Tuesday 17 November 2015

PERFECT Year Two: Michael Larkin

Today's post is by Michael Larkin, Senior Lecturer in Psychology at the University of Birmingham and co-investigator in project PERFECT. Michael talks about his research interests for this second year of the project, and focuses on shared experience and parity of esteem.

My colleague Lisa Bortolotti has written recently about Project PERFECT, and the importance of understanding those aspects of human cognition which are common to both those who seek support from mental health services and those who do not. Lisa’s conceptual work illuminates some of the ways in which, at times, we all may hold beliefs which are difficult for others to share, or act upon reasoning which is difficult for others to understand.

Yesterday, I spent a fascinating morning with two clinical psychologists and a group of trainee clinical psychologists, exploring some of the differences and commonalities between ‘knowledge’ and ‘belief’ in our research and practice. We discussed how the task for the clinical psychologist often involves the gradual building of a bridge – a collaborative process - to span the gap between one person’s view of the world, and another’s. The psychologist is able to draw upon a wide field of knowledge (theory and evidence about the kinds of difficulties which people experience, and the kinds of factors which tend to cause and maintain them, for example), but must work with the service-user to understand which of these elements might be relevant and helpful to understanding their particular circumstances and context. Thus, formal knowledge and informal belief (about experience, and its meaning, for example) are combined. From this shared understanding, a formulation can be developed, which provides the basis for any therapeutic work that the psychologist and service-user might then decide to pursue together.

Lisa’s article about Project PERFECT suggests that once we have mutual understanding, we can see the commonalities in human experience, and we become able to see the difference between ‘someone who uses mental health services’ and ‘someone who does not who use mental services,’ in a new way. We see it then as simply a difference in the intensity or persistence of a particular experience. 

For example, I saw the surreal and rather disturbing film The Lobster this week. The feeling of anxiety which it produced continued to perfuse my experience throughout the next day. Anxiety isn’t an experience which generally causes me too much trouble (I’m probably more prone to low mood), but when – after a good night’s sleep – the feeling had lifted, I did have cause to reflect on what it would have been like to cope with that feeling for longer, or for its effect to have been more pronounced. In circumstances where I had been required to cope with other stresses, and where I did not have recourse to that good night’s sleep, might my reaction have been different?

The intensity or persistence of our distress is often shaped by the context in which we find ourselves. This is generally a more helpful way of thinking about psychological wellbeing than considering the difference between ‘someone who uses mental health services’ and ‘someone who does not,’ to be a difference between two ‘kinds’ of people – something which is generally underscored by the complex findings of genomic research. The importance of PERFECT’s message for anti-stigmatisation therfore is that there is no ‘them’ and ‘us’.

For me, the implication can be carried further. The issue of ‘parity of esteem’ between mental health and physical health services should be viewed through this lens. We need to remember that these are our services, and not merely services for ‘other people.’ In fact, due to the sustained underfunding of mental health services in the context of growing demand, we are increasingly likely to view it through this lens. The strain on mental health services is so pronounced that very often only those coping the most intense and persistent difficulties are able to receive support, and the crisis is now becoming so pronounced that acute services are struggling to cope. So the difference between those who use services and those who don’t is being foregrounded by the increasingly limited access to the services themselves. In my role as a Welfare Tutor at the University, and as a researcher who collaborates with many colleagues in mental health services, I frequently see the results of this, first hand.

In some respects, these are exciting and encouraging times for mental health and psychological research. We have a culture change taking place with regard to experts-by-experience and their involvement in the planning and improvement of services. We have a strong and consolidating evidence base for the effectiveness of psychological approaches to therapy, and a growing case being made for psychologically-informed approaches to service development and organisational change. We have mental health on the agenda of the ESRC, the Wellcome Trust, and other important funders. There is growing interest in the development of innovative approaches to emergency care (e.g. RAID), working in a genuinely multidisciplinary way with psychosis (e.g. peer open dialogue and its variants) and working with young people and families. The ‘parity of esteem’ case is receiving sustained attention.

On the other hand, as noted above, services are under extraordinary strain, and concern has been expressed that specialist services have been diluted or worse. I have specific research interests in mental health services for young adults, and in how we can improve inpatient mental healthcare. I’ve been working on a draft paper (with Elizabeth Newton and ZoĆ« Boden) for a little while now, about the parallel which is often drawn between cancer and psychosis. One interesting indicator of how far we have yet to travel on parity of esteem is illustrated by the specialist provision for inpatient care for these two populations. 

Run an internet search for the young people’s cancer care inpatient unit at your largest local hospital and you will find something like this (supported by public donations to a high profile national charity). You might expect to find clear and positive images of a pleasant environment, equipped with resources to keep you occupied while you receive treatment. Often you will also see information about what those treatments are; guidance on what to expect and what to bring; contact details for the unit; advice for parents and families, and information about facilities to enable them to visit, and if necessary, to stay over. Run an internet search for the young people’s psychiatric care inpatient unit in your local mental health Trust, and you’ll be lucky if you can tick any of those things off your list. You’ll be lucky if there is such a resource available at all. The concept of parity of esteem has been recognised within policy documents, but it is vital that the policy is funded sufficiently, in order that it can actually be implemented.

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