First, my ongoing, unremitting struggle for sanity…
I wrote this article during the fourth and fifth week of the Coronavirus lockdown in England. I wrote it whist living in an Air B&B in London, in a room with an en–suite bathroom – no living room, no garden, just a small kitchen that I have been sharing with the other two Air B&B residents.
Since the beginning of lockdown I have been ‘self-shielding’ (to use the UK government terminology), being one of the 1.5 million people in the UK deemed ‘extremely vulnerable’ to Coronavirus. What makes me part of this very high-risk group is that I have an ‘underlying health condition’ (Crohn’s Disease) and I am immunosuppressed due to the Crohn’s Disease medication I am on. As a result of ‘self-shielding’, I have only briefly left my room four times in the five weeks of the lockdown – for food shopping and collecting medication. But I am luckier than many in that I am able to buy fresh food on-line, and I have a good friend who has offered to collect my medication.
‘Stay home, save lives’ – says the Coronavirus lockdown motto. I am nowhere I can call home (we are not all in this together after all). My ‘self-shielding’ has brought about acute feelings of isolation, as well as a strong sense of lack of control, a sense of existing in enforced captivity and solitary confinement in one fairly small room (I live alone). I have been reminded of that other (profoundly traumatising) place and time – the acute psychiatric ward in Manchester where I was sectioned for three months back in 2009 – where I experienced a similar sense of imprisonment, lack of freedom of movement, and deprivation of liberty. That other place and time is both similar and very different. During the Coronavirus lockdown I have not been severely depressed, psychotic and suicidal as I was back in 2009, and I would not need Section 17 leave from a psychiatrist to leave my Air B&B.
Being ‘clinically vulnerable’ to Coronavirus entails an increased risk of me falling severely ill and even dying of the virus. 9 in 10 Coronavirus- related deaths in the UK feature an ‘underlying health condition’. The thought of dying alone (due to social distancing) terrifies me. I have been thinking about the 13-year old boy in London who died alone and was buried without a proper funeral as his family had to self-isolate. I have not seen my parents, who are in their late 80s and live in Greece, for a year. The thought of dying without being able to see them makes me panic. Equally, the thought of them falling ill and dying of the virus alone and without a proper funeral is unbearable.
In addition to Crohn’s Disease, I have a long history of mental ill health. I started using mental health services in 1991. During the Coronavirus lockdown, NHS community mental health services have been curtailed and routine, but essential, physical health appointments have been cancelled. I strongly fear that if my mental health deteriorates seriously or I have a Crohn Disease flare up, I will not be able to access the services I will need.
And then there are the daily press briefings announcing the UK Coronavirus death toll. According to a Financial Times statistician, the true UK death toll is over 48,000 people – on course for 50,000. I’ve felt profound feelings of anger and grief, thinking that a lot of these people died preventable deaths, alone and neglected. Whilst surrounded incessantly by death toll announcements, I keep thinking about that one death that occurred about 87 years ago when my maternal grandmother died in childbirth at the age of 30. A death that has haunted me since my childhood, a death the legacy of which has been at the core of my serious mental health struggles, as I psychically ‘inherited’ (through intergenerational trauma dynamics) my mother’s (complicated) grief and survivor guilt associated with her mother’s death. Being mothered by a woman who wished herself dead, while I was growing up, left me with only death to identify with. In spite of my 25 years (and counting) of psychotherapy, I am still grieving. The Coronavirus deaths have intensified this grief and the relentless emotional struggle associated with my dealing with death.
Debates on Critical Psychiatry and other Controversies in the Coronavirus era: Should Anyone Care?
