In this episode, we speak with critical psychiatrist, Jon Jureidini about what it really means to be “not broken.” We explore why psychiatry often looks for simple solutions to complicated problems, how diagnosis can both help and harm, and what it looks like to support someone through tough times instead of shutting those feelings down. This episode is a reminder that not every hard experience is a medical problem—and it doesn’t mean we’re broken.
🧠 Follow The Not Broken Project:
Website: https://www.adelaide.edu.au/robinson-research-institute/critical-and-ethical-mental-health/not-broken-project
LinkedIn: https://www.linkedin.com/company/the-not-broken-project/posts/?feedView=all
📘 Check out Johann Hari’s book, Lost Connections: https://thelostconnections.com/
Come and listen with:
Lucy (She/Her) – A big fan of ice cream and storytelling
Rachel (She/Her) – Social Worker, Dialogical Practitioner, mad footy fan and wildly passionate about transforming the culture of mental health services to be person-led and human rights informed.
🎨 Incredible artwork @sharleencu_art
🍋 Shout out to Amplify for welcoming us into their recording studio
EPISODE TRANSCRIPT- Not Broken
[00:00:00] Lucy: This podcast has conversations around different mental health experiences that may be distressing for some people. If that doesn’t feel like something you want to explore today, you might want to visit another podcast and come back to us another time.
[00:00:13] Rachel: Discovery College acknowledges the traditional owners of country throughout Australia and recognises their continuing connection to lands, waters and community. We pay our respects to Aboriginal and Torres Strait Islander cultures and to the elders, past and present. They have never ceded sovereignty.
[00:00:31] Jon: We’ve been talking for years about people being broken hearted. Nobody wanted to give you heart medicine for your broken heart, but they do want to give you brain medicine for your broken brain. The danger is that people think that because we’re saying your feeling of great distress shouldn’t be dealt with medically, that we’re not respecting the distress, we’re not taking it seriously enough. That’s not the case at all. We know how horrible people can feel. They get to the point of wanting to end their lives. It’s not necessarily, or even most often a medical problem.
[00:01:11] Lucy: I’m Lucy.
[00:01:12] Rachel: And I’m Rachel and we’re the hosts of the Extremely Human podcast.
[00:01:16] Lucy: Sometimes we move through big human experiences that others might not understand, like psychosis, grief, addiction, euphoria, or moments that feel completely unreal.
[00:01:28] Rachel: On Extremely Human, we hear from people who’ve been there and share what they’ve learned along the way. Together, we ask, how can we meet the full range of human experience with kindness and compassion?
In this episode, we speak with critical psychiatrist Jon Jureidini about what it really means to be not broken. We explore why psychiatry often looks for simple solutions to complicated problems, how diagnosis can both help and harm, and what it looks like to support someone through tough times instead of shutting those feelings down.
This episode is a reminder that not every heart experience is a medical problem, and it doesn’t mean we’re broken.
[00:02:23] Lucy: Welcome back to Extremely Human. We’re here in Adelaide with Jon Jureidini, who’s actually been requested to be on the podcast. Did you know that, Jon?
[00:02:33] Jon: No, I didn’t.
[00:02:34] Rachel: Special request of listeners.
[00:02:36] Lucy: So, Jon, we have a starting question for all our guests. The question is, what’s something ordinary that’s felt beautiful to you recently?
[00:02:45] Jon: I guess last night, sitting outside eating with family and friends and magpies who used to inhabit our back garden hadn’t been seen for some weeks or months. And they reappeared. Five of them reappeared last night and were flying. And then a bin chicken came into the garden and there was the kind of territorial battle between the magpies and the bin chicken. And we.
[00:03:15] Lucy: Oh, really?
[00:03:16] Jon: We had to chase the bin chicken with a soccer ball to get rid of it so the magpies could have first use of the garden.
[00:03:23] Lucy: I’m beginning to feel sorry for bin chickens. They’ve got a bad reputation.
[00:03:26] Jon: They have.
[00:03:27] Lucy: No one likes them.
[00:03:28] Jon: Rehabilitate bin chickens. These are task for you.
[00:03:32] Rachel: Maybe we can start by getting you to tell us a little bit about yourself.
[00:03:35] Jon: Okay. So I’m a psychiatrist, critical psychiatrist. I’m very uncomfortable with a lot of what happens in psychiatry. My main contribution has been holding to account the misrepresentation of research that’s led to an overly positive view about medication, particularly antidepressants in children, adolescents, which is my area.
My starting position in life is always to be a bit critical and skeptical about things.
And so there’s plenty to be critical and skeptical about. The literature and evidence base for prescribing in young people. And so that’s kind of captured by attention.
And the frustrating thing is that you can present evidence which really clearly refutes the mainstream view about prescribing and it has little or no impact on practice.
