The Care Guy's blog

Hello and welcome to The Care Guy's blog.

Please have a look around and feel free to comment on anything that catches your eye.

I hope to make this a useful resource, not just a 'come and buy my services' blog and the comments and opinions of visitors is likely to be a big part of making the blog a success.

I look forward to hearing from you.

Stuart Sorensen

(The Care Guy)

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  1. As some of my more avid followers will be aware I edit Care To Share Magazine, a free internet monthly complete with blog support and downloadable PDFs. Issue 7 is out today and you can read it here.

    Highlights include contributions from some very prestigious authors including Tommy Whitelaw, an undisputed champion for those affected by dementia and their carers. We have articles supplied by Canadian Disability (Architecturally challenged) activist Terry Weins, Simon Duffy, Director of the Centre For Welfare Reform, Ellen Anthony, an American carer whose piece on her experience of elder abuse is a lesson for us all and two separate short articles by nurses from either side of the Atlantic describing the reality of ‘care’ and the frustration they share with care providers everywhere when they find that their ‘hands are tied’. And that’s not all by any means. Have a look at he contents list below to see what other goodies we have in store.

    Cover pic

    I hope you enjoy reading issue 7 as much as I’ve enjoyed putting it all together. All Care To Share articles appear on the Care To Share blog for readers to have their say on line too.

    And please do get in touch with your own articles for future issues. Just Email me on for more details. After all – issue 8 won’t write itself.


  2. “An enormous amount of research has examined possible physical causes of psychotic experiences. This research has yielded some interesting findings, but no definitive conclusions can yet be drawn. Work in understanding biological influences on psychotic experiences may have been hampered by a number of problems:

    The use of unreliable and invalid diagnoses. If diagnoses are misleading, real physical processes that are related to only some of the psychotic experiences might be hidden.

    The fact that two things happen together does not mean that one has caused the other. Few studies have made this distinction.

    The effects of complicating factors (such as medication) have not always been taken into account.

    It has often been assumed from the outset that the reason for these experiences is likely to be a biological one and so other possible reasons have not been investigated.

    It has often been assumed that there is likely to be just one cause. It is of course possible (indeed likely) that a number of things need to come together for someone to have these kinds of experiences.

    For example, someone may have an inherited sensitive temperament but only have psychotic experiences if at some point in their life they experience extreme stress.

    There are, of course, biological and brain events that correlate with all aspects of our mental functioning. This is equally true for ‘normal’ and ‘abnormal’ experiences. However, it is incorrect therefore to conclude that biological abnormalities are the primary causes of a complex range of experiences. The undoubted existence of biological aspects to our experiences does not in itself justify categorising them as medical illnesses.”

    British Psychological Association (2000)

    Recent advances in understandingmental illness and psychotic experiences

    British Psychological Society, Leicester. P.24, p.25, p.29,

    “The overarching message of ISoS is that schizophrenia and related psychoses are best seen developmentally as episodic disorders with a rather favourable outcome for a significant proportion of patients. Because expectation can be so powerful a factor in recovery, patients, families and clinicians need to hear this.”

    “Despite these notes of caution, the ISoS findings join others in relieving patients, carers and clinicians of the chronicity paradigm which dominated thinking throughout much of the twentieth century.”

    Harrison G. et al (2001)

    Recovery from psychotic illness: a 15 and 25 year international follow up study

    British Journal of Psychiatry: Number 178, pp.506-517

     “The only well-established structural abnormality in schizophrenia is lateral ventricular enlargement; this is modest and there is a large overlap with the normal population.”

    Chua S.E. & Mckenna P.J. (1995)

    Schizophrenia – a brain disease? A critical review of

    structural and functional cerebral abnormality in the disorder.

    The British Journal of Psychiatry: Number 166, pp. 563-582


    Dissenting voices

     “…the notion of schizophrenia is unsupported by scientific evidence and is unsustainable. Maintaining that schizophrenia exists is dishonest. It would be of more help to those in distress, and move forward the research effort to understand madness, if we stopped trying to fit their symptoms into a bogus diagnostic category.”