I recently read the debate on critical psychiatry in the last issue of Asylum magazine (Spring 2020, Vol 27.1). The debate is encapsulated in two articles – one by mainstream psychiatrist Dr Samei Huda (‘Critical Psychiatry: Dead Ends and Avenues of Opportunity’) and the other by critical psychiatrists Drs Joanna Moncrieff and Duncan Double (‘In defense of critical psychiatry: A response to Dr Samei Huda’). I felt it was a constructive and fairly respectful debate between clinicians with very different views on acutely controversial issues within the politics of mental health, such as the positive contributions and pitfalls of critical psychiatry, the nature of ‘mental illness’, the role of values and power in diagnostic assessments, the critical importance of the therapeutic alliance, the effectiveness of drug treatments in comparison to psychotherapy, problems associated with the use of psychiatric medication, as well as the advantages and disadvantages of different paradigms in mental health research (qualitative research vs. Randomised Control Trials).
The constructive and fairly respectful debate referred to above stands in stark contrast to the acrimony that more often than not appears to characterise discussions of these contested issues within the politics of mental health on UK social media, Twitter in particular. I have been actively using Twitter for nearly two years and during this time I have witnessed extreme polarisation between opposite camps involving both mental health professionals and service users who fight with each other relentlessly – for example, the pro- and anti-medication camps, the pro- and anti-diagnosis camps, the mainstream psychiatry vs. the critical psychiatry and psychology camps. I have often observed utterly disrespectful, vicious and what I view as abusive personal attacks replacing discussion and debate. I have seen – in all opposite camps – arrogance, dogmatism, ego and power trips, combined with what seems like a complete lack of self-awareness and ability to self-reflect. This is often disguised as responsible behaviour, taking a high moral ground and a commitment to protect patients from harm.
To what extent should mental health service users/survivors and frontline workers care about such acutely polarised discussions of controversial issues within the politics of mental health in the Coronavirus era?
To what extent do these polarised debates matter to mental health service users in crisis when NHS community mental health services and crisis services in the UK have been stripped away during the Coronavirus lockdown?
How relevant are these polarised debates to service users in inpatient mental health wards in the UK – wards that are more often than not understaffed and overcrowded and hence hotspots for Coronavirus infections and deaths?
Should mental health service users/survivors care about these acutely polarised discussions when they have been left starving and without essential medications because they have been wrongly omitted from the UK government list of ‘extremely vulnerable’ people – a list that is linked to the provision of crucial support from local councils during the Coronavirus lockdown?
Should I care about these polarised debates when I am struggling to save my sanity while ‘self-shielding’?
Far from being merely theoretical, I feel that debates on controversial issues within the politics of mental health are critically important in the sense that they shape mindsets and practices in mental health care, with vital consequences for both service users and workers. However, I feel I can only truly care about such debates when all of us begin to enter these debates with humility and an open mind. A key aspect of the Coronavirus pandemic consists, arguably, in the complete collapse of all certainties of our lives as we knew them. Hopefully, the acute uncertainty which has emerged during the pandemic, albeit painful and anxiety provoking, can help us to cultivate such humility and open-mindedness when entering difficult discussions of contested matters in mental health.
Finally, I feel that embracing humility and open-mindedness also involves an appreciation of the importance of ambivalence, whereby one is able to hold and negotiate contradictory thoughts, views and feelings. It seems to me that such an ability is a critical asset when it comes to controversial issues in the politics of mental health. I am reminded of Felicity Callard’s (2014) paper on the ‘indispensability of ambivalence’ about psychiatric diagnosis in the Journal of Medical Ethics. It called attention to the conceptual benefits of ambivalence vis-à-vis the achievements and problems with psychiatric diagnosis. She talked about the need to ‘keep in clear view greyer, more ambivalent accounts of psychiatric diagnosis’, as well as the need to avoid premature certainty. She referred to the potential ethical benefits that might be achieved through uncertainty and ambivalence.
These benefits include the possibility of attending to voices that are seldom or never heard in debates about psychiatric diagnosis, the possibility of more open and balanced interrogations of the achievements and limits of diagnosis, and finally the possibility of attempting to do ‘justice to the multifaceted ways in which those in receipt of psychiatric diagnoses live with, through, against and beyond them’. I think the same could be said about other controversies in the politics of mental health.