James Downs is a fellow Voice of Mind – and has campaigned tirelessly this last year to get mental health on the election agenda. Having been through a long journey with mental health services, James suggests that we can get so tied up with diagnoses and complex formulations that the most basic factor is missed – the quality of interaction between the person seeking help and the ‘helper’. Whatever the therapy, treatment, history or diagnosis, this all takes place between human beings. For James, being treated as a whole person rather than an illness has been vital not only in helping him remove a major eating disorder from his life, but in building of a life worth living.
People first: The need to be seen, heard and validated
“Were you abused? Do you think you might be gay? Or perhaps there’s someone in the family with anorexia?” Such are the types of questions I’ve been asked by probing psychiatrists fishing for an explanation of my mental illness.
Whilst some of these questions may well be involved in my coming to rely on a severe eating disorder, I’ve long been frustrated by the quest for ‘one’ explanation – a sole cause or triggering factor. Being led down a path of searching for what it was all really ‘about’ never helped me at the critical stage of illness where my life was at risk and behavioural change was the priority. Yet, at the same time, I didn’t want to be viewed only as a body in need of refeeding and a mind in need of correcting.
I find it hard to see a split between the medical treatment of eating disorders and the psychological work that needs to be done too. It was never enough to be treated as a physical object with only physical needs whilst disregarding how I felt as a person about making changes to my eating and my body. It was also never enough to see ticking a box of ‘gay’, ‘abused’ or ‘in the family’ as seriously addressing the sheer convolution of factors at play in the formulation of a major eating disorder. In fact, this isn’t an adequate way to treat any human being as it trivialises the complexity of existence and fails to appreciate an individual in a holistic manner. We must always think ‘both, and’ – not ‘either, or’.
Marsha Linehan’s theory of the development of emotionally unstable personality disorder proposes a ‘bio-social’ model in which a biological tendency to emotional sensitivity is encouraged to thrive in the context of an emotionally ‘invalidating’ environment. The type of environment that typically springs to mind here is a family home in which abuse of any kind takes place, where emotional responses are denied or dismissed.
For example, when in distress or terribly upset, being told that you cannot or do not have due reason to feel that emotion (or not being met with an appropriate response from a care-giver) can mean that you come to think of this feeling as unreasonable and not to be trusted. In my case, I became almost entirely unable to express negative emotion in contexts where I felt it was ‘all in my head’, where I had nobody to validate that my problems were real to me.
As well as the home, we live in a complicated social landscape where we seek validation across a broad number of environments. Even on the level of individual relationships we generate interpersonal environments which have the potential to be helpful or unhelpful by degree. When my symptoms of OCD overtook my life so much that I missed a lot of school (my days were instead dominated by compulsive rituals and anxiety) the responses from those around me were hugely damaging. Having a total lack of awareness of mental health in general, my school saw me as a bright boy who thought he was too good to turn up to lessons.
The failure to understand why I couldn’t “just walk into classrooms” (as I was clearly able to do physically) without huge anxiety and the compulsion to repeat increasingly elaborate rituals, undermined the validity of what was for me a very difficult experience. As a result, I assumed that none of my struggle was actually ‘real’ or could be distressing to a reasonable person.
Glimmers of self-validation
From my experience, an environment in which the importance of emotional validation is fundamental (and the damage of invalidation can be most pronounced), is the help-seeking environment. When somebody is able to come forward and express their concerns in the hope they will be met with support, there are glimmers of self-validation – a realisation that their difficult experience might well be objectively real. Where this is the first attempt at seeking help, the moment where the figure with the power to assist provides a response is especially important.
When I went to see my GP in university to explain how I wasn’t washing, was spending £50 a day on food for binges which numbed my tumultuous emotions and exorcised my pain with the physical depletion of vomiting, and was planning to end my life, I was told that bulimia can be seen as an attention-seeking behaviour and that I “looked fine”. At the point I most needed help, the failure to receive any offer of support told me that it was all unreal.
My experience was invalid, just as in the four years before when my BMI was too low to be given any psychological therapy for my eating disorder, and I was withheld treatment. If my problems weren’t important enough to warrant a helping response in these instances, then when were they? The next step for me was non-suicidal self-injury and overdoses, which like my extreme drive for ever more shocking thinness was partly me asking for somebody – anybody – to have the knowledge and expertise to hold me and help me.
I’d like to put forward the notion that ‘bad’ help is worse than no help – or more specifically, being actively denied psychological support and not being listened to by professionals is emotionally invalidating – perhaps even more damaging than not seeking help in the first place. Undermining already fragile self-conviction that characterises so much of mental illness is ultimately anti-Hippocratic and has been the leitmotif of my experience of eating disorders services in Wales and primary care for mental health in general.
People are complex, diverse, changing and feeling beings and professionals need to respect that.
Thinking of a solution to this brings us back to how professionals need to treat people as people first. The same comes to therapy and treatment. Whilst research into evidence-best practice is vital in the immensely under-researched sphere of mental health, the biggest source of evidence as to what might work for any one person is the person themselves.
Paying attention to models of formulation, diagnostic categories and doggedly following manualised, generic treatments is less compatible with the nature of personhood than an emphasis on the basic necessity of treating people as individuals; as Arthur Miller said “attention must be paid”.
Rationalist, reductionist attitudes which treat people as objects and their experiences as invalid if they do not meet current scientifically-validated methods of practice need to be abandoned in order to protect vulnerable people from harm that could reasonably be seen as emotional abuse. Whilst measuring compassion, validation and Rogerian core conditions may seem basic and less compatible with the current emphases of scientific research, these are the factors which colour the therapeutic relational environments in which individuals can hope to recover, and are some of the most pertinent aspects of what it is to be a person.
Thank you to James Downs for this honest, moving Guest Blog Post.