    King J, (2000)

    What in fact is schizophrenia?

    British Medical journal

    Volume 320: p.800

    David Whitwell challenges the Kraepelinian dogma of inevitable decline and cites the ‘plateau’ effect of deterioration levelling out after 2 – 5 years followed by stability or improvement. He argues that early intervention is the key to positive outcomes and recovery. This is the ‘critical period’ hypothesis.

    Whitwell D. (2001)

    Service innovations: early intervention in psychosis as a core task for general psychiatry

    Psychiatric Bulletin

    Vol. 25, pp.146-148

    “(People with schizophrenia) improve without fanfare and frequently without much help from the mental health system. Many recover because of sheer persistence at fighting to get better, combined with family or community support. Though some shake off the illness in two to five years, others improve much more slowly. Yet people have recovered even after 30 or 40 years with schizophrenia.”

    Froggatt, D. 2007

    Recovery Part 2: Concept of Recovery

     WFSAD Newsletter: 2007, 3, P1.

    For an overview of the research and theory concerning High Expressed Emotion in serious and enduring mental illness read:

    Leff J. (1998)

    Needs of the Families of People with Schizophrenia

     Advances in Psychiatric treatment

    Vol. 4 pp. 277-284


    Hooley J.M. (1998)

     Expressed Emotion and the Locus of Control

    The Journal of Nervous and Mental Diseases

    Vol. 186, No. 6,  pp.374-378

    We’ve now reached the end of the ‘Emotional Management’ blog series. I hope it’s been useful and perhaps even entertaining to read.

    Feel free to print this stuff and distribute it either physically or electronically to anyone who may find it interesting. All I ask is that you that you don’t edit or alter my words and that you keep my contact details and copyright intact.

    I’d also be very keen to receive any feedback about this. You can get in touch with me through the address at the top of every page or via the blog at

    Thankyou for reading.


    Stuart Sorensen

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

  3. By now the point ought to have been made that recovery from serious mental disorders is not impossible. It requires some hard work and dedication but that’s not the same as saying it can’t be done. In this post I’d like to outline a few of the many techniques we use to help people to re-evaluate their interpretation of their experiences. This is by no means the entire ‘arsenal’ of techniques – just a taster really. Hopefully it’ll shed some light on the sort of psychological interventions I’ve been referring to throughout this series.

    Pie chart

    One common issue for people with psychotic disorders is the tendency to jump to conclusions. This interesting research article published in 2009 makes the point extremely well: 

    The basic idea is that if they can’t immediately explain a thing then the individual will simply light upon the first remotely plausible explanation they think of and decide that this must be the reality. The magical thinking notion that:

    If I think it, it must be true.

    One extremely effective technique is to offer (and get the other person to think up) possible alternative explanations that can then be allocated percentage points in a pie chart. The basic process is to decide for each possible explanation how likely it is to be the truth. By beginning with all the alternative explanations before introducing the delusion it is possible to get a genuine approximation of plausibility that leaves only a fraction of the pie chart for the delusion. This doesn’t prove that the delusion is false – it simply introduces some doubt and so the individual is more willing to consider alternatives.

    explanations pie chart

    This only leaves 25% left for the delusional belief that the creaking noises the client hears are actually caused by the government agents sneaking around beneath the floor installing surveillance equipment.        


    Many people with mentally disorders have an unrealistic view of themselves – be that good or bad. By working with them to create an increasingly long continuum it is possible to get them to review their understanding of their worth, goodness, wickedness or grandeur. As an example let’s imagine that the client has delusions of guilt and believes themselves to be the most evil person in the world.

    continuum chart

    From this small insertion of doubt it is possible then to collaborate on experimentation to test out the service-user’s own beliefs in the real world and discover just how much evidence exists to support or refute the delusion.

