The context we work in
• Pathologising is expected of us
• We do not need to do anything active to be experienced as pathologising

The context we work in sets us up to be experienced as disempowering

The expectation of being pathologised (i.e: understood in terms of deficit and dysfunction) held by many people can function as a barrier to accessing care and frame perceptions of our interventions. At the time of seeking help from mental health services they often feel disempowered, experiencing their own knowledge and resources as overwhelmed and there is often a sense of relief if we take control in a paternalistic manner. There is a prominent role for judgment and pathologising even in general discourse. This can be seen in newspaper accounts blaming parents, condemning modern youth, politicians, administrators, etc. A group of people will commonly be more easily able to list ten of their faults than ten good points. Some families specifically seek pathologising of an identified patient.

Part of the set up which leads people who come to see us to expect to be told, not expecting their views to be respected lies in the predominance of 'telling' over 'listening' in common conversation. Much conversation consists of people putting forward their views and waiting for a gap to do more of this, rather than listening. Those with more power talk more, have their jokes laughed at more, are paid more attention, challenged less. Because of the risk that a conversation where people holding different ideas can deteriorate into battle for dominance people commonly will not express contrary ideas, particularly if experiencing themselves as holding a lesser share of the power. Thus a person seeking psychiatric help is more likely to expect to be told and hesitate to put their views forwards.

There are also popular beliefs that psychiatrists have special powers and will find madness/pathology lurking within people which they might otherwise be able to keep hidden. There are some roles which feed into these concerns. Mental health services have responsibility to identify and address risk, to self, others and care and protection issues for children. This means we cannot afford to confine ourselves to areas people discuss comfortably, to focus only on strengths and achievements. To fulfill the expectations placed on us we need to access people’s darkest thoughts and moments. In order for us to make the effective treatments we have available it is important to identify illness syndromes despite the stigma involved in attaching a label of mental illness, the sense of spoiled identity.

Particular roles which focus negative perceptions include instituting the Mental Health Act, prescribing and administering medication and compulsory care. Maintaining optimism is challenging in mental health service work. We usually see the least resourced people, and as they engage with their resource they will often move out of our services. Thus, the people we have the most contact with are those who do not manage to move out of our services.

Thus, mental health clinicians do not need to do any active pathologising, undermining or spirit breaking for the person to feel it. If we go with the flow it is likely some pathologising and undermining of personal agency will happen. Add strengths and stir is not enough (Rapp 1998). If we are to avoid being experienced as pathologising and spirit breaking we need constant attention to and skills for, interrupting the flow.

Fragility of holding of personal knowledge from a patient role
• People consulting us are often feeling overwhelmed
• What we offer can be experienced as dehumanizing and spirit breaking
• We need to take some responsibility for supporting people to bring their knowledge forward

Emanuel and Emanuel (Emanuel and Emanuel 1992) in their classic paper on models of physician-patient relationship, identified the option of working 'with the patient to reconstruct the patient’s goals and aspirations, commitments and character' (p. 2222) the patient themselves may not be consciously aware of. However they described physicians as unlikely to have the skills or time to do this, thus physicians may unwittingly impose their own values and the patients, 'overwhelmed by their medical condition and uncertain of their own views, may too easily accept this imposition.' (p. 2224). This same issue contributes to the experience some people describe, of mental health services as disempowering, deficit-based and spirit-breaking. Much of mental health practice, such as diagnosis, use of biological treatments and the medical model, is experienced as inherently disempowering (Rose and Black 1985) (Townsend, 1998). Patricia Deegan (1990), coming from a consumer perspective, describes mental health services as dehumanising and depersonalizing. From the recovery perspective our work is described as 'spirit-breaking'. Charles Rapp (1998), in advocating the Strengths Model, decries our dominance of deficit model, blaming the victim, etc, and described our work as 'oppression dressed up in the clothes of compassion'.

The British Journal of Psychiatry published an editorial by William Faulkner (Faulkner and Thomas 2002) stating:

“the dominant paradigm in psychiatry renders the views of people with mental illness invalid and negates the person as an individual.”

This focuses on the effect of being subject to psychiatric forms of description. A doctor visiting a psychiatrist in the role of a patient described this experience.

“I went because I thought I was having a few problems. And he told me I was depressed and that I needed antidepressants and I was devastated and I remember coming out of that thinking ‘God I didn’t realise it was this serious’ … it felt like I had my feet taken out from underneath me and it kind of felt a bit like I’d had my power taken away … I guess the thing I didn’t do… I didn’t argue against it. I didn’t argue with him because he knew.”

In order for people to experience contact with mental health services as empowering and collaborative rather than disempowering and colonizing we need skills in bringing forward people’s knowledge and resources.