Getting into the recovery position; Listening to and working with the psychiatric “voices” we can

and cannot hear.

Dr David Cameron PhD, CPsychol and PsychotherapistThreshold, Richmond Fellowship NI Ltd

&Patrick McGowan Service – User Consultant, Health Service

Executive and Dublin City University School of Nursing

The right to, without censorship, speak freely or seek, receive and input information or ideas, regardless of the medium, a basic human right constituted and protected under Article 19 of the Universal Declaration of Human Rights.

A basic human right

An oppressive regime

In circumstances where voices are oppressed, silenced or go unheard,

autonomy, agency and citizenship are forfeited, the truth remains

suppressed or undiscovered and the human spirit is crushed.

Finding your voice in the psychiatric system

“People have always heard voices. Hearing voices was what spiritual and artistic people

did and it was perfectly normal. But now, people who hear voices are simply labelled

as "mad". What has happened to inner voices: have they changed or is it society that

has undergone a transformation”.(Press release, Inter-voice, 2006)

Discrimination4- 5% of the general “normal” population

hear voices at any given time (Shevlin et al., 2007)The vast majority will never be in contact with

psychiatric services.Two thirds do not find the experience unduly

distressing (Romme, 2009). 84% of voice hearers are needlessly

discriminated against because of the 16% whose experiences are possibly indicative of a genuine illness (Romme, 2010).

I NAME THEREFORE I KNOW!

These bizarre experiences are being caused by your illness schizophrenia

We can diagnose you with the illness called schizophrenia because you have these bizarre experiences

How do you know that I have an illness called Schizophrenia?

Ah right ????

Circularlogic

Passive listenersIf this relational dynamic is internalized to critically

self-scrutinise it produces a specific style of subjectivity “governmentality” (Foucault, 1979) creating compliant or good “patients” (Roberts & Wolfson, 2004).

This once a schizophrenic always a schizophrenic strap-line although not supported by long-term follow-up studies (Harrison et al., 2001; Calabrese & Corrigan, 2005)

results in negative stereotyping, discrimination, social exclusion and self-stigmatisation, the aberrant and synergistic precursors for a career of dependency and chronic psychiatric disability which, effectively destroys any real hope of recovery (Harding, 1987).

Active listenersPsychiatric voice hearers who reject the

native language of biological psychiatry and resist having their "voices" subjugated as the incomprehensible ramblings of a “broken brain", risk being accused of lacking insight, which paradoxically is often taken as further evidence that they are suffering from a “treatment resistant” mental illness (Thomas & Bracken, 2004).

Treatment resistant

For these voice hearers, service - users the language of psychiatry is experienced as a powerful, oppressive and malevolent voice which, paradoxically can compound and accentuate the distress of the very "voice" psychiatry is charged with silencing (Walsh & Boyle, 2009).

The unspoken unspeakableSeveral large-scale research studies have

found that for many, hallucinatory or sensori-motor experiences are related to early traumatic-victimisation experiences, not least childhood physical and childhood sexual abuse (Read & Ross, 2003; Read et al., 2003, 2005; Whitfield et al., 2005; Geekie, 2004; Janssen et al., 2004; Spauwen et al., 2006; Shevlin et al., 2007).

Perhaps a more sensible approach would be to simply tune in the TV.. Privileging and “working collaboratively with the service-users frame of reference, whether he / she sees the experience primarily as medical, psychological or even spiritual phenomenon” (British Psychological Society, 2000, p. 59)

Tuning in

Talk not just tablets• Many service users are alarmed

that psychiatrists, mental health and allied professionals are not willing to listen to or help them understand and make meaning of their experiences in terms of social, cultural and relational contexts (Birchwood et al 2000; Faulkner & Layzell, 2000; Rose, 2001; Vaughn et al., 2004; Chandler & Hayward, 2009; Romme et al., 2009; Dilks, 2010).

• Meaning making is an especially empowering experience (Chandler &

Hayward, 2009; Dilks, 2010) while "biomedical [or other reductionist] interpretations are limited at best unhelpful and at worst harmful" (Thomas and Bracken, 2004, p. 361).