[00:04:33] Lucy: I was interested to know what it’s like to be critical of your own discipline.
[00:04:39] Jon: It’s interesting. There are a lot of people who like within the profession who like at least some of what I say, but they not very public about that.
[00:04:52] Lucy: Yeah.
[00:04:52] Jon: So they’ll tell me one on one.
Great that you do that.
[00:04:56] Lucy: Yeah.
[00:04:56] Jon: But very few people speak out publicly in support of the position that we adopt.
So that can be a bit disappointing. I’ve never had any overt attacks on me. But you feel like you’ve sometimes excluded professional opportunities or things like that that don’t come your way because people don’t much like your perspective on things.
[00:05:20] Lucy: What is it that they don’t like particularly?
[00:05:23] Jon: Well, it’s a. I mean if. If you take what I and others say about some of the problems with the way psychiatry is practiced, that’s a substantial cognitive and emotional dissonance for somebody who’s practicing in that way.
[00:05:39] Rachel: Yeah.
[00:05:39] Jon: And the kinds of things that we’re criticizing are relatively straightforward.
Like to implement like medicating somebody or hospitalizing somebody or putting them under treatment orders. That’s all you feel really that you’re doing something.
And to say take a step back. It’s more complicated than that. The harms are more than you might have realized, the benefits are less than you’ve been told.
That’s not very comfortable.
[00:06:13] Rachel: The Extremely Human podcast is about how we think about and respond to people experiencing altered or extreme States, how does that show up in your work with young people?
[00:06:24] Jon: The most common presentation to emergency acute services in young people relates to suicidal actions or thinking that scares people, often including the person themselves.
What tends to be the response to that, quite often mandated by the services that people work for, is a risk based response.
And even though there’s clear scientific evidence to show that risk appraisal tools don’t work, we’re still, people working in the public sector are still obliged to use them.
And so rather than thinking of a suicide attempt or people expressing a wish to end their lives, rather than that being taken as a communication that the person is overwhelmed and needs some scaffolding and support and understanding, it’s a signal to prevent that person from killing themselves. And young people. I’ve had more than one young person say to me, look, there was no problem about me trusting that that doctor didn’t want me to kill myself, but I didn’t feel at all that was anything about me, it was about them looking bad if I went out and killed myself. So it’s. So it, it kind of robs the interaction of what’s potentially healing about it, which is that a vulnerable person comes at a time of crisis. When we know at times of crisis we’re more susceptible to change and to reflection and so on. If the crisis is not so overwhelming that we simply can’t think so there’s an opportunity that just with what might seem to us to be a relatively simple, compassionate, humane response to somebody, we can make a real difference to them. But instead we’re too busy ticking boxes and making diagnoses and doing all kinds of things that the system demands of us. But it’s not what patients are asking for.
[00:08:36] Rachel: You feel like that’s system driven as well as fear driven?
[00:08:39] Jon: Yeah, well, the two things are the fear pervades the system and the system responds to reduced risk, risk to, to risk of reputational damage and risk of.
I mean, I’m not suggesting that it’s completely cynical and that people don’t care about the young people who are coming to them, but the priority is how, how is it going to look for our service?
We know that helping people is inevitably a risky business. Like they come to you at a time of risk.
It’s not reasonable to expect that you’re going to end the interaction with them, with everybody feeling that now life is completely safe and can progress without any complications.
And often the question that you need to ask is, we need to ask ourselves is what’s the least worst option here? Like you know, it’d be great if we could have the best option, but usually it’s not available too often in health systems.
The least worst option, default, is the risk averse option. I don’t think that’s right. But, but also we can’t expect junior unsupported staff to be taking good risks. Yeah, you can only take good risks if you’re working in a safe work environment where you’re getting support. There’s an opportunity for reflection. You can share responsibility with other people and make a decision that none of you are very comfortable about. But it feels like what is most likely to be helpful to the young person.
[00:10:22] Rachel: You started talking about suicide concerns. How different or similar are other presentations that young people present with and what they need from services?
[00:10:32] Jon: People presenting after something bad’s happened in their life, they’ve been assaulted or been in some kind of accident, or they’re ill in some way, that’s scary for them.
I think we do a better job with those kinds of presentations. I mean, the same concerns exist around being too ready to make a diagnosis, being too ready to prescribe medication or some kind of manualized therapy. But I think it is more of a less of a systemic impediment to being able to do work in those situations. You know, the sorting process, the triaging process is problematic because you’re doing that on the basis of what pattern is the person presenting with. So is this an ADHD pattern or a depression pattern or a psychosis pattern?
