If you have a mobile phone, a kindle, an iphone or ipad or any of a number of other electronic readers you can get the entire Mental Health Workers Guide from Kindle. If you don't have a kindle don't worry - just download the app (it's free) and turn your phone or PC into a Kindle reader.

Then nip on over to the Kindle store and get your copy of The Mental Health Workers' Guide in handy Ebook format.

You can buy it here

The ebook is the completed version of the developing blog series. It covers:

What’s a mental health worker worth?

The problem of specialisation

Three models of mental health and disorder

The biological (medical) model

The social model

Merging the two (stress and vulnerability)

The importance of physiology

The meaning of psychiatric diagnoses

Anxiety

The psychology of anxiety

Depression

The psychology of depression

Psychosis (introduction)

Hallucinations

Delusions part 1

Delusions part 2

Thought disorders

The dementias

Types of dementia – Alzheimer’s

Types of dementia – Vascular

Types of dementia – Lewy Body

Types of dementia – Parkinson’s

Types of dementia – Korsakoff’s

Types of dementia – Fronto-temporal

Types of dementia – Mixed

Orientation and memory

Delirium

The CAM scale

Working with the limbic system

Personality disorder

High Expressed Emotion

Sympathy is not usually helpful

More on the Stress & Vulnerability model of mental health and disorder

The invalidating environment

The Self-fulfilling prophecy

The meaning of recovery in mental health

The three types of recovery

Duty of care: A slug in a bottle

‘Hanged if you do, hanged if you don’t’ – a duty of care myth

There is no ‘us and them’

People are just people

Coping skills develop slowly

Lapse is different from relapse

Don’t expect your service user to perform perfectly.

The word ‘support’ is meaningless in and of itself

“It’s just behavioural” (A workers’ excuse for lazy thinking)

Challenging behaviour means….

Behaviours that harm the individual

Behaviours that harm other people

Do we need help?

Consequence, learned behaviour and the need for boundaries

Maintaining the problem

The whole team approach

Firm Boundaries

No ‘Pedestals’ And Staff Safety

Effective, Consistent Care

‘Corporate’ Identity – “You’re All The Same.”

Expectations

Self Harm

Self-harm as a response to trauma

Responding to a person who harms themselves

Individual v Organisational risk (Risk-free is impossible. Manageable risk is the way to go)

Don’t flap (more haste – less speed)

The saviour fantasy

You’re probably not an emergency service – don’t try to behave like one

Unhelpful thinking

Ignoring the positive

Exaggerating the negative

Overgeneralisation

Catastrophisation

Arbitrary inference

Determinism

Selective abstraction

Global thinking

Dichotomous thinking

Magical thinking (the Wizard did it)

Personalisation

Socratic dialogue and ‘the razors’.

The sticks we use to beat ourselves

Who put us in charge?

Final words

Part 24 of The Mental Health Workers' Guide considers the meaning of recovery in mental health care. Don't forget that you can download the podcasts and video clips that accompany this series here.

Welcome to the next part of The mental health workers' guide

Today’s topic is the Stress & Vulnerability model of mental health and disorder

Buy the entire series as an Ebook here

History is replete with different and conflicting theories about the causes and effective treatments of people whom we would now describe as suffering from psychosis and other mental health problems. From the divine guidance enjoyed by the Ancient Greeks and the demonic possessions of both the Bible’s Old and New Testaments to more modern assumptions about social pressures and genetic loading there seems to be no shortage of explanations. At first glance it seems as though people just keep on going round and round in circles without ever getting any nearer to solving the problems which can lead so many to despair and social isolation.

Fortunately there is a way to make sense of this situation and even include elements of all the other conflicting theories (even though many of the more primitive explanations such as possession tend to be seen as psychological rather than spiritual influences). The ‘Stress & Vulnerability’ model of mental health and disorder is a way of thinking about mental health problems, including psychosis in a way that makes sense to people from a range of backgrounds and beliefs. There really is something here for everybody.      

Back in 1977 Zubin & Spring published their paper outlining the Stress & Vulnerability model of mental disorder (Zubin & Spring 1977). The paper is quite detailed but the principle is simple enough.

The idea is that people become ill when the stress they face becomes more than they can cope with. Also, people’s ability to deal with stress, their vulnerability varies so problems which one person may take in their stride might be enough to cause another person to become depressed or psychotic.

People with low vulnerability need to experience a great deal of stress before they become distressed whereas those people with high vulnerability need only a small amount of stress to ‘tip them over the edge’ into serious mental disorder.

So what causes the differences in people’s vulnerability? What makes one person more vulnerable than another?

