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OF mental health care and mentally ill

User perspectives on mental disorders

Thus far, we have proposed a four-quadrant schema for understanding human experience and have described disordered human experience in terms of classification systems, incidence data and symptomatology. They objectify human experience into codified systems of description, including numbers. So, having proposed a four-quadrant integration we have subsequently planted our feet firmly in only one! Well, this says something of the dominant perspective in contemporary psychiatry. It is not in itself wrong, since human experience is made up of a subjective and objective sense of self and a subjective and objective sense of community.

But it is only part of the story, or more precisely, one-quarter. In this final section we begin to redress the balance with reference to the personal accounts of mental health service users and the research they have conducted. When people who have experienced mental disorders describe the connections that are important to them in the expression of their distress, their needs, and thus the imbalances that have led to their condition, there are striking similarities across individuals and groups. Users value common things such as respect, choice, self-help and advocacy. Their expressed needs include intimacy and privacy, satisfying social and sexual lives, happiness and meaningful activity. These all stem from left quadrant territory, both self and community, and we should be grateful for the reminder. But service users also draw attention to the lower right quadrant where objective–community forces can threaten their well-being. Income, housing, benefits and employment are typical examples.

So, what of upper right? Well, mental health service users are actually much more connected to human experience than the professional literature might have us believe. Upper right does not need developing anywhere near as much as the other quadrants, since the objective sciences have that base covered, at least for the time being. And service users readily acknowledge that they have benefited from these objective–self sciences. A survey of more than 500 service users, conducted by a research team of service users, concluded that ‘while many users suffered from the side effects of psychotropic drugs, most also appreciated the benefits and lessening of symptoms’. This seems a balanced view. The evidence points to an integrated understanding of the origins of human experience and a corresponding focus on those areas where care and attention is required (self and community in both subjective and objective terms). This point is made clearly in the service user research introduced above. Through rigorous methodological procedures, out of respect for the scientific method (upper right), this service user research team designed an interview schedule that could be administered by service users (trained in interview techniques) to describe the perspectives of current mental health service users on community and hospital care. The instrument, which it is hoped will contribute to the formulation of a set of user-defined standards to compliment those already in the NSF (DH 1999), covers all four quadrants.

Personal experiences of self, such as the ability to make choices based on sufficient information (subjective–self) are key items in relation to various health care practices, including medication (objective–self). Rose’s interview method taps social forces that may be experienced as oppressive or liberating, such as the police or user groups (objective–community), and also incorporates subjective–community interests such as relations with professional staff.

A psychotherapist once declared a client’s criticism of her service to be a symptom of their psychopathology. This is a crude analysis in which all experience must be reduced to upper right and stands in sharp contrast to the integrated, four-quadrant, holistic orientation of many service users. From the evidence to date it would appear that mental health service users do not distinguish one mental health nursing approach or set of skills (model and its treatment implications) as being the correct one or the only one, but recognize the potential value of all, providing no one approach is applied oppressively and providing all are delivered with respect for the person and their choices.

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