And that these are final common pathways for very diverse sets of circumstances that lead a person to run out of resources to deal with things in what we might regard as a constructive, positive way. And so they’ve fallen back on some kind of coping mechanism that causes them and other people trouble. That’s what we’re seeing in mental health. We’re seeing people who’s, who are making their best attempt at coping with circumstances, whether it’s through suicidal behavior or disruptive behavior or whatever.
If we sort them according to the pattern of disruptive coping that’s evolved, we’re not really understanding them. Two people presenting with what might be classical, like, you know, completely out of the textbook pattern of a major depressive episode, and then a third person presenting with what’s out of the diagnostic manual, an ADHD case.
But actually the two depressive cases have got virtually nothing in common. And one of them has a very similar story to the person who’s now being labeled with adhd. So if you just sort them according to their diagnostic labels, you’re Going to miss the most important part of the story.
[00:12:53] Lucy: Jon, I’ve heard you speak about developmental breakdown in relation to extreme states. It’s the first time I’ve heard that concept. When I did a quick Google search, not much came came up. So I was wondering if you could explain that and how it relates to extreme states?
[00:13:10] Jon: Yeah. The principle is that perhaps particularly in adolescence, we cope with our life circumstances. We develop coping patterns and coping styles that might serve us well. So to give a concrete example, we might have a child who’s growing up in a family where there’s a lot of parental conflict and the child develops a kind of pacifying role in that family. So they get good at distracting one or other parent when they’re worried that the level of hostility is becoming scary.
And so that kind of more or less works. The family reaches a homeostasis where life goes on. People are able to get on with their daily activities without too much impairment. And from inside and outside, it looks like, and is, I guess, a reasonably functional family.
But then as the young person gets to adolescence, frequently there’s not necessarily consciously, but there’s a kind of reflection and a recalibration about what they want to be. And maybe the young person realizes that they don’t want to be the peacemaker in the family, that the cost of that in terms of emotional constriction is not working for them.
And so they begin to experiment, and that. That conjures up the idea that they made a deliberate decision to do that. But they kind of, you know, it evolves that they start to engage in some kind of disruptive behavior that they, you know, might, instead of pacifying, tell one of their parents to off or, you know, respond in an aggressive manner. And that might evolve into something that looks like a clinical presentation. The person becomes moody and withdrawn and doesn’t want to sit with the family, goes to their room, starts to miss school.
What is very easily interpreted as a diagnosis, as a medical problem, and looks to even a reasonably careful observer like a deterioration in functioning.
But actually it’s progress, it’s development, it’s. The person is opening themselves up to a much more, much broader emotional repertoire.
And it’s clumsy and awkward and unpleasant for them and unpleasant for other people. And so it can easily be interpreted as sickness. If what you do is intervene at that point to dampen down those new emotions, either with drugs or other means, then you can see that that developmental breakdown gets suppressed. What instead is needed is scaffolding to allow the young person to go through the experience and come out the other side of it. That scaffolding, it’s different from just being totally permissive and saying, okay, I know you’re going through a difficult time. Just do what you like, you know, swear at me, leave your stuff all over the house, drink, use drugs. Like, I know you’re going through something difficult, just do it. It’s not that there still need to be the ordinary family responses to behaviour that’s dangerous or unacceptable or whatever, but you’re not trying to make the pain go away at all cost.
We don’t want our kids to be in pain, but we also don’t want to numb them so much that they can’t feel pain, but can’t feel anything else. And that developmental breakdown is not kind of trivial. It might end up being, you know, quite severe drug use problems or worrying, dangerous suicidal behavior or something that looks like psychosis. It’s understandable that people panic in the face of that and do things that suppress it. It really takes a lot of effort and experience and wisdom to be able to discern which of these out there emotional and behavioral characteristics need to be respected or not. Not stomped on.
[00:17:21] Lucy: Yeah, that makes a lot of sense. Now that you’ve explained it in that way, we are very quick to shut down natural developments. Is that. Is that true for all young people in your perspective?
[00:17:31] Jon: No, it’s not. I’m not saying that every time an adolescent gets into a situation of distress that that’s a positive developmental event. One of the things that is a bit of a clue that it might be developmental is when you see this happen in people who have had what appears to be relatively good adjustment up to that point. And, and there’s been a significant change.
And so that, on average, I think, is more likely to be one of those developmental breakdowns than somebody who’s been troubled all their life and, you know, things have just got worse during adolescence. Kind of helps me to sort it a bit.
[00:18:11] Lucy: Yeah. Thank you for bringing that idea to this podcast.
[00:18:15] Rachel: Jon, you’ve mentioned a few times concerns about rapid or reactive diagnosis.
Is there a role for diagnosis in your mind?
Where or when it can be helpful?
[00:18:27] Jon: So diagnosis, the kind of literal meaning of it, refers to distinguishing between different explanations.
