Wednesday 19 September 2007


I've said earlier this week that a key trait in mental health work is an interest in the patient's experience. It's from this that we can sleuth out both meaning and management plans.

Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.

What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.

Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.

Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.

Solid evidence of psychosis?

Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.

Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.

Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7

PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?


Jan said...

Thanks Shrink. Myself, Jan, aka Just another nutter, has been facilitating "user perspectives" training for a variety of MH professionals for a number of years now. I believe in a continuum model of mental health - that all psychiatric signs and symptoms are simply extensions or exaggerations of so-called normal human experience. There is no such thing as polarised "illness" or "wellness" in mental health. One of the beauties of this model is that it means everybody must in some way have the capacity to empathise with anyone who is psychiatrically "ill". Put simply, we're all mad to some degree. The shrinks where I work routinely tell med students and junior docs that there is no way they can empathise with anybody who is hallucinating or delusional. I can now add your citations to those of Romm, Escher and others to help counter this argument.

There is another beauty to the continuum bit: as one of those people who works within the NHS in a "service user" role, I'm paid to be mad, whereas the rest of you are paid to pretend to be sane. I just wish this arrangement could be as satisfying financially as it is to my own sense of smugness. Can't have it all eh?

The Shrink said...

Thanks for stopping by, Jan. Having been to conferences and meetings with the Hearing Voices Network (HVN) who advocate similarly to yourself I've been influenced by Marius Romme's work on voices being experiences (not a "well/ill" dichotomy).

As an aside, it's interesting to see you call youself a "service user" since it's a term that folk in my patch hate! They've flirted with client (but they aren't clients so rejected that) and although the HVN have many who call themselves "survivors" that doesn't sit well locally either.

Here, it's all come full circle and folk want to call themselves "patients" so all Trust documentation and stuff's printing that up. I think, like homosexuality and stigma there changing over time so the term "gay" is fine (and even seen by some as trendy) the stigma of being a "patient" is also being challenged and locally folk believe they should look it in the eye and tell it like it is. They're recipients of healthcare, they're patients, that's how it is and that's what we're being told very vocally! :-)

Calavera said...

I read this entry twice - the part about the hallucinations is fascinating. I had no idea such a phenomenon existed.

Thanks for linking the papers, too.

Jan said...

Hi Shrink. Mmmmm the term "service user"...... It's in my job title (Service User Development Worker)so it's hard to avoid it. Remarkable the number of people where I work who switch off after they hear the "service user" bit and don't credit me with actually having a job.

Any term that is introduced in order to replace a stigmatising one has a limited life-span. It will eventually acquire the negative associations of the term it replaced, within about 10 years according to some Oxbridge Prof of Eng Lang who's studied all this stuff. So the "service user" expression has had its day (I first saw it in the early '90s).

I can live with "patient", as long as it's understood that I am an active and equal participant in the caring process. I shiver at the memory of Foucault's descriptions of judicial processes in latter-day France, where the word "patient" (he who endures) was equally applicable to the occupant of a hospital bed as to the man standing on the trap-door of the gallows wearing a sisal collar.

This idea of me as some kind of "customer" rankles though. I can't change bins in the same way that I can walk out of Tesco and into Sainsbury. May the lords of darkness rot the knickers of HMG for trying to flog that one.

The Shrink said...

Agreed, language changes and connotations/associations attached to words change as ideas move on.

May the lords of darkness rot the knickers of HMG for trying to flog that one.
That's precious :-)