    The process of experimentation is a little more complicated than it first appears and really it deserves a separate few blog posts to do it justice. So for now I’ll simply say that experimentation is based upon the scientific method which involves generating a hypothesis, predicting what will happen in certain circumstances, testing the hypothesis by providing those circumstances and then debriefing before creating a new, revised hypothesis and starting again. By this process eventually it is possible to mover the service user in gradual, incremental steps toward a reasoned and reasonable interpretation of their perceptions.

    Another very useful habit to encourage is journal-keeping. The journal can take many forms but there are a few elements that are worth considering and really that are invaluable to the therapist. The first is a record of thoughts, feelings and behaviours in particular circumstances. This can be used to plot patterns in the person’s experiences. For example it may look like this:

    basic journal

    The completed record allows us to plot self-fulfilling prophecies, thinking errors, behavioural problems and a host of other potential issues that we might use as the basis of experimentation.

    As well as plotting thoughts, feelings and emotions as record of coping strategies and their usefulness is helpful as is a narrative account of what happens on a daily basis, any thoughts that arise and any attempts to dispel delusions or hallucinations as well as records of successful ways to cope with thought disorders and other difficulties.

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

  4. There are many disagreements about what recovery from serious and enduring mental disorders might mean or even if it is possible at all. It should be clear from the preceding posts that I believe that recovery is not only possible – it is also a relatively simple concept. I think that when you add together the information from the preceding 33 posts in this series it becomes startlingly obvious that recovery from serious mental disorder is far from rocket science.

    All it requires is the methodical and committed application of some very straightforward principles. Admittedly ‘simple’ isn’t the same as ‘easy’ and there are an awful lot of simple principles to consider but that doesn’t change the fact that it’s straightforward to understand. By way of illustration let me demonstrate the difference between ‘simple’ and ‘easy’.

    I live in Workington on the North West coast of England. By applying just a few ‘simple’ principles I can get myself to Newcastle – a town in the North East of England.

    The principles are as follows:

    • Walking involves repeatedly placing one foot in front of the other.
    • To get from Workington to Cockermouth follow the A66
    • To get from Cockermouth to Carlisle follow the A592
    • To get from Carlisle to Newcastle follow the A69

    That’s all there is to it – four simple principles will get me from Workington to Newcastle. It really is simple to understand. However it’s not easy. The distance from Workington town centre to Newcastle city centre is around 92 miles. Simple but not easy.

    The same is true of recovery from serious mental disorder. It’s simple but it’s not easy. Just like a walk from Workington to Newcastle it requires perseverance, commitment and stamina. But it is possible.

    So what are we trying to achieve when we talk about ‘recovery’? There are several different definitions – I’ll overview some of them here.

    My own favourite is the tripartite model first proposed, I think, by Ron Coleman. He breaks down the components of recovery into three broad subgroups which he terms:

    • medical recovery – absence of symptoms;
    • social recovery – the person has a valued place in their society;
    • psychological recovery – the person is not particularly distressed.

    The idea is that any two of the three is enough.

    For example many of us hear voices but that doesn’t prevent us from functioning. Many voice-hearers have valued places in society and have learned to understand and deal with our experiences. They do not experience medical recovery – auditory hallucinations are a psychotic symptom after all – but quite frankly so what? If we’re able to function and we’re not distressed what does it matter if we hear voices?

    After all – many of our most respected citizens hear voices. Religious leaders often describe hearing the voice of God or the virgin Mary and mediums such as Derek Acorah have grown very wealthy indeed from this phenomenon.

    Social and psychological recovery are more than enough. Indeed any two of the three constitutes meaningful recovery in a practical sense. The psychiatrist may not agree – indeed in my experience once diagnosed with a mental disorder most psychiatrists are only interested in the absence of symptoms to the exclusion of other concerns but that’s neither practical nor, in most cases, achievable without heavy doses of medication that also robs the individual of much of their cognitive function.

    Coleman also adds another dimension to the tripartite model – the person is off medication and paying tax. Off medication because that means they are no longer dependent upon chemicals to maintain their stability and have left the ‘illness’ model behind. Paying tax because until they are working they are still presumed to be part of an ‘underclass’ of disadvantaged people in our society.

