See Saw Margery Daw does mental health need a new master?

I’ve just written a blog aimed at new parents in the context of Covid. It has plunged me right back to when my children were babies and to my own childhood too. That is the thing about lockdown – you have time for your thoughts to wander – for good and for bad. I was remembering nursery rhymes and See Saw Margery Daw came to mind. Then it dawned on me that I rarely notice seesaws these days. They were always the first thing we would run to in the park – the thrill of the bounce at the top, and the glide down to the bottom being the draw. But in reality it was so hard to achieve, so dependent on who you were with, their relative weight to yours, and how serious they were about ‘getting it right’. The realisation that it wasn’t going to work, and being stuck either at the bottom or at the top was so disappointing we would run off to find something else. Occasionally I would brave it on my own by standing in the middle – desperate to find that ‘sweet spot’ where you hover between one side and the other. It was scary, and rare to achieve but thrilling too. We would always go through the same ritual every time; never quite ready to let go of the possibilities that the seesaw held.

In true lockdown mind wandering style this whole scenario made me think about all too familiar struggles we have in mental health services; and how achieving that balance, the ‘sweet spot’, can be so hard without tipping one way or the other. It was very present in my blog for new parents. On the one hand, Covid has resulted in devastating losses – from partners not being able to attend scans and even limited access around the birth, to restrictions on just about every aspect of life with a new baby. On the other hand, and this is the ‘sweet spot’, it has provided more opportunities to just ‘be’ with your baby, and from the babies perspective this is all to the good. By focusing too much on how wonderful this opportunity is would deny altogether the reality of the costs; but by over focusing on the negatives risks leaving people feeling hopeless and stuck in their grief about what should have been. Feedback from the blog suggests it hit the ‘right spot’ for some, but I am less likely to hear from the ones for whom I got it wrong, and there will be many I’m sure. Of course, it mostly depends on the moment it ‘catches’ you. Interestingly some of the most positive feedback came from parents to be and those who went through lockdown with a baby first time around; and are relieved to see the experience through a hopeful lens. Also from professionals, grandparents and friends as it gives them ‘something’ to offer new parents at a time that has left them feeling utterly helpless. I have heard little from parents going through it right now, and of course they are less likely to have the headspace to even read it. Here it is if you are interested:

Achieving that balance of truly understanding someone’s pain whilst at the same time offering hope is at the crux of what mental health services are all about, and is the ‘sweet spot’ we all strive towards. Sadly though, for many we are still getting it wrong. The raging ‘diagnosis debate’ immediately springs to mind when I think about this dichotomy. On the one hand to have your difficulties described as a disorder can be very validating. It means they have been taken seriously and elevated from the ordinary to the extraordinary. It also offers hope that people have been on this path before and the experts know what to do to help. On the other hand, it unhelpfully implies that there is a clear and absolute line that people are on one side or the other of – you either ‘have a disorder’ or you ‘don’t’. It also risks losing sight of the individual, and the many contextual factors that may have contributed to how they are feeling and what they might need. The ‘problem’ becomes located within the person and seen as their ‘disorder’ rather than a complex interaction of many things over many years; often external and beyond their control. This can be very disempowering, as though they are some how at ‘fault’ or ‘disordered’ and need to be ‘fixed’. It also focuses the solutions on them rather than the root causes of the difficulties.  For example, is it helpful to tell a child they have an anxiety disorder when they are terrified of school because they have been bullied every day? One family might think “yes! it shows how serious it is and helps us know what to do!” Another family might think “Why should my child be labelled as having the problem when it is because of how they have been treated? School needs to sort the bullying problem out and take steps to make my child feel safe’. The children themselves will also have a view, and that may be different altogether.

Of course it is rarely so black and white, and a ‘both/and’ approach where the child and family have access to support and strategies if they want them, at the same time as the wider issues being recognised and addressed proactively is ideal. Currently, however, most mental health services are set up to work with the individual child, and often require that they meet the criteria for ‘disorder’ before they can even access help in the first place. Going back to our seesaw, this heavily weights the balance in one direction, the individual, and despite the best efforts of most practitioners who do formulate more broadly, the wider work is hard to achieve. Pressure on services, waiting time targets, increasing rates of urgent presentations all keep the focus on the individual with the wider work seen as ‘a useful addition’ rather than core. Covid helps to shine a light on this bias with the increased concern about mental health that it raises. It begs the question: are we going to go down the road of declaring that the pandemic has created many more children and young people with ‘disorders’? Or do we need to acknowledge as a society that it has impacted distress levels significantly for very obvious and understandable reasons? And if we do choose this then will we also choose to pay more attention to the other contextual factors that impact mental health like poverty, discrimination and adversity, all of which existed long before COVID, and have only served to exacerbate its impact?

Back to the seesaw. At the ‘acknowledging distress vs offering hope’ level clinicians very much put children and families at the centre of helping to find the ‘sweet spot’ that is unique to them. We are open to listening really hard to feedback; and changing our approach accordingly (or at least we certainly should be!) What we are less good at is putting this voice at the centre of service design. We are getting better at co-production, but I’m not sure that it is at the level that asks the big questions. For example,  what should the balance of focus be between the ‘individualised approaches vs wider determinants’ and the ‘disorder led vs needs led’ debate? These are unsettling questions – both for service providers and service users alike because they challenge the status quo. However, a bit like standing on top of the seesaw, the ‘sweet spot’ that we can potentially find when we ask them together is well worth the risk.

Barry Mason, a renowned Family Therapist, referred to such a leap of faith as moving towards ‘safe uncertainty’ in his classic paper from 1993. I heard the sad news that he died today and so I am dedicating this blog to his legacy.

Mason B (1993) ‘Towards Positions of Safe Uncertainty’. Human Systems 4 (3-4) 189-

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