Biology

Evidence from family studies, particularly studies involving twins seem to show a strong genetic element. It seems that one aspect of a person’s vulnerability is related to their genetic make-up. However this is not the whole story. Other biological factors (stressors) include poor diet, overwork, exhaustion and sleep deprivation, the use of substances (illicit and prescribed), infection and other illnesses, inadequate oxygen supply and even constipation. We are biological organisms and as such we are extremely vulnerable to stressors that interfere with the normal functioning of the body.                                                                                                   

Coping style

I remember as a teenager my preferred method of dealing with life’s problems was to fly into a rage and attack (physically as well as verbally) whoever or whatever was nearest. I’m happy to say that those days are far behind me now but for a few years in my adolescence I was much more likely to punch people than talk to them. That was how I dealt with life’s problems then – my coping strategy.

The only problem was, it wasn’t nearly so effective as I’d hoped it would be. I was a big adolescent (I reached 6’ in height by the age of about 13) and so I could easily defeat most of my peers in fights but that didn’t really solve anything. Instead it made my problems worse.

I developed a reputation as a thug and a bully. I soon found myself with significantly fewer friends than I used to have. I wasn’t always violent. I changed very dramatically following a traumatic family bereavement. That change cost me a large part of my social group. It also cost me the support of most of the teachers at school and it definitely made it harder for those who were interested enough to try to help me.

The cumulative effect of all this was a powerful vicious circle. The worse my behaviour became the smaller my support networks became. The smaller my support networks the worse my behaviour because I had fewer and fewer chances to learn better coping strategies. It’s as though every attempt to cope with life’s difficulties moves our mental health either forwards or backwards and although it’s easy to set off on the wrong path it’s much harder to turn back when we’ve made a mistake.

Good coping, effective coping involves maintaining supportive friends, not driving them away. It also involves being open to experience and learning how best to deal with situations as they arise.

People who use effective coping skills seem to deal with stress better than those who do not. They can handle much more stress before they develop symptoms of mental disorder (Warner R. 1994).

Thinking style

How a person thinks about their self or the world around them seems to make a major difference to their level of vulnerability to stress. This is more than simply being optimistic or pessimistic – there are certain thinking methods which help people to cope better than others (Thomas P. 1997) (Warner R. 2000). We will cover some of the principles around thinking style as this series progresses but there’s much more detail in my earlier series and free PDF, ‘Emotional Management’ which is available for free download here.

Environment

The way a person deals with stress (their options) is often related to their environment. Anything from the state of a person’s home to the neighbourhood they live in can make a difference.

This is true even at the most basic level.

For example, I’m a bit of a hoarder. I don’t necessarily hoard junk, as such, but information. I hang on to old journals ‘in case they might be useful’ for years – long after the information they contain has become obsolete. My study regularly becomes so full of paper that it is difficult even to find a chair to sit on.

One way I know that I need to do something about it is I periodically find it very difficult to relax enough to concentrate on the course I’m writing or the blog post I’m researching. When that happens I have a clear out, my environment becomes more ordered and less frenetic. As it does so my concentration improves too.

That’s a small point of course but it does illustrate a wider principle. More serious environmental problems relate to inadequate housing, inherently dangerous or violent surroundings, overcrowding or isolation. The environment in which we live has a huge impact upon our mental health and can certainly contribute to psychosis as well as a range of other psychological problems.

Social skills

The better a person’s social skills the easier it is for them to get other people to help them when things get too tough for them to handle alone. People with lots of supportive friends tend to do better in times of crisis than people with fewer or perhaps no other people to turn to.

So what can we do about it?

There is little that can be done to alter an individual’s genetic make-up. Even if we could change that it probably wouldn’t be a good idea. The trick probably lies in helping people to examine the other things which make them vulnerable and looking for ways to change them (Coleman R.1999).

For example it is possible to adopt different styles of coping and thinking. Social skills can be developed just as other skills can and although sometimes a little more tricky, it is possible to change a person’s environment for the better. These things can help people to move away from high vulnerability to low vulnerability.

Additionally it’s often possible to reduce the amount of stress people find themselves under. It’s surprising how much can be achieved by making a few, relatively simple lifestyle changes. This can have a huge impact on the risk of further episodes of illness.

We will examine some of these potential changes as the series progresses but for the most part it’s not rocket science. Common sense principles about diet and rest, exercise and relaxation, problem-solving and social interaction can be massively beneficial. Additionally, working to develop improved mental habits and a realistic (not necessarliy positive) attitude is extremely powerful. There is more to mental health management than medication (although that has a place).

References

Caplan P. J. (1995) They Say You’re Crazy Perseus, Massachussetts

Coleman R. (1999) Recovetry – an Alien Concept Handsell, Gloucester

Gamble C. & Brennan G. (2000) Working with Serious Mental Illness Balliere Tindall, London

Thomas P. (1997) The Dialectics of Schizophrenia Free Association Books, London & New York

Warner R. (1994) Recovery From Schizophrenia Routledge, London & New York

Warner R. (2000) The Environment of Schizophrenia Brunner-Routledge, London & Philadelphia

Zubin J. & Spring B. (1977) Vulnerability - a new view of schizophrenia. Journal of Abnormal Psychology Vol.86, No.2, pp.103-124

In case you missed it...