    Personally I’m not sure about that last part. I do believe that it is necessary for the person to be capable of working in order to be recovered or not but I think that whether or not they do has as much to do with the national economy and with personal choice as it might have with any measure of health or illness.

    Others would say that recovery is possible even whilst taking medication because it doesn’t matter how you achieve stability – it’s simply important that you do. I have some sympathy with this view but the pedant in me insists that if a person needs treatment then they are not recovered. Why take medicine if there’s nothing to treat?

    However it’s a pointless and relatively circular argument. The biological vulnerability is just as relevant as the others and if we achieve recovery by psychological or social intervention then it’s equally reasonable to acknowledge recovery that’s achieved by biological intervention. To insist otherwise is probably fairly irrational because all we’re doing is pretending that biological intervention is somehow more like ‘treatment’ that other interventions which is hard to justify to say the least.

    Still other talk about the life-changing experience of psychosis. The term ‘Kundalini’ is often used to signify the spiritual crisis and ultimate spiritual renewal that psychosis causes. Unlike the traditional medical model that aims to return people to their premorbid state (how they were before) this view of recovery insists that it is the spiritual growth that is important and that simply returning to previous functioning would be both undesirable and ultimately impossible. Psychosis changes a person’s perspective on life forever – they can never be the same but then again why should they?

    So we can see that there are several different ideas about what recovery means. What they all have in common (except the medical definition) is that they are rooted in the idea of function. So long as people can cope they are recovered. Only in traditional psychiatry do we find this insistence on absence of symptoms. For everyone else it is the ability to cope with life that matters.

    So – the truly simplistic statement is this:

    Recovery from serious mental disorder is all about learning to cope.

    What’s so mysterious about that?

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

  5. In practice the stress and vulnerability model requires much more thought and much more attention to detail and assessment than traditional biomedical psychiatry. It’s not sufficient merely to identify symptoms and then intervene with medication. People are not simply machines to be reduced to their component parts and ‘fixed’ with a little tampering.

    If we are to use the stress and vulnerability model in practice we need to take a much more careful look at the person, their lifestyle, their vulnerabilities and stressors but also their strengths.

    We need to develop a proper formulation (more holistic than diagnosis) in co-operation with the service-user and then identify areas of need to work upon. At the same time we concentrate upon strengths and try to discover what can be built upon or what skills are transferrable. If the person has always been good at football for example then see if they can join a team.

    This will have an enormous impact if they commit to it because it will affect various vulnerability factors:

    Activity chart

    By understanding the value of non pharmacological interventions such as this we can keep an eye upon the many aspects of a person’s life that make the difference between misery and dependence or fulfilment and inter-dependence (nobody in our society is ever truly independent).

    Of course there are many options and the above example of joining a football team is only one of them. It will not be suitable for everyone but there’s always something.

    In the past I’ve enrolled and accompanied clients on evening classes or other training courses (and learned much myself in so doing). I got one man to teach me how to draw and sketch. He’d been a semi-professional artist before he became ill and the opportunity to teach someone else benefited him immensely in terms of self esteem and also in forcing him to organise his thoughts in a structured way with a set goal. It also benefitted me – I learned how to draw people and represent perspective when sketching landscapes much more effectively than I had before.

    Other clients have been encouraged to begin to venture outside of their comfort zones by building upon their strengths in various ways, gradually facing more and more difficult situations until they learned/developed progressively more difficult coping skills.

    As the client develops better coping techniques in all the areas of vulnerability we have identified they become able to manage with gradually reducing doses of medication. It may well be that in the most acute phases of mental disorder large amounts of medication is needed to suppress symptoms or even to provide a measure of containment as well as personal relief for the service-user. However the disadvantage to psychiatric medications is that they tend to interfere with thought processes – they slow down cognition. It’s interesting that ‘poverty of thought’ is described as a symptom of schizophrenia even though antipsychotic medications blunt the thought processes.