And so you diagnose somebody with appendicitis, you’re really saying that they don’t have Crohn’s disease or, you know, what might be the alternative explanations for what’s going on. And it has to be from. For diagnosis to be meaningful, it has to be explanatory that is, as soon as you say somebody’s got appendicitis, you know that that is something that’s caused by some kind of infective or inflammatory process in the appendix. And. And so that then steers the response to that.
So unless a diagnosis is serving those purposes, from the point of view of the person applying the diagnosis, it’s not going to be valuable. If I diagnose somebody with depression, given that antidepressants are, if they’re not completely useless drugs, they’re almost useless drugs. When you balance benefits and harms, given that I don’t have something that I can give that treats depression, what I’ve got some. I can give something that numbs feelings, but not something that treats depression, then there’s no value from me as a doctor making a diagnosis of depression. However, for the patient, having the label of depression might be something that’s helpful to them. It might be, you know, okay, so we’ve now got a name for what I’m experiencing.
I’m not a unique person here. Lots of people go through this experience.
People who have this label find these things helpful, like these interventions helpful.
So there can be benefits to the patient from having a diagnosis, but as with any label, there are also harms from it. So there’s a loss of agency that goes with attributing difficulties to some kind of process that you have no control over. There’s the risks of getting stereotyped treatments for a condition that don’t actually work or aren’t actually helpful. There are always harms and benefits. But if, for example, I can make a diagnosis, that matters. So one of the few times that this has happened to me was a young person who was engaging in a bizarre set of behaviors. They were eating everything that was available to them, whether it was, you know, appropriate to eat or not. They were very sexually disinhibited. And then they’d fall asleep and sleep for 16 hours, and then they get up and the cycle would start again. That was referred as a psychiatric problem because that’s what it seemed to be, these bizarre behaviors. But might this person be psychotic or have some kind of dissociative disorder? It turns out there’s a rare neurological condition called Kleine Levin syndrome, and that’s what this young person had. And so they didn’t have a psychiatric problem at all. They had a neurological problem. So in that case, making a diagnosis was really important because it. Even though it’s a bit of a mystery what causes Klein Levin syndrome, at least we knew that this was something that is a brain related condition that didn’t, didn’t belong in the, in the mental health sphere. I guess another more common example would be somebody with a presentation of depression. But if you know that the person’s had glandular fever, you know that a certain percentage of people who have glandular fever for several months afterwards will be, have a kind of post viral set of symptoms that might include depression. So it’s not that diagnosis shouldn’t be practiced, but we need to recognize the limitations of it. And most of our psychiatric diagnoses are descriptions pretending to be explanation. So depression, most of us know what you mean when you’re talking about depression as a shorthand description. It’s not a bad one, but it doesn’t explain anything. And so then we reverse engineer explanations like the idea that there’s a chemical imbalance, which there isn’t. But most, most people in your audience will, if they don’t now, will at some time in their life have believed that depression is caused by a chemical imbalance.
[00:22:44] Rachel: Yeah, it really is a common belief still operating in community.
I meet parents all the time that believe that it’s a chemical imbalance that’s behind their young person’s distress or difficulties in life.
[00:22:57] Jon: And doctors are still talking about it and some of them in with the idea that they don’t. They might not actually believe it, but they think it’s a useful trope to pass on to people to give them a rationale for understanding their condition and the treatment that’s going to be offered.
[00:23:15] Rachel: So it’s an acceptable lie? Yeah, because it might be helpful.
[00:23:19] Jon: Yeah.
[00:23:25] Lucy: So in a previous chat, Jon, you spoke about the importance of helping people make meaning of their experience.
What does that look like in practice?
[00:23:36] Jon: So if I have family come in and say we think our daughter’s got adhd, I’m not going to kind of dispute that up front.
We’ll talk a little bit more about what makes you think that. But first I’d like to get to know something about you and your family.
And so I try to get a bit of a feel for, you know, what social determinants might be in play, what kind of interpersonal issues are going on.
And what I’m aiming to do is to understand the most common explanation for troublesome symptoms, behaviors, thoughts, is that there’s some kind of avoidant function.
The person is doing something to avoid something else. And by the time we get to see people often what, what they’re doing to avoid it is causing much more problems than if they hadn’t avoided in the first place.
[00:24:38] Lucy: But can you give an example of that?
[00:24:40] Jon: Okay, so this is a, an example in an educational setting. Young person who is very bright but has problems with receptive language, so has trouble making sense of complex verbal instruction. So if you say do X, they have no problem. But if you say Do X, then do Y, and if A, then do B, even though they’ve got the cognitive ability to make sense of all of that, they struggle with that. Okay, so imagine a young person for whom that’s the case. And they’re used to being one of the smartest kids in the class. And they get a lot of personal gratification out of being clever. But they have these situations where the teacher says something that everybody else seems to understand and it’s incomprehensible to them or confuses them and they feel stupid and that’s the last thing they want to feel. So that’s a really uncomfortable feeling. It’s quite arousing in a negative way for them to feel stupid. And so they start to. And without any planning. But they, it evolves that they play the clown whenever the teacher’s giving lengthy instructions to the class.