I recently delivered training on mental health (the basics) to a group of support workers in Glasgow. Not only were these people a joy to work with they were also generous enough to let me record the training and then post the recordings on the internet. Thanks also to Frank, the organisation's training manager for consenting to these recordings 'going public'.

You can listen to the sessions (minus group exercises and some of the lengthier group discussions) from this page

.

Readers of my blogs might be forgiven for thinking that I’m opposed to psychiatry and the biological model. After all I regularly complain about the standard medical approach with it’s heavy reliance upon medication to treat mental disorder – especially relating to antipsychotics for people diagnosed with disorders like schizophrenia and bipolar disorder. But that doesn’t mean I’m ‘antipsychiatry’ – it just means that I’m cautious. This is especially true where medications are concerned.

The list of side effects that accompany psychotropic drugs can be a major problem but the same is (and has always been) true of all medications from AZT to aspirin. If a particular person suffers side effects from a particular drug then there’s a case for trying a different drug or even a different dose but that, in itself, is not really a case for scrapping all antipsychotic medication. All we can really say is that we need to be cautious about medication and avoid the ‘hammer to crack a nut’ approaches of the past.

Medications are biological tools. They are chemical preparations designed to make chemical changes in the body. This is because of an assumption that mental disorders are caused by physical (specifically chemical) problems. But is this always true?

Combat veterans are known to develop psychotic disorders as a result of their experiences whilst on active service. It seems ridiculous to assume that all these men and women (who had passed psychological evaluation before entering the battlefield) suffer from organic brain disorders. Yet their symptoms are similar, if not identical to those experienced by many of their civilian counterparts, diagnosed with major psychotic disorders and treated with chemical medications.

Combat veterans suffer a form of psychosis that is

caused not by biology but by stress.

For these people I think that there is an excellent case for using medication to treat their distress and to provide a degree of respite from their symptoms but that’s not the same as cure. That’s one thing I do disagree with traditional psychiatry about…

I believe in recovery.

Happily though, so do many modern psychiatrists. People like me who advocate recovery aren’t so much joining the mainstream as the mainstream is catching up. That’s a nice feeling.

There are, of course many people who argue vehemently that psychiatry is flawed and that medication should never be ‘used on’ mentally ill people. However, sincere though I’m sure these people are, they may well fall into the same trap as the overly zealous arguments in favour of medication. They may be too general.

Just as not all cases of psychosis seem likely to be chemical, so not all cases need necessarily be purely stress related. Whether the argument is in favour of medication or against it there is a real problem with polarisation and over-generalisation in mental health care. The disadvantage of these ‘black or white’ arguments is that they assume that everyone is the same and that everyone needs the same sort of intervention.

This sort of one-sidedness can feel easy and comfortable for those doing the arguing but there’s a price to be paid for superficial reasoning. The price is poor treatment because of flawed assumptions that compare chalk and cheese and assume that they are the same thing.

And that price is not generally paid by the individuals doing the arguing. It is paid by the mental health service-user whose options for recovery are limited not by ignorance but by stubborn refusal on both sides of the argument to look beyond their own, pet theories.

If I seem a little hard-nosed about this it’s for good reason. I was trained in the traditional way where medication and unquestioning acceptance of the biological hypothesis were everything. I was at the extreme ‘medical’ end of the continuum.

Then I was lucky enough to be selected for further training at the Post Graduate level. I spent two years part time being exposed to the other side of the argument and, like many of my peers, became just as rabid in my defence of social and psychological perspectives instead. I was for a while the typical antipsychiatrist (or more accurately ‘antipsychiatric nurse’). And that felt good.

Today I’ve moved on a little from either of those two positions. Now I am able to see past the partisan posturing of either side and I try to walk the middle line. It seems to me that balance is everything. Isn’t that usually the case in the real world?

I no longer see much of a place for extremism in

mental health care – especially when those

who pay the price are not the ones making the arguments.

Please don’t misunderstand me though. I am far from an apologist for the biomedical status quo. I believe that biomedical psychiatry may well have something positive to offer psychotic individuals in relation to symptom management but in most cases that’s about all. I think that true recovery is generally achievable in other ways. But that’s for a different post.

Part 12 of 'The Mental Health Workers' Guide' covers the third in the ‘big 3’ trilogy of psychotic symptoms: Thought disorder.

Buy the entire series as an Ebook here

Thought disorder is, for many people, the most difficult to understand. Unlike delusions which are all about ‘what’ we think, thought disorders are about ‘how’ we think. It’s thought process, not thought content.

Psychosis (Delusions part 2)

Buy the entire series as an Ebook here

Part 11 of 'The Mental Health Workers' Guide' will concentrate upon the sorts of delusions commonly experienced by people on the caseloads of support workers up and down the country.

Psychosis (Delusions part 1)

Buy the entire series as an Ebook here

Delusions are the second of the three psychotic symptom groups that we will consider.