    Nevertheless it is true that medication has a very real place in the initial stages of disorder but true recovery requires the person to think through their difficulties. This is not helped by over reliance on medication. So gradually we reduce the medication over time as we help the client to develop new coping skills. It’s a shifting balancing act with the emphasis moving inexorably away from medication and toward more natural and cognitive behavioural strategies. Eventually the coping ability they have may become sufficient that they do not need medication at all.

     meds and coping

    Systematic attention to coping skills moves people back along the vulnerability axis of the graph.

    Stress and vulnerability graph

    Eventually they become as robust as any other average person. This means that they will react in the same sorts of ways to normal stresses and are just as capable as the rest of us. They will, of course remain susceptible to stress and can react badly when overwhelmed but that is true for all of us. So long as they can handle as much stress as the average person that’s enough.

    It makes no sense to expect people to exceed the coping skills of the rest of society before we can call them recovered although in truth many people do exactly that.

    The effective therapeutic process unpicks, examines and deliberately installs coping skills in a way that most people never do. It’s not surprising then that many recovered people are significantly more ‘emotionally robust’ than their counterparts who have never been mentally disordered in the first place. They often have more coping skills than the rest of society because they have needed to develop them – and because (unlike most people) they have consciously worked hard to learn them.

    This is meaningful recovery based around coping and function rather than around an increasingly meaningless catalogue of ‘symptoms’, most of which are really only choices or poor coping strategies themselves. For example one of the ‘symptoms’ of schizophrenia is said to be non-compliance with medication. It’s clear just how silly this is when we consider that the compliance rates for people diagnosed with schizophrenia are no worse than the compliance rates for people with insulin dependent diabetes. We don’t say that non-compliance is a symptom of diabetes so why should we decide it’s a symptom of schizophrenia.

    After all – if you were told that you’d have to take a medication for the rest of your life that would dull your thoughts, caused weight loss and blurred vision, lead to impotence in men and menstrual disturbances in women and that carry a risk of heart problems that just might kill you how keen would you be to take it?

    Other ‘symptoms’ include responding to hallucinations (telling the voices to leave you alone for example) or avoiding others (bear in mind how people with mental disorders are treated by the general public), loss of volition, loss of libido and lack of self care (symptoms of depression and side effects of medication, not necessarily ‘schizophrenia’), a sensation that your body doesn’t work as it should (neuroleptic medications cause problems with motor control) and many other ‘second rank’ symptoms that really are more to do with coping or treatment than with the psychosis itself.

    In the next post we’ll look at what we mean by recovery itself and how it differs markedly from traditional (symptom based) medical definitions precisely because the emphasis is upon coping rather than upon diagnostic labelling.

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

  6. I’ve mentioned the International Study of Schizophrenia (ISoS) several times already in this series. That’s the World Health Organisation’s study that followed people from all over the world from first diagnosis of schizophrenia for 25 years.

    Actually it started out as just 15 years but the American Psychiatric Association protested that they weren’t comparing ‘like for like’ so the WHO funded it for another 10 years using APA’s own researchers to make sure there was no bias. The results after both 10 and 15 years were the same. Because they ran ‘back to back’ with the same subjects we now have a 25 year longitudinal study concerned with the outcomes for people diagnosed with schizophrenia from many different cultures.

    The reason that the American Psychiatric Association didn’t like it is the same reason that most Western psychiatrists don’t like it. It demonstrates extremely clearly that in the industrialised West (the nations with most psychiatrists) recovery rates are much poorer than in other cultures where medication is limited or non-existent and where psychiatric professionals are scarce to say the least.

    Here in the West we have a recovery rate (we actually tend to rediagnose rather than admit recovery is possible) of around 33%. It’s interesting that this has remained constant since decent records began and certainly since before the advent of antipsychotic medications (major tranquilisers).

    In the rest of the world rates vary and it’s true that some cultures have even poorer recovery rates but some are very much better. In some communities the recovery rate rises to around 90%.

    It’s no accident that I used the word ‘communities’ in that last sentence. It seems that the quality of a person’s social involvement and the nature of that group’s cultural beliefs and expectations has a major impact upon the prognosis for psychotic disorders.

