From ‘them and us’ to ‘us and us’

Inside Out, Outside In: Transforming Mental Health Practices (PCCS Books), edited by Lydia Sapouna, Harry Gijbels and Gary Sidley, reviewed by Rebecca Regler.

If you are interested in exploring alternatives to the biomedical conceptualisation of emotional distress, then this is the book for you. It starts with ‘inside out’, exploring the education of mental health professionals through multiple routes. It looks at how to integrate broader, more critical understandings of emotional distress within training courses to develop the ‘critical thinkers’ needed for reforming the mental health system. ‘Outside in’ explores interesting accounts of services using alternative approaches such as Open Dialogue, peer support, trauma informed care and independent advocacy. There are some similar themes to the 2019 book Drop the Disorder! edited by Jo Watson, as both seek to introduce non-medicalised approaches. Broadly speaking Drop the Disorder! sets out why a paradigm shift from asking ‘what’s wrong with you?’ to ‘what’s happened to you?’ is needed. Inside Out, Outside In explores how this transformation could begin. These cross-cutting themes are indicative of a growing enthusiasm to challenge the status quo in mental health care.

The book argues that more criticality in training and practice is needed to acknowledge emotional distress as a meaningful response to trauma, injustice, inequality and adversity rather than individual pathology. To challenge the oppression and injustice which people using services often experience, a radical rethink of power, language and knowledge is needed. This involves changing the ‘them and us’ narratives that are held in services and wider society by not using diagnostic labels and symptoms to define people. Instead, the book argues that positive value should be placed upon diversity, to close the gap between them and us. It is suggested that peer support can be one way in reconceptualising ‘them and us’ to ‘us and us’. An assertion which is repeated throughout is that relationships and humanity should be at the centre of mental health care. Recovery and healing can be supported through the transformative power of these relationships.

A trauma-informed approach is proposed as one way to de-medicalise the response to emotional distress. This includes understanding the link between traumatic experiences and emotional distress, and responding in a way which avoids re-traumatisation. However, as is astutely raised in the book, a ‘what happened to you?’ narrative in isolation – without due attention to the wider issues such as perpetrator behaviour, systemic inequality and oppression – can be equally pathologising as the medical model. Embedding this critical sociological perspective into theory and practice can ensure attention is also paid to the broader context and causes of trauma within society. 

The ‘wider context’ section of the book issues a call for truth and reconciliation within mental health services and wider society. As part of healing and moving forward there is a need to acknowledge and reconcile the hurt caused by coercive treatment. The new Power, Threat, Meaning framework (PTMF) is introduced. It is described as a meta-framework for conceptualising and identifying patterns in distress and troubled and troubling behaviour as an alternative to diagnosis. One of the challenges of implementing non-medicalised approaches is how it translates into a neoliberal medicalised society. This could have been explored further, although I am aware that could probably fill another book! Inside Out, Outside In is an interesting and welcome addition to the growing library of critical mental health literature.

- Reviewed by Rebecca Regler, MSc student at the University of Hertfordshire studying Mental Health Recovery and Social Inclusion

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