Opinion: Them and us in mental health services

There is a dichotomy in mental health services: 'them and us', or what Pilgrim (2005, p.123) refers to as 'two groups of humanity'. This is the process in which some clinicians, psychologists and allied professionals treat the recipients of their services as being in some ineffable, but very real way, 'other'. Buber (1958) refers to this as 'I-It relating' in which we only see part of the other person and limit our view of them to that, rather than the 'I-Thou relating' that we do when we recognise that the person in front of us is as fully human as we are ourselves. I will argue that within medicine, psychology, social care and beyond this may lead to iatrogenic 'illnesses' which are the result of 'care' that necessarily positions the recipient as 'other' (Johnstone, 2000; Laurance, 2003).

We can see this even in third sector organisations' conceptions of mental distress. For example, the current 'Time to Change' movement – a project with a budget of £18 million conducted by an affiliation of Mental Health Media, Mind and Rethink, and evaluated by the Institute of Psychiatry – has the stated mission: 'To inspire people to work together to end the discrimination surrounding mental health'. This might seem a laudable aim. However, they go on to repeat the commonly used assertion that 'one in four adults experience mental health problems in any one year' (tinyurl.com/mqhek7). Presumably the intention is to suggest that one in four is quite a high number of people and so people with mental health issues should not be discriminated against because they are just like everyone else.

However, there are problems with the 'one in four' estimate. Although seldom referenced explicitly, it seems that it pertains to a 2000 Office of National Statistics study (Singleton et al., 2001) or to the World Health Organization's (WHO) World Health Report 2001 (tinyurl.com/msqmy7). The WHO report refers to one in four families rather than people. A reading of the Office of National Statistics study demonstrates that the figures do not allow such a simple breakdown as 'one in four' as a cumulative figure, because the study uses a variety of different timescales, evaluation scales, and different (not mutually exclusive) categories of mental distress.

Aside from the problems with the figure itself, I suggest that the reading of the figure may be rather different from the intent of the bodies who so readily use it. That is, that if 25 per cent of people are in the group who have a mental health problem then 75 per cent of people – the substantial majority in fact – are not. It suggests that the 'one in four' are different from 'most people'. This is concerning because as we know, difference (especially minority difference) is a cause of discrimination (Infinito, 2003; Sherif, 1956). Thus people with mental health problems are being situated as 'them' even by the very organisations set up for 'their' assistance.

There are clearly societal factors, then, in the dichotomisation of mental health service providers and their patients, but there are also intrapersonal factors at work. Clinical psychologist Lucy Johnstone (2000) explains this by stating that '[some] staff need patients to continue to be patients for their own personal reasons' (p.206). She argues that this is because of (broadly) a desire for job security (as effective clinicians makes themselves redundant) and adherence to an enveloping system in which power is granted to those who comply; meaning those with the most power are the most invested in the system. Johnstone goes on to report the great anti-psychiatrist Loren Mosher's suggestions for the four deadly sins (in the eyes of upholders of the orthodoxy) of critical psychiatry (and one would imagine applied psychology): de-medicalising madness, de-hospitalising people, de-psychopharmacologising and de-professionalising. This might be summed up in Johnstone's later statement that 'psychiatry has not been well served by the philosophy of "studying people as if they were things"' (p.252). The august, albeit fictional, 'headologist' Esme Weatherwax (in Terry Pratchett's Discworld novels) agrees, stating: '…sin, [young man], is when you treat people as things. Including yourself. That's what sin is.'

This 'treating people as things' may also be explained by the cognitive dissonance set up in some clinicians when they come across a patient who, due to contextual factors, such as an advanced degree, substantial income, etc., upset the clinician's conceptions of what a mental health patient should be like (for a brief discussion of clinician stereotyping see Byrne, 2000). The clinician may attempt to resolve the conflict between the apparent facts and their conception of the patient with one of three methods: classing the patient as an exception to the rule; suggesting that the patient is not really a patient; or changing their mind about the nature of psychiatric patients. This last possibility is seldom seen, and a reason why may be inferred from a study by Fowler and Christakis (2008). This suggested that happiness spreads dynamically within a social network and is mediated primarily by social, rather than actual, distance between people.