    In a subsistence economy such as certain parts of rural India there’s just no time to ‘carry’ someone who is too busy responding to voices to work in the fields. They have to do their part and so the community works hard to involve and include them for the good of the community. This provides them with other things to think about and to focus upon (remember the earlier posts on activity and on unhelpful thinking). It also maintains a link to the ‘sane’ society they belong to and these influences and distractions appear to have a very positive effect upon the psychotic individual.

    The expectation then is positive because the community has seen people overcome psychotic problems many times before. Nobody sees any reason to consider this as ‘an incurable illness of deteriorating course’ because they know better. The community involvement coupled with the cultural expectation of recovery becomes a self-fulfilling prophecy and people get ‘better’ (if we can use the term).

    Of course here in the West we do things rather differently. We have a cultural expectation of incurability and a social exclusion practice that typically leaves people unemployed, isolated, living on benefits and funnelled into ‘activities’ involving other people who are also excluded from the mainstream society that exists outside the walls of the day hospital or the mental health resource centre.

    This is the community based equivalent of the old Victorian asylum with it’s policy of ‘congregate and segregate’ to keep the ‘mentally ill’ away from the rest of ‘normal’ society. This is the sectarianism that leads to ‘social drift’ and the pessimistic self-fulfilling prophecy that prevents so many from recovering in our society. This is an appalling state of affairs for the most developed nations in the world to have to acknowledge – and we do have to acknowledge it because the evidence is there for all who wish to see it.

    And yet in spite of the massive social and cultural problems our society causes with its negative assumptions about incurability people can and do recover. We know from research dating back to the early 1950s that the effect of social involvement and the quality and type of social interaction has a massive impact upon the likelihood of relapse and conversely upon the probability of recovery.

    We know from research in education and also on personality disorder work that expectation and socio-cultural norms make a massive difference to the likelihood of recovery from all forms of distress and mental disorder. We know that involvement is the key and yet our society persists in excluding those people who most need involvement.

    However that doesn’t have to spell futility and pessimism. It’s surprising how little intervention and interaction can make the difference. The wider world of UK society may have its prejudices and ill-informed bigotries but those of us who work in mental health services need not be so limited in our outlook. We can use our therapeutic influence to model the world in microcosm and find valued roles for our service-users. We can help the families of service-users to practice principles of involvement and help them to understand what can be achieved. More than that – we can help them to learn how to make positive change come about. Society at large may be ignorant of the possibilities but society at large is usually far less important and far less instrumental than the small social group that the service-user belongs to.

    By influencing this small group to be positive and inclusive, to be encouraging and active the social and cultural stressors associated with mental disorders from anxiety and depression to schizophrenia and bipolar disorder can be kept at bay – at least long enough for the individual to develop their own robust coping strategies – to change their degree of vulnerability.

    Social interaction and social modelling is another, non-medical way to treat psychosis as part of a whole system affecting a fully rounded individual who is far, far more than mere chemistry.

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

  7. What do you do when you feel stressed? Where do you like to go?

    Most people have their own favourite places. Often they’re quiet or if there is sound involved it is carefully chosen, perhaps a favourite piece of music or somewhere near a gently babbling stream. Others enjoy a visit to the coast or maybe just the quiet solitude of their own home.

    Whatever environment you choose it will most probably be somewhere where you can feel safe and where you can find the time to reflect upon your situation or to simply ‘chill out’ and escape from your troubles for a while. Environment can have a major impact upon your ability to cope with what life throws at you.

    I remember when I first changed from living alone to sharing my life and my home with another person. It was a positive change and I was certainly pleased about it but it did create a few problems initially. I’m sure I’m not alone in that.

    Before this change I used to relax by stretching out on the sofa and listening to various pieces of music. All the music I chose had a tempo that mirrors the human heart at rest and this helped me to relax. I would simply lie flat and stare up at the ceiling while my thoughts drifted and invariably I found that the solutions to any problems I faced would become clear within a relatively short space of time. That was my coping strategy.