And behaviors like that have a tendency to generalize that you play the clown in that particular circumstance. And it kind of works in a way.
It doesn’t get rid of bad feelings of arousal, but it gets rid of the worst of it. You’re not getting back to a comfortable state, but you’re substituting a very unpleasant state of over arousal to a less unpleasant and sometimes even rewarding state of overarousal because other kids laugh at you playing the clown. And so that gets reinforced. That becomes a pattern of behavior. Nobody’s ever really recognized the link between those two things. And so the kid is presented as being inattentive and overactive. But actually there’s nothing wrong with their attentional skills or their ability to sit still.
But the need to avoid feeling stupid overrides those skills. What looks like what we would call dysregulated or unregulated behaviour actually is regulating behaviour. This is their best attempt to keep themselves together in those circumstances. So if we don’t, if we make meaning of that, if we can understand that the kid has problems with receptive language very quickly, all those problems disappear. Even if the child themselves doesn’t develop any understanding of, the teacher gets it. If the teacher happens to notice that and formulates what’s going on and starts now to give clear, simple instructions to this boy and make sure that he never gets confused by them. Then the problem goes away. So that’s a kind of non, you know, it’s not very emotionally laden version of what’s. What happens when you make meaning. And the meaning might be grief, it might be violence in the family, it could be any number of things. But what you’re looking for is some kind of meaningful explanation of why the person’s distressed. But it’s not necessarily going to be very proximal to the behaviors. You often have to do quite a bit of work of going back to find out what the antecedents might have been.
[00:28:03] Lucy: You might see that more clearly than they might see that at some points. How do you get them on that journey?
[00:28:10] Jon: Well, I think the way in which you explore it is with curiosity and in an interactive, relational way.
So you’re discovering it as they’re discovering it. And the ideal situation, which maybe happens once every, you know, five years or something, is that somebody says, oh my God, I never recognized that. Wasn’t that stupid of me. Like, I should have seen that all along. Everybody’s hugging each other and crying and, you know, like you bottle that and get you through the next five years.
Yeah.
[00:28:45] Rachel: Can you tell us a little bit about what you’ve learned from the people you work with about how they understand their own extreme states?
[00:28:53] Jon: Well, I guess the most common thing is that when you come to see people, they’re frightened by their extreme states.
One very simple thing we can do is to validate the experience. Like once you know enough about, you don’t have to know very much. You don’t have to have a complete understanding of what’s going on. You don’t have to have made meaning of it all. But just to be able to understand a little bit about why the person might be in that extreme state and to recognize it as a meaningful response. Not something that’s been visited on them out of the blue, but something that is a reaction to something. And that idea that we can de pathologize if you like. A lot of our medical labels. If we replace disorder with reaction, if we talked about attention deficit hyperactivity reaction, then we’d be inviting people to think, what’s it a reaction to? Rather than a disorder, which is something that, you know, state you’ve got into and nobody knows how you got there, but we better get try and get you out of that state. Whereas if it’s a reaction. Well, there are two broad categories of responses you need to have once you identify what it’s a reaction to, is it Something that needs to be changed, like family violence?
Or is it something that can’t be changed? Something that’s already happened, like a bereavement that that has been undervalued or not. The distress caused by the. By the bereavement of the child has been underestimated. And so it needs to be respected in an appropriate moratorium. So I talked about scaffolding before. One thing we provide for young people at times of distress is, you know, a sense of safety and making sure that they’re still sleeping and eating and getting them to do things that they don’t really want to do because we know that it’s good for them. But there’s also the idea of a moratorium, which is making space for people just to experience, just to comfort them.
It’s very much like people be familiar with the idea of circle of security, where you provide both a safe haven, which is a place of comfort and acceptance, and a safe base which is a launching pad to get back out into the world and re engage with things. And so what we’re trying to do when we’ve got somebody in an extreme state is provide them with the comfort that they need in order to feel loved and accepted and validated, but also to begin the process of gently pushing them back out into doing the things that they need to do to get better. Somebody might say to me, I need to get rid of my depression so I can go back to school. And I say, sorry, it doesn’t work like that. We need to get you back to school and you’re still going to feel depressed, but we’ll get on top of the depression eventually. But if you don’t go back to school, we’re not going to get there.
[00:31:50] Rachel: Why do you think that these ideas are so unacceptable to mainstream psychiatry?