If social distance mediates happiness then it might be reasonable to assume that it mediates unhappiness too. However, Fowler and Christakis found no evidence for this, reporting instead that additional happy social contacts (to a maximum of three) increased happiness, but additional unhappy social contacts had no effect. They do suggest, however, that 'we might yet find that the "three degrees of influence" rule applies to depression, anxiety, loneliness…' (p.8), a comment that is echoed the work of Hatfield et al. (1993).

This, then, may be why some mental health workers have grave concerns about behaving in a friendly manner (not 'become friends', which is a different ethical issue) with the people that use their services. It may be an implicit (questionable) concern, and reaction to, the possibility of socio-proximally mediated affective contagion: mental health workers are trying to keep themselves healthy through creating an ingroup of 'us' and an outgroup of 'them'. This accords with the Fowler and Christakis (2008) finding (albeit regarding co-workers rather than patients), that '[there was] no effect of the happiness of co workers…suggesting that the social context and distance might moderate the flow of happiness from one person to another' (p.7). Even if clinicians could be motivated to change due to an understanding that social prophylaxis through distance is unnecessary, it is possible that some mental health professionals who have been practising for many years may find the prospect of changing their practice  to be more friendly to patients too threatening to their psychic integrity to countenance. Menzies (1960), in a hospital-based study within the psychodynamic tradition, suggested that this is an internalised social systemic defence against anxiety predicated on systemically induced underdeveloped (or regressed) psychic defences.

While there appears to be little hard evidence in the literature pertaining to this idea, I offer my own previous experience of working with contemporary clinicians as a start and a call for further research. The reasoning concerning clinician reticence to change runs thus:
'I have been doing things this way for years and will continue to do so as this way must be right' (because if I have been doing it wrong for all these years look at all the pain I've caused/ time I've wasted/ good I could have done). It boils down to: 'I can't act in the future, because that proves I could have done so in the past', although the resistance to change has historical roots that are often not in conscious awareness and the inference that it 'proves that it could have been done in the past' may be faulty.

Interestingly this effect – let's call it the 'Richards effect', for narcissistic reasons – crosses domains. Clinically, I see it in patients in their forties and older who seem stuck by the notion of what they could have achieved, if only they had beat their depression or changed gender role earlier in life. To do so now would suggest to them that it is possible, and so by inference would have been in the past; the very idea of which is intolerable. I also saw the effect in my previous incarnation as a climbing instructor, when people would be resistant to learn how to safely hold the ropes for other climbers in the 'modern way' – imagine the idea of having been a dangerous climbing partner despite your best intentions. The examples are endless.

Perhaps, rather than maintaining these in- and outgroups of staff and patients with all the associated costs attendant to that process (cf. Fiske & Taylor, 1991) and to the patient, we should look to the literature that has shown the benefits of a genuinely collaborative effort (e.g. Ross & McKay, 1979) and to the nascent recovery approach (Deegan & Drake 2006; Glover, 2005; Oades et al., 2009). In these approaches there is a common effort towards the actualisation of the resources of the person who is suffering, and a recognition of the skills and experience that both this person and the professionals bring to the endeavour.

Perhaps, despite the distress it may cause those of the 'us' who work in mental health, we could combat stigma and work more effectively and humanely by realising that we are all just one big 'group of humanity', one big 'us'. We should understand that there is a continuum of mental health that we all share, rather than being on one side or another of a 'one in four divide', and that we all need to rub along as best we can.

It can be done: not all clinicians create an 'us and them' dichotomy with patients. My current colleagues, perhaps because the unusual field we work in draws exceptional workers, act as exemplars of how this situation may be resolved in a way that is both professional and sensitive. But it requires us to accept the risks attendant to the professions, including cognitive dissonance, the possibility of emotional contagion and societal pressures. As clinicians, we need to work to ameliorate any adverse effects, not through the alienation of patients, but through other endeavours such as ensuring we take enough physical exercise, cutting down on smoking, eating well, meditating and the like.

References

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Fiske, S.T. & Taylor, S.E. (1991). Social cognition (2nd edn). New York: McGraw-Hill.
Fowler, J.H. & Christakis, N.A. (2008). Dynamic spread of happiness in a large social network. British Medical Journal, 337, a2338.
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Singleton, N., Bumpstead, R., O'Brien, M. et al. (Office for National Statistics) (2001). Psychiatric morbidity among adults living in private households. London: The Stationery Office.