    Unfortunately it became more difficult to do this quite so regularly as I had been accustomed to with the presence of another person in the house and so my environment became less conducive to mental and emotional health. I no longer found it easy to relax and until I found a way around it this lack of ‘down time’ became a significant issue. The solution was relatively simple I’m happy to say and involved no more than a conversation and a little forward planning. Had I not been able to resolve this issue though I wouldn’t like to think what would have happened to my mood and mental state – environment plays such a huge part in my preferred coping strategies.

    Imagine how difficult it would be for you to deal with all that life throws at you if your environment wasn’t right. If there was nowhere you could go to get a little peace and quiet or if you could never feel safe. Imagine trying to think things through from the starting place of an abusive relationship in a tiny flat. How would you fare in a bedsit surrounded by violent substance-users (not that all substance-users are violent but some are).

    What would you do if your home was a cardboard box in the middle of a bustling city? How safe would you feel when it was time to sleep?

    There are many ways that the environment can either help or hinder our ability to cope with stresses. The chart below outlines some of the environmental needs that people may have. As with previous charts this is designed simply to provide a few examples – not an exhaustive list of all possible environmental issues.

     positive and negative environments

    Mentally disordered people tend to have a much greater need for a conducive environment than those who are not mentally disordered – they have more work to do on themselves. So it would make sense to help them to maintain a good, positive environment in which they can fulfil their environmental needs before beginning work on the other issues that trouble them. This is very similair to Maslow’s hierarchy of needs which suggests that environmental needs for safety and shelter etc come before other forms of coping or social concerns.

    What actually happens is a thing called ‘social drift’. It is well understood in this country that people diagnosed with serious mental disorders are likely to lose contact with others, lose their jobs and end up living in much less positive environments than they did before they became ill.

    Just as we said in a previous post:

    The more inclusive societies have the best recovery rates.

    It’s no wonder that recovery from serious disorders such as schizophrenia is so unusual in the industrialised West that most British citizens believe it to be impossible. And yet research from the World Health Organisation’s ISoS study demonstrates that many countries that lack our resources but that have more inclusive societies have much higher recovery rates.

    If you want to help someone to overcome their psychotic or other problems you must help them to get their environment right first.

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

  8. There are many ways that biology can impact upon a person’s wider mental state. This is not all that surprising given the fact that we are biological beings and that the brain and body are not really separate entities but rather two aspects of the same, human system.

    For those people who doubt that – those who believe that the mind and body are very separate entities I’d like to provide a little illustration that outlines the connection in real-life terms.

    Many people insist that there is no connection between mind and body because they object to the assertion that illicit drugs can contribute to mental disorders. Personally I have no doubt that they do but realistically it doesn’t matter how  many times I make this point from my own perspective by drawing upon my own experience it isn’t the same as drawing upon the other person’s own experience.

    So let’s consider illicit drugs for a moment. This isn’t because I think that all people reading this blog will be drug users – but rather because it makes the point rather elegantly by building upon what most people already understand and accept.

    If we consider a substance such as cannabis – people take it because it has an effect upon their mood. It changes perception and many people find this to be a pleasant experience. However it is essentially a physical stimulus – it’s a chemical that acts upon the central nervous system to produce euphoria and in a number of cases actual hallucinations. That’s a clear link between physical change and cognitive (perceptual) impact. It also affects mood (euphoria is common) by the same chemical or physical process.

    When people tell me that there is no way that cannabis can cause mental disorder they are saying that it has no effect upon perception, affect (mood) and cognition (thinking). In reply I ask them why they bother to use it then since it has no effect.

    In reality people use chemical substances precisely because they have an impact upon these things – precisely the processes that are affected in mental disorder. So it seems an inescapable truth to me that physical stressors such as drugs (prescribed or not) have an effect upon mental state.

    • That’s why amphetamine sulphate leads to anxiety and anger.
    • That’s why hallucinogens lead to psychosis.
    • That’s why depressants such and alcohol lead to depression and isolation.