[00:31:56] Jon: Well, because it’s complicated and difficult and it requires a lot of reflection and you have to make yourself a bit vulnerable in order to do it. So it’s attractive to look for simple solutions to complicated problems. I often think about it as the syphilis solution. So there are a lot of people in psychiatric hospitals with the effects of syphilis, and lots of different medical and psychiatric presentations were all caused by syphilis. And once it was recognized that syphilis was causing that, we just had to give people penicillin and the whole problem went away. People in psychiatry are looking for the next syphilis. The next thing that we can find, one pill or one treatment or one response that’s going to make a whole pile of People healthy who were very sick beforehand. And there’s much more. That’s where all the money goes. That’s what all the medical research is. Money is spent on. It’s looking for the next opportunity to. To crack it and to take a step back and say, we’re not going to crack it. Life’s much more complicated than that.
People’s distress is always best understood on an interpersonal level rather than at the level of the individual. There’s brain damage. Like our brains are damaged by things that happen to us.
But we’re not going to find the cure for that by identifying the damage in the brain and then treating it. We’re going to find the cure for it by identifying the damage in the social network and interpersonal relationships. And as much as possible, healing that, or if not helping the person to come to the level of acceptance enables them to survive that. What stands in the way of our capacity to be therapeutic is that it’s hard work.
[00:33:46] Lucy: I was wondering if you hear from many people that they want to be working in the way that you’ve described and slowing down the pace of how they work with people, but the culture in which they find themselves in, in their workplace doesn’t support that. Do you. Do you hear that at all?
[00:34:02] Jon: Absolutely. In the. I mean, I.
When I’m supervising senior child psychiatry trainees, that’s one of the most common things that I get from them, is that they see a direction that they want to go with the family and the algorithms for the service prevent them from following that pathway with independent clinicians. The time pressure, the financial pressures, you know, it is. Even if you’ve got the strongest principles. Yeah.
Financial pressures are always going to play. Have an effect on us. We all know that some people are cynical about it, but there are many good people who are doing things for financial reasons.
[00:34:46] Rachel: Yeah. We’re also serving a community that is seeking instant responses and instant. Certain explanations and solutions.
[00:34:53] Jon: And too many of them are coming to us for that. We could provide a much better service if less people were asking us for stuff.
But the whole mental health discourse is about convincing more and more people that they need to see people like us.
[00:35:10] Lucy: How do we even change that? Like, it seems like such a broader issue. I don’t even. That’s a giant question.
[00:35:17] Jon: Well, I mean, I guess Not Broken, that’s what Not Broken is about. Because many of us involved in not broken have completely failed to have any impact through academic debate.
We’ve failed to have any impact through government lobbying. And so we think, well, before we give up completely, could we have some impact through interacting with, trying to introduce these ideas into public discourse, finding people with lived experience who say, wait a minute, you know, I thought that coming into the mental health system would be helpful for me, but it hasn’t turned out to be. And these guys have got a different idea about how you might approach distress.
Maybe there’s some truth in that. Maybe I want to talk to my friends about that or my local member of parliament or whatever.
[00:36:03] Lucy: I think that’s a great segue. So you and Rach are part of The Not Broken project. Can you tell us a little bit more about it?
[00:36:10] Jon: The overall goal is to get people to not assume that very significant distress, distress that matters, the fact that it matters doesn’t automatically make it a medical problem, a problem of life.
We don’t want people to suffer for the sake of suffering, but suffering is an ordinary part of life, and we shouldn’t be too quick to conclude that dampening down suffering is the right way to go. So we should respect people’s ability to go through distressing times and come out the other side of it. Not to think that somebody who’s still miserable a couple of months after their partner’s died needs medical treatment. So what do you have instead? Well, what we want instead is support from family and friends and communities.
Now that’s lacking in our society. And so you can see where the drive is coming from for people to seek it out in the medical system. Because on the whole, mental health and medical professionals can be kind and validating and nurturing and so on that level, it’s not a bad place to go looking for something that’s, that’s not available in other places. But the trouble is, once you go looking for it there, on average, what you’re going to find is a very medicalized response that is going to likely do more harm than good. So what Not Broken is trying to do is to convince people that there are better places to go looking for ways to deal with stress. And so the broken metaphor is very powerful. Like you do, if you’re bereaved, you do feel broken, you do feel sick.
It is in that sense an illness. And so the drive to take it into the medical system and for the medical system to do something about it is very strong. We’ve been talking for years about people being broken hearted, which was, I think, a much more benign metaphor than a broken brain. Because nobody wanted to give you heart medicine for your broken heart, but they do want to give you brain medicine for your broken brain. So the danger is that people think that because we’re saying your feeling of great distress shouldn’t be dealt with medically, that we’re not respecting the distress, we’re not taking it seriously enough. That’s not the case at all. We know how horrible people can feel that they get to the point of wanting to end their lives.
That’s not necessarily or even most often a medical problem.
[00:38:40] Rachel: I think I would just think about how the role of social prescribing fits. If we hold a position that someone’s not broken, what does that open up in terms of possibilities?
[00:38:50] Jon: So social prescribing kicks in when somebody finds their way into the medical system, but the clinician judges that it’s not a medical solution or treatment that’s available, it’s a social treatment. And so in order to fit that more comfortably into medical discourse, we call it a social prescription.
So it’s anything that involves making suggestions or recommendations about changing the person’s life circumstances, whether it’s lifestyle changes or seeking financial counseling for financial difficulties. The danger with it is that it is still locating the problem with the person and expecting the person to come up with the solution rather than looking at more upstream social factors like social inequality and housing insecurity and family violence and all those kinds of things. Although social prescribing is a very valuable tool, it still has to be conceptualized and thought about in the context of recognizing that it’s not dealing with problems at their source. At their source, it’s a down downstream intervention, but a more, I think, developmental, benign, health giving, health promoting. So if you just take, for example, the. Whether you give antidepressants or exercise for somebody with depression, there’s not much to choose. Neither of them have very dramatic effects. But if you think, well, if exercise is no worse than drugs, wouldn’t exercise be in general a healthier option to recommend for people? You know, nobody’s arguing that exercising is going to get to the root cause of the person’s problem, but nor does giving medication.
[00:40:41] Lucy: What are some other examples of things that are commonly socially prescribed?
[00:40:46] Jon: I think, you know, any social prescription that involves enriching people’s social connections is going to be more desirable than something that just involves them doing something by themselves. By, I mean, old fashioned form of social prescription. Prescription for somebody with a drinking problem would be suggesting them going to aa. And for some people that’s life saving and life changing and, and there’s nothing medical about it. I mean, there are all kinds of religious overtones that might Be uncomfortable for some people. It’s not a medicalized approach to the problem. So anything that increases social connection. There’s a wonderful book by Johann Hari called Lost Connection that I think spells out some of the. And these are not in. In that book. They’re not so much social prescriptions identified by clinicians, they’re things that have evolved in through people’s limited social networks, allowing an expansion and an enrichment of those networks.
[00:41:43] Rachel: Are there other possibilities that become available to people when we stop thinking about the situation being related to a broken brain?
[00:41:51] Jon: Yeah, I think the other thing is about the person helping the person to become a protester, an advocate, you know, I’m always struck by how beneficial a legitimate advocacy role can be for people who’ve got into a situation where their level of functioning engagement has become quite compromised. And finding a voice through a lived experience, organisation or some such has been really powerful experience for them. Unfortunately, the consumer movement has been kind of co opted in typical capitalist fashion. So what you see is psychiatrist and consumer standing arm in arm saying we need more beds or we need more clinics or we need more money. What I think is healthy engagement from people with lived experience is, is that they’re actually saying you’re doing a shit job and you need to do better, not you need more money or we need more of the same.
And so that is something that some people can do. And I’m not expecting that that’s something that’s in everybody’s repertoire, but that’s something I think that we as clinicians can. You’ve got a really important story to tell. Have you thought about writing it?
[00:43:11] Rachel: As you’ve been talking today, particularly about the story of the child in the classroom, I’ve just been thinking a lot about the role of shame. What role does shame play, do you think, in perpetuating problems and the way that individuals see themselves?
[00:43:28] Jon: A really central role. We would do almost anything to avoid shame. So people will very rarely come to us and say, I need your help because I feel shame.
They’ll present us with another feeling, whether it’s despair or anger or fear.
And our job is to discern what other feelings are behind that.
I think of people as sort of having a particular card that they like to play or that they do play. I’m interested in the cards they’re not playing.
And shame is often one of those.
That’s what drives the avoidance. And that’s one of the reasons why I’m skeptical about two very prevalent interventions that happen not just in mental health, but more broadly. One is behavior modification and the other is motivational actions. I’m not talking specifically about the term technique of motivational interviewing, but trying to motivate people.
And both of them share this idea that if you reward people for the behaviors that we agree are positive, then that’s the best way of achieving change.
And it’s often presented as though you can give rewards without punishments.
And the language is you often talk about conflict, consequences rather than punishments. The reality is that there’s no reward without punishment because the absence of a reward is a punishment. And more powerfully, the absence of a punishment is a reward. That’s where the avoidance comes in. And so if we engage in some kind of attempt to motivate somebody by giving them rewards, how can that be successful? It has to override whatever internal reward and punishment processes are going on. So, you know, in a simplified kind of way, a lot of our decision making in life is, is based on is that going to feel good or is that going to feel bad. So is that going to be rewarding or punishing? And so we make the choice that we think is going to be more rewarding. And as we become more sophisticated, we’re able to take the path that initially is more punishing, but ultimately will be more rewarding. But actually what we’re looking for is, is what makes us feel best. So what we’re saying that in competition with that internal system, in ignorance of that internal system, we’re going to put in place an external system of maybe a star chart or something that feels like it might be rewarding, that might trick the person into trying harder. And if they try harder, they might succeed. And if they succeed, they’re going to feel good about themselves.
And that’s going to be a successful intervention.
But for every time that happens, it doesn’t work. And there are a couple of reasons why it doesn’t work.
One is that the extrinsic reward and punishment system is trivial compared to what’s going on inside. So you want to reward me for sitting still in class. If I sit still in class, all these thoughts about my dad belting up my mum come back to me. Your rewards and punishments are trivial compared to that. So I’m not going to play this game. The second reason why they likely to fail is that the person’s already trying really hard.
And people are more like hares than tortoises. They try and then they give up, and then they try and then they give up. And it’s easy to catch people not trying and to assume from that, because they’re not trying right now, that they’re not actually trying to resolve the problem.
So what your reward and punishment program is doing is saying try harder and they might try harder, and then they fail and they have a greater sense of shame and failure. And so they’re worse off than when they started. All you’ve done with your motivational attempt is to make them feel worse about themselves. And so this is where making meaning becomes important. If you can work out what it is that the person, person’s avoiding, then what you can do, instead of following the guidelines of operant conditioning, which is about rewards and punishments, you follow the guidelines of classical conditioning, which is about desensitization.
And so if you identify what they’re avoiding, they usually weigh away from there and what they’re doing. And so together you can work out baby steps towards resuming an ordinary range of activities. So somebody who’s not going to school, you discover that it’s about anxiety, as it often is about what’s happening at home.
Ideal response to that is to deal with what’s happening at home. But let’s say you can’t, so you don’t expect them to suddenly go back to school full time.
You take gradual steps to overcome the avoidance and for the person to build their confidence and to become less aroused by their attempts to overcome that avoidance.
[00:48:45] Lucy: So, Jon, this has been a very refreshing conversation to have with you today.
[00:48:49] Jon: Thank you.
[00:48:49] Lucy: Out of everything that we’ve spoken about today, or maybe we haven’t touched on it, but what message do you feel is most important for people to take away about extreme states and the way we approach them.
[00:49:01] Jon: So extreme states need to be taken seriously, but that doesn’t mean that there’s a medical solution, intervention needed for the extreme state. Our response to somebody else being in an extreme state, we need to try to manage our own anxiety that’s rightly caused by being in the presence of somebody in an extreme state and make sure that we don’t let that anxiety lead us to make bad decisions or decisions aren’t in the best interest of the person who’s struggling.
[00:49:31] Lucy: That’s a beautiful summary.
[00:49:33] Rachel: All right, Jon, up to our wrap up question, I wonder if you can tell us about a time where you’ve witnessed an act of care, either big or small, that’s really stayed with you.
[00:49:45] Jon: It’s a kind of personal one, really.
Got a phone call in the middle of a teaching session several years ago from a very distressed friend telling me that her husband had just killed himself.
And the care that was mobilized around that family at that time was amazing. But I have to say that my wife Julia’s year of devotion to her friend that followed was amazing. Amazing to witness that somebody would kind of give over their life, not in any kind of mawkish or self congratulatory way to help the person through that unmanageable experience.
[00:50:30] Rachel: I feel really moved hearing that. Thank you, Jon.
[00:50:32] Lucy: I feel like a lot of us, we get into the mental health world with good intentions and bright hopes for the future and we find ourselves in sometimes systems or situations that can be harmful. So speaking you today has just like been a beautiful way to strip back of why we started in this work. And I feel like you’ve just been a compass, like navigating like this is what we’re here for. This is what we’re here to do with people that we care about. The Not Broken project. How can people get involved?
[00:51:03] Rachel: Yeah, it’s easy to check us out via our website, notbrokenproject.com.au I think we’ll put it all in the show notes Luce, won’t we? But on the website and on our LinkedIn page, people can see things that are coming up, like webinars and other ways of getting involved.
[00:51:19] Lucy: Thanks so much, Jon. It’s been a delightful conversation with you.
[00:51:22] Rachel: Thanks for everything you do.
[00:51:24] Jon: Thank you.
[00:51:37] Rachel: discovery college acknowledges that the views shared in this podcast reflect personal experiences and are not a substitute for professional mental health advice. They do not represent the views of Alfred Health.
[00:51:49] Lucy: Thank you for listening to our podcast.
[00:51:50] Rachel: If you wanted to stay in touch.
[00:51:52] Lucy: Or learn more about discovery college, please head to our website, discovery.college.