“The “madman” as defined by others, is part of society’s cultural heritage. Whether “madness” is explained by religious authorities as demonic possession, by secular authorities as disturbance of the public order or by medical authorities as “mental-illness” the mad themselves have remained largely voiceless” (Chamberlin, 1990, p. 323)

Discovering or recovering a voice

These voices, no longer satisfied with or muffled by a dominant illness saturated model are vigorously reverberating from within a recovery oriented movement.

A synchronised symphony of concerted and coherent voices united in reasonably demanding that they are listened to in the design, implementation and evaluation of mental health service provision .

From maintenance to recovery

This voice is beginning to speak a liberating language that is shifting the emphasis from maintenance to recovery, entering into open and honest dialogue with the voices, personal experiences and narratives of psychiatric voice hearers.

Prioritising the preference of the service userService users are clearly telling mental health

and allied professionals what they want: A humane response to what is a largely human

predicament, one which does not simply interpret “voices” whether audible or inaudible as indicative of an illness .

Voices which must be liberated not subjugated or silenced . A shared belief in the fundamental human right to

interpret their experiences in a way which is meaningful and personally empowering .

A shift in emphasis from maintenance to recovery supported by a broad choice of alternative interventions not least those designed and delivered by service users that is experts by experience.

Getting into the recovery positionRecovery must be self-defined and self-directed

by the ideographic narratives of those who own and are living the experience.

Equally, because recovery defined from this perspective assumes a sufficient level of “interpretative agency” which, hitherto, may have been undermined by prescriptive paternalistic interventions that have candidly dismissed the value or validity of the contextual interpretation of the service – user’s experience this agency may have to be first discovered not recovered. (Chandler & Hayward, 2009)

From unsafe certainty to safe uncertaintyCrucially for the professional the radical dimension is an

open “willingness to collaborate with experiential worlds that may disconcert your own” (Chandler & Hayward, 2009, p. 8)

This means moving from the prescriptive solution focused position of “unsafe certainty” which, is unreceptive to individual difference and supports or rigidly defends risk adverse practices to a position of “safe uncertainty” founded on the belief that “uncertainty is part of the human condition” (Mason, 1993).

From this perspective “the less curious we are the more we understand too quickly, leading to a position of premature certainty” (Mason, 1993).

Authoritative doubtThis does not mean haphazardly abandoning

or undermining knowledge and expertise but rather holding them together with uncertainty, foregrounding safety, attending to the variables that can be reasonably managed but recognising that it is impossible to account for and cover every eventuality.

In the asymmetrical power relations of the mental health system if effective peer collaboration is to become more than an aspiration professionals must take up the position of authoritative doubt.

Coercion and duty of careFeeling threatened compounded by an absence of

hope and low expectations of change produces a toxic combination that results in Unchallenged paternalism (“duty of care”). High use of coercion (46,770 compulsory

detentions in 2004/5 in England). The prescriptive imposition of misconceived

explanatory models whether recovery oriented or otherwise to “improve insight” eroding hope and colluding with chronicity (Roberts & Wolfson, 2004)

To be buried alive

Linguistic lobotomy

Mental health and allied professionals, therefore, must avoid the less obvious but equally disempowering and disabling linguistic lobotomy which, severs ownership of the experience from the person owning the experience, as well as denying them their own attempts to make meaning of these experiences (Bracken & Thomas, 2005).

Getting into the recovery position

For the person in recovery this means accepting that nobody is going to recover for you.

For the mental health-allied professional it means relinquishing the omnipotent but delusional belief that recovery is something which can be either prescribed or colonised according to the dominant yet misconceived theoretical presuppositions of our time.

Radical collaboration“Recovery [is and must be based on

radical collaboration it] is not a gift from Doctors but the responsibility of us all… We [service users – survivors]must become confident in our own abilities to change our lives: we must give up being reliant on others doing everything for us. We need to start doing things for ourselves. We must have confidence to give up being ill so we can start becoming recovered” (Coleman, 1999).

Thank you for listening