    This does not mean that every time someone has a couple of pints they will become depressed. Nor does it mean that every cannabis user will develop a psychotic illness but it does mean that the substance itself has the potential to cause these problems.

    People have differing degrees of vulnerability to these substances in the same way that some people can drink caffeine all day without experiencing any significant effect whilst a single cup of coffee can leave other people unable to sleep all night. They have different levels of vulnerability.

    This is a crucial element of the stress and vulnerability model and we need to make it clear before continuing. The vulnerability itself does not create the disorder. It simply makes people more susceptible to the other types of stressor that can cause difficulties. For example certain tribes of native Americans respond very badly to alcohol. They have a high vulnerability to it. However they do not experience any problems until and unless they drink alcohol – until they are exposed to the ‘stressor’.

    This is true for all types of vulnerability – they only matter when the person is exposed to the stressor itself. A person with psychological vulnerabilities is only affected when they come under psychological pressure. A person with social vulnerabilities only becomes disordered when faced with socials stressors.

    An easier way to think of this is to consider physical disorders such as diabetes. It is well known that some people have a genetic (biological) vulnerability to cancers. However not everyone who has this vulnerability will develop cancer. Many people also need to be exposed to carcinogenic (cancer causing) substances as well – smoking for example or working with certain hazardous chemicals.

    How much exposure is needed before cancer develops also varies depending upon the level of vulnerability. That’s why not everyone exposed to tobacco smoke develops cancer and why not everyone exposed to psychological stress develops psychosis. We vary in the amount of stress we can comfortably manage.

    However we all have a limit and sooner or later, given enough stress, we’ll reach it and then exceed it. When this happens we become unwell.

    In terms of biology there are a number of stressors that have an impact. In fact there are too many individual stressors to even attempt to list them all individually but we can categorise them and then list some of the categories. This seems to me to be a much more reasonable approach.

    Categories of biological stressors:

     Biological stressors

    Other aspects of biological vulnerability might include the biomedical assumption of the cause of schizophrenia – an organic brain disorder. Unfortunately the evidence for this brain disorder is still not good in spite of decades of research aimed at demonstrating it. However……

    Not proven is not the same as not true

    There may well be a structural or chemical cause for schizophrenia. However as yet it has not been demonstrated particularly well. That’s why the dopamine hypothesis is still just the dopamine hypothesis.

    In their original article Zubin & Spring acknowledged this way back in 1977 (there’s still no real proof over thirty years on) but they also made the point that often treatment cannot wait for absolute certainty because the person in question is suffering now. Whatever the truth about the biological brain disorder assumption it is true that medication can have a major positive impact upon the experience of mentally disordered people.

    Where the stress and vulnerability model varies somewhat from the traditional medical model is that it allows for other interventions and suggests that since medication is not the only remedy then it can be used less and in lower doses so long as other areas of vulnerability are addressed as the same time. This can be extremely positive and in fact, many recovery based programmes begin with a relatively high amount of medication because it brings initial relief but then reduce the medication gradually as the other coping skills are developed.

    What we end up with then is a balanced but very clear assumption with regard to the stress and vulnerability model:

    Biological vulnerability to mental disorder exists and research in genetics and familial morbidity rates (frequency of illness) strongly suggests a genetic or hereditary element to this.

    This biological vulnerability causes problems when the individual is exposed to stressors (be they biological or otherwise) and biological interventions such as:

    • medication;
    • exercise;
    • work, rest and recreation lifestyle balance;
    • diet;
    • avoidance of harmful substances

    can have a major impact upon the development of illness. Attention to stressors such as these can also shorten the length of time the person is ‘ill’ and go a long way toward preventing any recurrence of the disorder.

    The ‘Emotional Management’ blog series first appeared during 2010 on Stuart’s personal blog. It is reproduced here as part of an ongoing process of ‘rationalisation’ to compress the contents of 5 blogs into just 2. You can download a PDF of the entire series (along with much more free stuff) from

Contact The Care Guy at or by telephone on 07872 102626

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