below) is bound to impact on society’s representations and therefore the propensity for stigma.
Clinically – where is the cut-off? What are we treating? What if one of the 2% of people above who believes there was a group trying to harm them presented to services? Where would treatment stop? What is that person’s illness and what is them? These are important questions which ought to be asked (clinically I say ‘where is this person’s baseline – not ours, theirs?). I doubt there are any medications which would change someone’s thinking if they’ve thought that way for all their life. Should we try to change that? Where is the problem and who defines it?
If we use thoughts to define mental illness we’re in trouble (for example see Abell and Hare 2005 showing the prevalence of ‘delusional’ thoughts in people with Asperger’s syndrome). The thoughts are attributed as being delusional by professionals but that leads us/them to understand the person and their presentation very differently. There are no thoughts which are exclusively psychotic or depressive, it’s what occurs with them, namely distress or dysfunction which defines them as problematic.
Our thoughts don’t define us, whether we have mental health difficulties or not.
Not many people would argue that if someone said “I believe there is a group trying to harm me” that this person may be interpreted by some professionals as having a mental illness, indeed ICD10 criteria states: A paranoid person may have delusions that people are trying to harm him or her. But as I’ve crudely illustrated, it’s more complicated than that. (ICD 10 also refers to ‘psychotic behaviour’ – but that’s another post).
Wider Education regarding Mental Health – Possibly the most important issue. If we are to really change society’s attitudes we have to start with the basic education. School plays a huge part in this, but what do we teach. My Psychology course in year, 19 ahem, taught ‘Abnormal Psychology’ which was clinical psychology. Wrong on so many levels. We need to teach the continuum from primary school, what emotions, thoughts are and then what happens when they take over our lives, there is no clear line between problem and not.
Services – Employing this model needs much greater collaboration with the person seeking support/being assessed. The person with the thoughts is an expert in themselves and their views are central to the assessment. Where treatment stops is not defined necessarily by a reduction in thoughts but by functioning, which again, is defined largely by the person themselves not by the expectations of the professional. This is defined by the impact on the person, how they can function, one person could have the thought that people are out to get them and manage this fine, they can go to school or work and are happy with how they are, another can have the same thought and be so scared they daren’t leave the house. What does it matter what else they think or feel, that’s a problem for them so they should be offered some help.
There is an individualistic aspect to mental well being that is lost in the systems which currently attempt to assist people to achieve that end.
We all have thoughts but it’s not the content of them that’s the problem and there aren’t thoughts exclusive to mental health difficulties.
We all exist on that continuum of well being.
If we accepted that and promoted that maybe people with mental health distress would not suffer stigmatisation so much as they do.
Dr Gordon Milson
Other studies referred to: Bebbington, Mcbride, Steel et al (2013) The Structure of Paranoia in the General Population. British Journal of Psychiatry 202, 419-427.
Freeman, Pugh, Antley et al (2008) Virtual Reality Study of Paranoid Thinking in the General Population British Journal of Psychiatry 192. 258-263.
For further reading if interested I’d recommend this: