We need to talk about… shame

CW: emotional pain, bullying, emotional abuse, self-destructive behaviour, anxiety


Why do we need to talk about shame?

Shame is a normal human emotion that most people feel in varying degrees.

It becomes problematic when it starts to negatively affect our thoughts, emotions and behaviour, and so also our mental health, our self-esteem, and how we function.

I only recently discovered the extent to which shame has affected me. I realised it had fuelled the majority of my actions, emotions, and thoughts for a vast chunk of my life, and was most likely what kept me in cycles of self-destruction and pain.

Learning how to recognise and take control of this powerful but elusive human emotion has made a huge difference to my self-esteem, how I deal with anxiety-producing situations, and how able I am to engage with other people and feel confident to reach for the things I want in life.

It can be painful to learn about at first, but I think it is important that more people are aware of shame and how it affects them, and that we talk about it more. If I had learned about shame years ago, I might have been released from cycles of pain long ago.


What is it?

I realised recently that I didn’t actually know what shame was and how important it can be. I had always equated it with embarrassment and self-consciousness. It is similar, but much more powerful and potentially damaging to your self-esteem and mental health.

Feeling shame is feeling really bad about your worth and adequacy as a person, and often incredibly self-conscious about it at the same time. It is a disabling and debilitating emotion that can lead to us feeling that we are intrinsically flawed, bad, and unworthy of love or inclusion by others.

Feeling shame doesn’t mean you have done something bad. If you are feeling bad about something you have done, that is more likely to be guilt. Guilt can be easier to deal with because it tends to be due to something specific that has happened, and we are more likely feel an urge to talk about it with others and perhaps try to make amends in some way.

Shame is more often felt when you haven’t done anything wrong, for example feeling it due to how you look or for who you feel you are as a person. We are much less able to talk about shame because it is so tied up with our feelings of the bad or flawed person that we might feel we are inside.

Shame makes us want to hide away or hide parts of ourselves, because it is such a deep and painful emotion that makes us feel incredibly vulnerable.

It is important to know that shame is not about blame. It is not because of something you have done. We can feel bad about ourselves due to strict standards we hold ourselves to, but shame more often starts due to how we are treated by others or due to difficult situations we have found ourselves in.

If you feel deep shame, it could be due to having been mistreated, put down, made to feel small, or like you are in some way unacceptable, undesirable, unworthy, or defective. If this was particularly painful, you can internalise the shame and it can stay with you for years, even a lifetime.

Shame is such a powerful emotion that it can cause us to react in strong ways in order to cope with how painful it feels inside us.


The Compass of Shame

These strong reactions are best explained using a model called The Compass of Shame (Nathanson (1992)).

This is one of the most useful concepts I have come across and I was able to recognise myself in it instantly.

It shows four ways that people tend to react when feeling shame. You may find you do any number of these in any combination and also may react using different ones at different times.



  • Withdrawal – wanting to isolate yourself, avoiding relationships, people and situations
  • Attack Self – negative self-talk, being mean to yourself, self-hate and self-loathing
  • Avoidance – denial, self-destructive actions, thrill-seeking, substance abuse
  • Attack Others – blaming others, lashing out at others

We all feel shame but when we have internalised shame over a long period of time it can have a much bigger hold on us and our reactions on the compass are more likely to have become ingrained coping mechanisms.

I immediately related to the ‘attack self’ and ‘withdrawal’ compass points, and I had definitely spent a large part of my life using ‘avoidance’ to cope.

All that time, I hadn’t consciously known what it was I was avoiding, what I was withdrawing from, or what I was attacking myself over.  All I knew was that I was in pain and that I felt really bad about myself.

Understanding what has been going on all these years has made such a difference to how I am able to function today, and how I treat myself.


How to spot shame in yourself.

I have had terrible social anxiety for over 20 years now, but I only just discovered that shame has actually been a major driving force behind it.

It was a personal revelation.

The thing about shame is that it is sneaky and that it likes to keep a low profile. It hides underneath other emotions such as anger and anxiety. It stays powerful by staying hidden.

It was only when I learned about shame in my psychology sessions that I discovered how to spot it.

This is what I discovered shame looked like for me:

When I was around others, whether they were strangers or good friends, I would begin to feel really bad about myself and my inadequacies as a person. I would get loads of negative self-talk going around my head, criticising me and telling me what a worthless person I was, beating myself up for the things I had said and making me feel like crap.

I would feel physically sick with self-disgust and self-loathing so intense that I couldn’t even look people in the eye. I would desperately want to leave the situation, not out of fear I realise now, but out of feelings of such deep inadequacy and unworthiness to exist, let alone be around others.

I used to think this was all just part of my anxiety, but after looking at The Compass of Shame, I realised that it was deep-seated shame that was leading me to ‘attack self’ and ‘withdraw’.

Noticing that was the beginning of a process of slowly removing and releasing the shame I had internalised and had been feeling for so long.

I still get anxiety. It still makes me feel hot and shaky; my heart beats fast, and my mouth goes dry. I can’t stop moving my body and I feel awkward and uncomfortable, but it is much more bearable than it used to be. This is because now it is largely a physiological reaction and not an emotional one.

Separating shame from anxiety has radically changed how I am affected by social situations.

Are you able to recognise any of the actions and reactions in the Compass of Shame as underpinning your emotions?

If yes, you may be carrying internalised shame.


How I began to release internalised shame.

Name it and acknowledge you’re feeling it.

Learning to spot shame was the first thing. Next, I began to label it as such and acknowledge that I was feeling it.

Whenever the negative self-talk would start up in the middle of a situation, or feelings of self-loathing, I would note it and then say to myself: “I am feeling shame”.

Acknowledging the fact that you are feeling shame in the moment immediately takes power away from it.

This is because shame works though opinions, such as ‘I’m a worthless person’. If you reject opinions in favour of a fact ‘I am feeling shame’, the opinions lose their power.

It also puts it into context: I am not thinking/feeling this stuff because I am a bad, unworthy person, I am thinking/feeling it because I am feeling shame.

And remember, feeling shame is normal and human and is not your fault. It doesn’t mean anything is wrong with you.

Shame thrives on being unseen and as soon as you start to notice and point at it, it weakens. It also thrives on (crappy) opinions, so when you start to challenge them, they don’t tend to hold their own for long.


Challenge the ‘shame scripts’.

My psychologist and I made a list of all the things that my negative self-talk (also known as my ‘shame scripts’) was saying. It included:

“You’re weird and no one will ever like you”, “you’re a joke”, “no one cares what you have to say”, “you don’t deserve to be here”, “you’re nothing” … etc.

When I looked at what I had written in front of me, I noticed that all these phrases were things that I had been told or made to feel when I was a child and young teen. Decades later, I was still being plagued it.

It made me realise how long I had carried all this stuff, which was never mine to begin with, and how it had continued to affect me most of my life. It had been with me so long, constantly battering away at me, that I just assumed it must all be true. I had never sat down to analyse it or challenge it. It was something that I had simply got used to as a part of me.

Now, I took time to pick apart each phrase to see if it was fact or just an opinion. I also looked at whether it was helpful to me or my mental health – and then I argued with it.


Example 1: “You don’t deserve to be here”.

Is this a fact?

No, it’s not a fact, it’s an opinion, because there is actually no proof to back this up. I also think if you asked people who know me, they would disagree.

Is it helpful?

No, it’s definitely not helpful, in fact it is actually a really horrible thing to say to someone.

In fact, why don’t I deserve to be here, in this social situation? I feel like everyone else deserves to be here. I’m a good person with things to offer, so why the hell can’t I be here with everyone else?!

Example 2: “You’re weird, and no one likes you”.

Is this a fact?

Actually, no, it isn’t a fact at all because people on the whole don’t dislike me. I tend to get on well with most people. I’m friendly and kind and compassionate and I have friends who definitely do like me.

I have a unique look with tattoos, piercings, and pink hair, but that doesn’t make me weird. I’m sensitive, and sometimes I hear voices and sense things others can’t, but that doesn’t make me weird either.

Is it helpful?

Definitely not – it is rubbish spouted by people decades ago and I refuse to believe it anymore.


I found that getting annoyed with the words and phrases and telling them how I refused to believe them actually helped me fully reject them, but you could do it in any way you like really: whatever works best for you.

You could even write them out on paper and rip each one up after you challenge it or burn them – safely! This way you are truly saying goodbye and good riddance!


Keep at it.

Now when I’m feeling anxious and uncomfortable and I start noticing the ‘attack self’ scripts starting up again, I silently tell them to go away and that I just don’t believe them anymore (though usually phrased as ‘piss off, you know that’s bullsh*t’).

It does take practice, and you have to expose yourself to some uncomfortable situations a bit in order to do the practice (go gently at first) but I have found it does work.

Even when I wasn’t practicing it, I would reflect on it, and just try to notice it popping up here and there. I began to notice it when I was just walking around in public and when I went into shops.

I had always felt really self-conscious, but now I could see it was shame making me feel that way because the script was telling me I looked weird, and that people were all judging me and hating me.

I understand now that the emotional abuse I suffered when I was young was the cause of me always feeling so uncomfortable around other people.


Combat it with something you know is true about yourself.

Sometimes I repeat things to myself inside my head to double-down on keeping the shame away. I do it when I’m sitting in meetings feeling anxious or even when I’m walking along the street feeling self-conscious.

I repeat to myself:

“I am a good, kind person with a lot to offer other people”.

I want nothing more than to be kind to people and help them – that is who I am deep down. This is a fact, not an opinion. This is my fact about myself.

Reminding myself of these intrinsic good qualities always makes me feel instantly stronger.

If the self-talk is saying I’m ugly, or weird, or I don’t deserve to be somewhere, I’m basically arguing back and saying that even if those things were true (which they are not), I am a good, kind person with lots to offer other people, so who cares what you think!

You will have to find what phrase works best for you. It could be ‘I am kind and loving to animals’, ‘I am a good parent’, ‘I always try my very best to do the right thing’ etc. Search deep inside for one thing that you know is good and true about yourself – you don’t have to share it with anyone, so it doesn’t matter what other people would think or say about it. It is a fact about you that you know to be true, so search deep inside yourself – you will know it when you find it.


I still find social situations uncomfortable and anxiety-producing, but now I mostly just have the anxiety itself to deal with (the body reactions of racing heart, dry mouth, feeling shaky). It isn’t pleasant, but it is manageable now, compared to when there was deep shame attached to it, where I sat there in severe emotional distress, wanting to cry, and run away.

I still feel shame, too, in areas of my life, but I have managed to tackle the shame that was disabling me the most – the shame I felt in social situations. As I notice shame pop up in other situations, I use the skills I have learned. I spot it, acknowledge it and then later write it down and analyse it.

None of this has been easy, but it has definitely made a big difference in my life.

The reason I decided to write this is because I think it is so worth sharing with others.

We need to talk about shame more, even if that can feel hard to do.


Why is it so hard to talk and think about shame?

Talking and thinking about shame can make us feel extremely vulnerable. It can make us feel more ashamed.

It is an emotion tied up with very personal thoughts and beliefs about being unacceptable and unworthy and so we automatically feel we need to keep it to ourselves and not share it with others, in order to protect ourselves. That is a natural way to feel.

After my first psychology session about shame, I felt withdrawn for quite a few days as I needed to process the fact that I felt it at all. I realised it had been there my whole life, ruling me in so many situations, massively affecting my mental health, and yet I had not even known it was there. It was difficult to accept at first.

I recently read ‘The Gifts of Imperfection’ by Brené Brown (2010), and in it she says that shame has the most power when it is in the dark. To make it less powerful, the best thing you can do is drag it out into the light.

You can do that by doing what I have described in this article, but Brené says it is also useful to talk about it with someone who you can trust to listen and not judge.

After a week of reflecting on the whole situation, I was talking on the phone to a friend and began to tell her about what I’d been doing in my psychology sessions recently. It felt too difficult to just dive into the subject, but leading up to it generally seemed to be a good way in. I went on to say something like this:

“Last week I learned about shame – it’s actually not what I thought it was at all. You know those times when you feel bad really about yourself, that you’re not good enough? That’s actually shame talking. I’ve started to realise all those times when I’ve felt bad about myself in front of others, I was feeling shame. I realise that it was shame making me attack myself with all the negative self-talk, making me do so many self-destructive things, and also why I’ve found it so hard to be around people so much. Do you think you’ve felt it sometimes too?”

I know not everyone has someone they can trust to talk to about their deep feelings. If you have a psychologist or therapist, they might be happy to look at it with you.

If not, just having conversations about shame in general, even without talking about your own personal experiences, helps to raise awareness of this emotion. I think this is a topic that should be more acceptable for people to think and talk about and that it could lead to many of us understanding what really lies behind our strong emotions. Perhaps it could help more people heal more quickly.

Spotting it, naming it, and talking about it gets it out of the shadows where it prefers to be and helps reduce the power it can have over us and how much it can rule our lives.

Even once we release internalised shame that has been there a long time, shame can still come along here and there through future experiences. Learning to notice when we are feeling new shame and to recognise it for what it is, as it happens, can make it much less likely to become internalised again and to have such a hold on our lives as in the past.


And finally.

Please remember – shame is not your fault.

You have no need to feel ashamed if you recognise shame in your emotions or in your life. It could mean that you have not been treated very well at times in your life.

Shame can become overwhelming and can really affect people’s lives, but it is a normal human emotion that everybody feels to some extent.

Nothing is wrong with you for feeling shame.

In fact, noticing it and being aware of it makes you one step ahead of the many, many people who still have no idea that they are feeling shame and continue to be ruled by it.


I recommend reading anything by Brene Brown. Her work on vulnerability, courage, and shame, researched and written as both a professional and as someone who has intensely felt both, is incredibly heart-warming and honest and I have gained so much from her.

This is her website: https://brenebrown.com/


References

Brown, B. (2010). The Gifts of Imperfection: let go of who you’re supposed to be and embrace who you are. Center City, MN: Hazelden.

Nathanson, D. (1992). Shame and pride: Affect, sex, and the birth of the self. New York, NY: Norton.

Nathanson, D. (1997). Affect theory and the compass of shame. In M. Lansky and A. Morrison (Eds.), The widening scope of shame. Hillsdale, NJ: Analytic Press.

Papercuts: restorative approaches and cumulative harm in mental health care

The cynicism and hope of a long-term service user

(Please note: there are academics and practitioners actively studying this topic who will have more knowledge about this subject than me. I write as someone who has personally experienced trauma within mental health services and has had glimpses of ways in which restorative practice could help to tackle it.)


How it began for me

A couple of years ago I was asked to be involved in a participation project with mental health staff called ‘Reducing Restrictive Interventions’.

We split into separate groups (one of staff and one of service users), each with a facilitator, to brainstorm. One member of staff misunderstood the instructions and joined our group. None of us said anything, assuming there was an unspoken reason for her joining.

We talked about restrictive practices on the ward and how they affected us, from small things like not being allowed to congregate and chat in the corridor, to more painful things like restraint and seclusion. The staff member listened intently to what we said and acknowledged our experiences, saying it was very helpful to hear. She then tentatively told us about how imposing restrictions upon us sometimes made her feel, and we listened in return.

It hadn’t been planned. Out of nowhere a safe space materialised where testimony was heard and acknowledged on both sides. For that 20-minute slot, we were no longer staff and service users – we were human beings, equal to one other, listening and acknowledging with empathy and compassion.

The whole group agreed that it had been an enlightening experience, including the member of staff. I thought about how incredibly helpful it would be to have opportunities like this occur more often. It wasn’t until I recently came across a piece written in in the British Medical Journal by Dr Sarah Markham, that I realised what had emerged that day was the kind of space and situation that restorative practice (also restorative justice/approaches) works to create.


What is restorative practice?

Restorative practice can take many different forms, and for more comprehensive explanations, please see the links at the end of this piece.

The way I understand it is as a coming together of people who have been involved in a conflict, difficult experience, or trauma, in order to share the impact it has had upon them.

It can be used to repair specific relationships or harms that have occurred, or it can be a more general expression of thoughts, feelings, and needs in a mediated safe space where everyone is listened to without interruption or judgement. The idea is to create empathy, enable mutual understanding, and to then work towards a satisfactory resolution for the benefit of all.

Restorative practice and approaches are already used in various forms in a number of sectors, such as criminal justice, community mediation, and in schools.


Why might we need restorative approaches in mental health?

Restorative approaches could help by:

  • Reducing the impact and level of trauma felt by those within mental health services.
  • Improving staff/patient relationships.
  • Improving mental health outcomes and quality of life for all.

Despite it being a contentious issue that not all are yet ready to accept, harm occurs regularly within mental health services and on psychiatric wards.

Many are harmed by the most obvious major practices of Mental Health Act detention, coercion, restraint, forced seclusion and sedation (which is another article in itself!) but harm also occurs in smaller, more insidious ways.

These include verbal abuse, gaslighting, neglect, withholding care, lying, making decisions without the patient, breaking trust, not listening, ignoring, being dismissive, and acting without care or compassion.

When cumulative, these can become more painful than the bigger harms. They are thousands of papercuts that never heal.

They are also inflicted upon us by individuals, with faces and voices that we never forget.

It is these cumulative harms that I would like to focus on in this article, because it is these that I feel are most unacceptable, most avoidable, and also could be most easily tackled by restorative approaches.

Of course, mental health staff are also harmed by what they experience at work. This could be directly through violence and abuse from unwell patients, high-stress work environments, or by being implicit in restrictive interventions or practices that they do not necessarily feel comfortable with.

Staff are not subject to coercive and restrictive practices, and they implicitly have more power than a service user even at the lower end of their pay grades, but they are certainly still vulnerable to stress and trauma.

Psychiatric wards are trauma machines: harm is recycled and passed from person to person in an enclosed space within a rigid, heavily bureaucratic, emotionless system, totally unfit to deal with the complexity that is humanity and human emotion, let alone that of mental distress.

Relationships between staff and service users are often strained. Each views the other as an oppositional unit which they should be wary of and therefore protect themselves from. This creates huge rifts that undermine the therapeutic benefit of services.

Mistrust stops people reaching out for help in the future. Although I am engaged with certain staff in community services, I definitely think twice about calling the office in crisis in case I speak to someone who is less than kind. I have learned over time that this happens as often as not, and mine is not an unusual experience.

A lack of trust also adds to service users’ issues with healthy relationships in general: feeling suspicious or afraid of others can lead to further isolation from peers and greater society and worsening of the original mental illness.

Of course, there will always be those who find their interactions with mental health services supportive and helpful. This must be acknowledged, and I am happy that those people certainly do exist.

Where trauma is felt, however, patients are dealt an extra burden to recover from in addition to the illness or condition that brought them to services in the first place.

In this way, mental health services actually perpetuate mental illness and distress.

In particular, those deemed to have a personality disorder (a contentious label at the best of times) have often been on long journeys through services, experiencing exclusion, gross misunderstanding of needs, verbal abuse, threats, coercion, prejudice, not being believed, and a stark lack of compassion. All of this mirrors and reinforces trauma already experienced in personal lives and outside of mental health services.

Like a snowball rolling down a mountain, trauma and pain and their associated difficulties stick to the original, core problem as you as you go, eventually making you so heavy with pain that you become formidable, dangerous, and impossible to treat in the eyes of those who helped make you this way.

Those who have spent years in services can find it impossible to detangle the trauma that existed originally from that gained since.

It doesn’t make sense to be healing and hurting people at the same time, particularly if you want them to thrive and get free of the revolving door of repeated discharge and re-admission.

Only months after being discharged from mental health services, I was referred back again by my GP for serious dissociation triggered by memories of what I had experienced as a psychiatric inpatient. I displayed many symptoms of PTSD, including flashbacks, nightmares, hyper-vigilance, and numbness, and needed another round of psychological sessions to help me work through them.

Not only was this extremely distressing for me, but it set back my recovery by at least another year, something that I’m still working on. It also meant I used precious mental health resources that could have gone to someone else had I not suffered the trauma in the first place.


Are restorative approaches feasible in mental health?

Formal Approaches

In a dreamworld, everyone who has been cruel and neglectful to me in a healthcare setting would come and sit with me and we’d use restorative approaches to work it through. We’d have conversations about how it affected me, and they would listen. I would ask the ‘why?’ questions I’ve always wanted to ask and listen to them in return, hopefully they’d apologise or at least reflect, and we’d repair things and find a way through that felt better.

This is an unlikely situation for service users.

There is rarely a single ‘perpetrator’. We often hurt from many actions from many different people, that have chipped away at us sometimes over decades of damaging interactions with mental health services, when we were already at our lowest and most vulnerable: those papercuts.

We have no chance of facing all of those who hurt us. Would they even remember the nasty comment they made years ago? Would they remember a single situation even months ago, during yet another busy, understaffed double shift?

(Most likely not but, rest assured, we definitely do.)

They might not even see what they did as wrong or negligent, or may not want to admit it.

One of the underpinning principles of restorative practice is that it must be voluntary – everyone has to consent to join in and so there needs to be a willingness to engage.

Services and staff may feel that restorative practice will involve some admittance of mistakes or of neglect and abuse, and it is unlikely they will be happy (or able) to do that.

Due to this, I feel that more formal restorative approaches like those used in criminal justice, with an obvious victim and offender, are most likely not feasible in mental health services.

Grassroots Initiatives

Spandler and McKeown (2017) suggest that grassroots truth and reconciliation initiatives might indeed be what is needed, particularly in the absence of the interest or enthusiasm of services and psychiatry.

They describe instances of grassroots and service user led mental health organisations in the USA that have made use of community-based models and healing circles to hear testimony from those harmed, whether staff or patient, and also to hear from those who did not feel harmed – all viewpoints being equally welcome and compassionately acknowledged.

Perhaps something like this could be helpful.

I know from the experience I described earlier that if you can turn a room of service users and staff into a room of human beings, even for a short while, amazing things can happen.

There would need to be a level playing field offered, and a space of safety for all to be able to speak and listen, wearing no official ‘hat’ of service user or staff member.

There would need to be no repercussions for sharing, and it would need to take place in a neutral space, so not in a hospital meeting room.

There already exist initiatives amongst service user only communities where testimony is heard in safe and non-judgemental spaces, providing those who have been hurt a forum in which to express pain and anger, and for that to be acknowledged.

I am currently involved in project ‘For The Record’ with the grassroots service user group #MadCovid, where experiences are shared via closed-group presentations of writing and creative pieces on the theme of iatrogenic harm.

Supporting each other in this way is helpful, and for some it is the only forum in which they feel safe enough to truly express their feelings. However, it is no surprise for us to hear the trauma of our fellow service users. We know it only too well.

There is absolutely a place for this work, but for true restoration I feel that those with other viewpoints, perspectives, and experiences need to be included and need to listen, or we risk remaining in a well-meaning echo-chamber, with no real movement towards remedying the situation.

I like to think that there are staff and patients who would genuinely want to take part in informal initiatives that aim for better understanding for those on all sides.

Service-user led initiatives may not be impartial enough for this specific task. We need projects formed by both ‘people who work as staff’ (a distinction from ‘staff’, which is their official capacity whilst at work) and service users, and/or by allies who are completely impartial.

As it would be a voluntary activity engaged in outside of work time, that could be off-putting to staff who already work long hours, but if touted as an exercise that could enrich them personally, rather than a work-related box-ticking exercise, it could perhaps be more attractive. There will always be those who are not at all interested, but I believe there will always be those who are.

Meetings or circles should be trumpeted as positive, welcoming, healing spaces that are not about apportioning blame. The idea is to enrich understanding and empathy on all sides, which could go some way to better relationships within services and hopefully to change opinions and behaviour towards those previously seen as an oppositional group.

They would need to be closely guided by restorative principles, impartially managed, and only joined by those distinctly wanting to work towards restorative ends.

An important question at this point is: do we need to come together with specific people who were involved in our own individual experiences, or is hearing testimony from anyone, even people we don’t know, still helpful? In an informal meeting like this there would be no guarantees about who might attend.

As I said earlier, we may wish for the opportunity to face those who wronged us, so we can ask specific questions, understand particular instances, maybe even share apologies, but the chances of this are low.

Hearing from others who have been in similar situations (on either side) might not give us that, but it could still help expand empathy for and understanding of each other, break down oppositional barriers, and help us see each other as human beings, all with capacity to hurt and be hurt.


Will restorative approaches actually make any difference in terms of harm?

Despite me advocating for restorative practices, there is a dark, hurt voice of cynicism deep inside me, one which most long-term service users will know well. It says that nothing will ever be enough to make up for the pain that has been inflicted.

I’m trying not to listen to that voice, because I want to be more hopeful than that, but I acknowledge that there are many who have been hurt so badly that these drops in the ocean will seem nowhere near good enough, and I fully respect that.

There will be many people who won’t like these ideas. They won’t want to relive their traumas or remember certain times of their lives. Some understandably won’t feel able to be vulnerable around the ‘opposite team’ who has caused them so much harm. Many will be afraid of repercussions and further victimisation.

We need to acknowledge and be mindful of this.

I do think, however, that proactive restorative approaches could go some way to lessen the cumulative harm that occurs within mental health services.

If we deal with each papercut as it occurs, we can help to stop it building up into trauma.

Proactive Approaches

A difficult interaction occurred recently between myself and a professional within services. She made a mistake that broke trust and at the time it really upset me. Trust of mental health staff is already something I find difficult.

When we were next in touch, she set aside a good 15 minutes of our appointment to talk about it. She apologised and completely owned the mistake. She didn’t make excuses and she listened to me explain why it hurt me so much. We talked through it. She did not rush me or minimise my emotions or reaction.

The fact that she had the courage and integrity to initiate this conversation made a huge impression on me.

It may seem obvious that someone would do this, but it is not something I have experienced from a member of staff before.

She was so demonstrably honest and compassionate that we quickly repaired the relationship and the hurt I had felt disappeared. I also apologised to her for how I had reacted when it happened, and we were both able to agree to move on.

Just a single restorative interaction like this can give a service user hope and a renewed faith in services in general. It creates a welcome contradiction against the idea that ‘all staff are bad’, or ‘I need to protect myself from staff’.  

The more examples we are shown of compassion and kindness, the more that serves to challenge ingrained views of staff and services as a homogenous group of cruel, neglectful people.

This experience has helped me to believe it is possible to have the restoration we seek with those who have directly hurt us if it happens as soon as possible after the incident.

Apologies are probably best left to occur in organic and spontaneous ways in order to protect their sincerity, however proactive restorative approaches could be part of a new way of working. Examples include improved communication styles and time set aside for restorative and reflective catch-ups with service users, as the need arises.

Restorative approaches in schools often include the use of restorative communication. Staff and pupils are encouraged to make ‘affective statements’, where they communicate to each other how they have been affected by the actions of the other, both positively and negatively. They also use ‘affective questions’ to explore things that have happened and how they could be best resolved as they arise, avoiding the use of blame or accusation.

Time is taken out to have restorative talks, as needed, which could just be a couple of minutes or longer if needed.

Something like this might be really helpful if it was embedded within mental health services, for both staff and service users to make use of.

It might be viewed as more work for already under-resourced staff teams, but I genuinely think it would be worth it in terms of improved relationships and outcomes for all involved.

It could also help improve communication skills, assertiveness, and skills for dealing with confrontation on both sides.

I acknowledge that issues of mental capacity, distress, and illness are factors to consider that aren’t as relevant in the school environment, but ways in which proactive restorative approaches could improve the mental health environment are definitely worth exploring further.


In conclusion

In believe that informal restorative approaches, utilised as we go, may be the best format for mitigating cumulative harm within mental health services. These have certainly made the most difference to me personally.

In addition, there could be grassroots initiatives that bring people who work as staff and people who are service users together voluntarily and on equal grounds, in order to learn more about each other’s experiences.

Restorative approaches may seem too meagre to make a dent in the impact of harm caused by mental health services. There is no doubt that social action aimed at general reform of mental health services and legislation is desperately needed in addition to any restorative work.

Bloom & Farragher (2010) call for organisations to be “trauma-informed systems” run to be more like living organisms, “capable of all the same emotions, processes, learning, disease and change that any other organism experiences”, instead of cold machines.

I think restorative approaches, especially proactive communicative ones, should be a key part of that vision.

I don’t have all the answers, but I know that ignoring the fact that trauma occurs within our services isn’t working and is a ticking mental health timebomb.

I also know that the interactions I have had with staff on a human level have made the biggest impact on my ability to heal and have faith in people, more than any psychology session or medication ever has.

Those interactions have expanded my own capacity for empathy with those who care for me and have most of all allowed me to feel hope that things can change.

I do think it is important to bring restorative approaches to mental health services, even if the efforts at first seem small. More opportunities, spaces, and interactions like those I have described – informal, voluntary, human – would contradict negative experiences, foster better relationships between staff and service users, and make small but solid steps towards repairing harm.

To achieve this, big work desperately needs to be done, but I personally believe enough small, reticent stones cast out in hope could cause enough ripples to begin to rock the boat.


References:

Bloom, S. and Farragher, B. (2010), Destroying Sanctuary: The Crisis in Human Service Delivery Systems, Oxford University Press, New York, NY.

Markham, S. (2018), “Dealing with iatrogenic harm in mental health”, British Medical Journal Blogs website, available at: https://blogs.bmj.com/bmj/2018/12/04/sarah-markham-dealing-with-iatrogenic-harm-in-mental-health/ (accessed 26 Mar 2021).

Spandler, H. and Mckeown, M. (2017), “Exploring the Case for Truth and Reconciliation in Mental Health Services”, Mental Health Review Journal, Vol. 22 No 2., available at: https://www.researchgate.net/publication/316848109_Exploring_the_case_for_truth_and_reconciliation_in_mental_health_services/ (accessed 26 Mar 2021).


Links for further reading:

What is restorative justice?

Principles of Restorative Practice

Restorative Justice and Restorative Practice

Restorative Justice in Everyday Life

Restorative Approaches in Schools in the UK

Time to Think: Using Restorative Questions


Copyright 2021 Zoe Layton. All rights reserved.

9 key principles working in customer service taught me about supporting people in crisis

Customer service is often viewed as menial, low-skilled work, but there is an art to doing it well.

I have had a number of customer service jobs, including working for various auto breakdown services, and a private pathology lab. I was often on the phone to distraught people: perhaps they’d had a smash on the M25, and they had 3 terrified children with them, or they were waiting for a breast cancer test result that was running late and were petrified the delay was due to bad news.

Those calls were much trickier than the average; however, through them I learned some fundamental principles that have continued to help me help others, including work with prisoners and rough sleepers, for many years since.

Whether you are dealing with a vulnerable person in crisis or a customer on the phone, they come in handy.

Here are 9 that I see as the most important:


1. What people define as a crisis is relative

A crisis can be an enduring situation where your whole world is literally falling apart, or it can be a sudden, short-lived incident that causes acute stress but is able to be resolved within a day, or even a few hours.

What one person experiences as a crisis may not be the same as another.

Timing is also a consideration – someone might normally cope well with a situation, but they might not have the emotional resources to cope with it other times.

All reasons for distress are valid and relevant because of the meaning they have for the person experiencing them.

It is best to avoid judging someone coming to you in crisis, even if their issue does not resonate with you, or you see it as minor or silly in comparison to others.

People need to feel like their problems are not just valid, but that the extent and gravity of their problems as they see them is acknowledged.

People, understandably, need to feel like they matter, and that their problems also matter.

2. You can make a big difference in just one interaction

When someone is already stressed out, whether it is because their car is damaged, or they’ve dropped their phone down the loo, or they’ve found themselves suddenly homeless, the last thing they need is a difficult interaction when they reach out for help. This only makes people feel more stressed, angry, and frustrated with their situation.

We all know what a relief it can be to have a problem sorted out speedily and adeptly. The call handler is friendly, empathetic, and competent, immediately putting you at ease. They give you opportunities to ask questions, explain what you’re not sure of, and tell you what they will do to help. You come off the phone feeling lighter and less worried about your problem, now it is in someone else’s capable hands. Your stress levels decrease immediately.

Most of us have had experiences at both ends of this spectrum and can remember how differently we felt after each of them.

You can radically affect how stressed someone feels in quite a short space of time, depending on how you approach their issues and how you treat them.

Make the most of those opportunities.

Lessen their burden, instead of adding to it.

3. Anger is fear and a need to be heard

When someone in crisis appears angry, it is often fear in disguise.

Understanding this is key to being able to help someone whose stress comes across as anger.

If someone seems frustrated or angry, I stop talking and listen. I let them do all the talking.

After they get their initial rush of frustration out, most people begin to relax, especially if they aren’t coming up against resistance from you, and it is obvious that you are listening.

A calm, attentive reaction often takes people by surprise. They’ve most likely been expecting a battle, and it doesn’t happen.

You will notice their relief emerging as they begin to slow down, take some breaths & eventually stop talking. Sometimes they even start to feel a bit embarrassed at their outburst, and they apologise. So many times, I have heard the words:

“Sorry, I know it’s not your fault – I’m just so worried about it all and I don’t know what to do.”

People often just need to be heard and have their fears acknowledged. They need to be able to share the impact a situation is having upon them and have someone be a witness to that. They need to feel the emotions they are having are externally valid.

Anger is rarely about you as the helper: it is more about the person’s situation, and how afraid and out of control they feel because of it.

(N.B. I am not saying anyone should have to tolerate aggression. It is not okay for someone to get abusive. I have found that active listening, followed by focusing on joint problem-solving, is very effective in deescalating anger. If it isn’t working, it is important to be assertive and possibly end the interaction if they are being aggressive towards you.)

4. People need allies

Someone in crisis who is reaching out for help longs to feel that they aren’t alone anymore.

Being distressed and alone is something no one should have to experience.

Knowing that someone somewhere is helping to shoulder the weight of their problem (especially someone who has access to resources to help them fix it) can make a huge difference to how powerless someone feels.

It doesn’t mean that you should do all the work for them, or that you should step outside professional boundaries. Just ensuring someone has a positive interaction with you will help them feel less alone.

Even if there’s little you are able to do, sometimes just listening and acknowledging is the best way to be an ally.

5. Be reliable

This is one of the simplest, but also most powerful, of these principles.

I cannot stress enough how important it is to be reliable when you are working with someone in crisis.

It is likely that you represent a glimmer of hope for that person, so don’t just throw that away.

If you say you’ll do something, you must do it. If you forget easily, make a note, or put it in your calendar.

If you’re not able to do what you said you would, let them know. Get in touch and tell them that you’ll need a couple more days to find something out, or that you’re going to be trying something else instead.

Not doing something when you said you would (especially when someone is relying on you to help), shows that person that they don’t really matter – even if that is not your intention.

Don’t just leave someone in limbo, wondering what’s happening – they will most likely be worrying. Call them. Get in touch and let them know.

It might feel easy to get lazy about these details, but don’t let that happen.

If you can’t commit to things, it is probably best not to make those commitments in the first place.

6. Be honest

Don’t take the easy road and tell people what they want to hear, just to make your life easier. Honesty is everything – even if it means delivering less than satisfactory news.

People appreciate being told the truth.

Most people prefer news that isn’t the best to lies given only to placate. This is otherwise known as ‘fobbing someone off’, and most of us know how that can feel.

7. Move people forward

A manager and trainer at Citizens’ Advice taught me this:

You may not be able to solve someone’s problems in one go, but you should aim to move them on a step further than when they walked in.

Openness, warmth, and a listening ear may be helpful in the moment, but you should also think about what you could give the person that they can take away with them.

It might be something tangible such as an information leaflet or a telephone number to call, but equally important are hope, the relief of a problem shared, the courage that comes from having an ally, or even some restored faith in humanity.

We can all think of times when we’ve walked away from an interaction feeling more hopeful, whether it was from a medical appointment or a call to the insurance company.

People feel better when they can see where they are going, or what steps to take next. It is like finally receiving a map to somewhere when you’ve been completely lost.

8. Everyone can benefit

We could probably all do with more customer service in our lives! You don’t have to be in an official ‘helper’ position.

I use these principles in my daily life to support others, even my partner, my parents, and my friends. I regularly ask myself:

“What can I do to help this person? How can we sort this situation out? Will letting them talk while I listen help? How can I help take them from feeling stressed to feeling a bit better about things?”

9. Be human

I’m not suggesting by using customer service principles we should all become call-centre robots. Not at all. Good customer service is warm, supportive, and validating. Everyone is treated as an individual equally as important as the last, and everyone’s plight is as valid as the next.

I was once assessed over on the phone by a mental health worker who sounded like she was reading questions from a script. I later gave feedback about this to a manager, and was told, ‘yes, that’s because she was reading from a script’.

My point was missed completely: I knew she was. The point was that she was not in any way bothering to disguise it. That felt impersonal and hurtful when I was already feeling vulnerable and being asked such sensitive questions. I needed to speak to a human, not a robot.

Nurse, doctor, receptionist, call handler, or friend: any of us can make a difference to other people’s distress by thinking about how we interact with them, and what effect it might have on them.

It doesn’t matter who you are or what position you hold.

Often it is just about being a human being talking to another human being.

The simplest things are often the most powerful.


8 ways long-term trauma can affect someone physically

Experiencing trauma activates our stress response as our brains and bodies gear up to deal with threats. If you are exposed to severe stress and trauma that goes on over a long period of time, your body and brain will constantly be reacting to threats, and will actually begin to change in order to be able to cope. Over time, your systems become fatigued and physical effects begin to develop.

Examples of situations that can cause this include growing up in a stressful or abusive environment, being in an abusive relationship, having a long-term mental illness or disorder that means you get stuck cycles of trauma (such as ‘BPD’), sleeping rough and being homeless, working in the sex industry, and being detained for extended periods of time.

I would like to demonstrate this by sharing 8 ways I was personally impacted by experiences of long-term trauma.

All of these symptoms began to occur about a year after a serious mental health crisis, which was just one in a series of traumatic experiences I have had in my life.

Although I had begun to feel much better mentally a year or so after this, my body and physiology continued to remain in a stressed and traumatised state, and I developed the following:


1. Fibromyalgia

I was diagnosed with fibromyalgia by a neurologist after I began to experience chronic pain all over my body and fatigue. I found it hard to move around or do daily chores without being in a lot of pain. I was exhausted all the time.


What is fibromyalgia?

Fibromyalgia is a neurological condition that is mostly experienced through chronic pain all-over body pain and fatigue, but can also include cognitive (thinking) problems, sleeping issues, migraines, and other symptoms.

Although doctors aren’t completely sure why it happens, they have found that it often seems to be triggered by a physically or emotionally traumatic event. It involves changes with how the nervous system processes pain.


2. Dissociative ‘Attacks’

About a year after being diagnosed with fibromyalgia, I began to have dissociative episodes that would happen in response to certain environmental triggers.

Whilst I had experienced various forms of dissociation on and off throughout my life, it had always been more of a mental experience. These new episodes affected me physically.

My body would become rigid and I would be unable to walk properly, move, or speak, for hours at a time. It felt like my brain had completely disconnected from my body and got stuck, and I was waiting for it to come back again.

Even after they dissipated, I would feel exhausted for days afterwards.


What is dissociation?

Dissociation is when you experience a feeling of detachment and disconnection from either your own body or your surroundings. It is something most people experience in mild form, such as when you are daydreaming or going into ‘autopilot’ when driving a car. It becomes a problem when it is going on for longer periods, seriously affects your perception, and when it makes you feel distressed – all of which can affect your daily functioning.


3. Chest pain and rigidity

When I found something upsetting or emotional, I very quickly got really bad chest and upper back pain. It felt like I had a rock inside me trying to get out. The ache and the tension was so severe that I’d have to lie down and take painkillers. It could last for days.

It was a very specific pain and rigidity that only seemed to happen when I felt strong emotions, such as hurt, anger, and sadness. I would often get the rigidity in my face and jaw too, making it hard to smile, be expressive, or even talk properly, for days.

4. Cognitive Issues

My memory increasingly got worse, from me constantly forgetting where I’d put things or what I was doing, to causing stranger and more worrying things to happen. These included finding things done around the house that I didn’t remember doing, like hot cups of coffee sitting on the kitchen counter when it was only me in the house, or fresh washing hung up in my wardrobe!

I had difficulty concentrating, being able to understand and retain verbal information, and being able to respond to people verbally in a way that was timely or made sense. This could vary according to the circumstances, such as where I was and who I was with, and also on my levels of anxiety or emotion, but was one of the most difficult things I had to deal with.

I actually wrote about how cognitive issues like this can affect your ability to have a conversation. You can read it here: 5 reasons why having a conversation is so tricky when you have anxiety

These issues are one reason why I like writing so much – the written word is so much easier to manage!

5. Visual Snow Syndrome

This is an interesting one, and apparently also controversial because most of the professionals I see think it is a transient stress reaction or hallucinations.

I have had it diagnosed by an ophthalmologist and I’m pretty convinced it is not due to transient stress as the symptoms are there all of the time, from the moment I wake up until I go to sleep. They are even there when I have my eyes closed, and it has been that way for over a year and a half now.

It is a condition that not much is currently known about, and after further research I have found that most people have trouble getting it acknowledged by professionals.

Visual Snow Syndrome involves changes in your vision, such as seeing static everywhere, seeing traces when you look away from objects (palinopsia), light sensitivity, night blindness, and flashing colours and lights.

It is not a problem with the eye. The issue is thought to be how the brain is interpreting the information and the messages coming from the eye.

I call it ‘tinnitus of the eye’ because that is one of the best ways I’ve been able to explain it to people so they understand.

If you are interested in finding out more, read my other post: What it is like to live with Visual Snow Syndrome.

6. Tinnitus

About the same time that the visual snow started, I also began to get tinnitus, which for me is a constant high-pitched ringing in my ears.

Tinnitus is quite common and is the perception of sound when there is no actual sound. The exact cause of tinnitus is not known, though it is believed that it has to do with changes in the signals going to the brain via the hearing nerves.

It can get overwhelming, especially if I am already feeling stressed, or if I am in a very quiet room. I tend to listen to white noise when I’m trying to get to sleep, or if I want to relax and read a book, so the noise doesn’t disturb me as much.

7. Migraines

I have always been a headachy person, but along with the fibromyalgia I began to experience really bad ones, which then turned into migraines. I was getting them nearly every other day, though with medication I have managed to get them to a point where they only happen once or twice a month at most.

Migraines are thought to be a neurological condition, and I have found them to cause severe head pain, light and noise sensitivity, nausea, and issues with speaking and seeing properly.

8. Random physiological reactions

Although I have suffered from anxiety for over 20 years, it tended to be more about social situations, crowds, or feeling embarrassed and awkward in front of people.

These new ‘random’ anxiety attacks began to happen when there is no obvious trigger. I would be doing something that doesn’t normally make me feel anxious, like having a shower, or eating breakfast, and not thinking about anything bad at the time.

I got hit with waves of anxiety out of nowhere. I wouldn’t experience it as anxious thought, but in terms of my body and my physiology. My heart would thump, I’d feel like I wasn’t getting enough oxygen, and I’d have to take deeper breaths and sit down. I’d feel sick and afraid and find it hard to think properly. It usually lasted hours, sometimes days, so it wasn’t like a ‘simple’ panic attack.


These are 8 things I personally experienced, though I’m sure there are others I have not included that other people will experience too.

I’m very glad to say, that other than the fibromyalgia, visual snow and tinnitus, I no longer suffer with these issues on a daily basis. It is possible to over come physical issues that have been caused by trauma. I did it by looking after myself and my working with a psychologist to overcome the emotional traumas. When your mind is feeling better, your body begins to get better too.


Despite my mental health radically improving after my crisis, my body continued to suffer. I believe this is because I did not do any work on what had caused my trauma/s. Once I did start addressing this, with the help of a psychologist, I improved radically.

I think this shows how important it is that trauma is recognised, and that people be given the opportunity to work through it with professionals in a safe way, in addition to learning coping mechanisms and healthier ways of living.

I think going deeper into what had happened can often make the most lasting difference to someone’s quality of life.

I believe that most people with a serious mental health condition, especially those who experience repeated crises, and those who have been detained, will most likely have been affected by trauma, whether that was via an earlier stressor that brought them to services, or the result of repeated and long-term interactions with services.


8 ways you might feel when you’ve been sectioned under the Mental Health Act

Being detained under the Mental Health Act and confined to a psychiatric ward is something that is supposed to be done in your best interests, but it most likely won’t feel like that at the time.

Of course, everyone will feel differently, but here are 8 ways you might feel.


1. Powerless

Being free to mostly do as we choose is vital for us as human beings in today’s society. Being told that you cannot leave somewhere, or go out for a walk to stretch your legs, or being forced to do things and go places you do not want to, can have a profound and lasting effect on how you feel about yourself and about the world.

2. Angry

One of the most natural emotions to feel when you are no longer in control of what is happening to you is anger. You might feel angry with the professionals who assessed you, because you don’t agree with their decision. You might feel angry with your family if you feel that this has happened because of them. You might be angry because you feel you are not being listened to, or because you feel the staff are against you.

There are many things you might feel angry about, and often other emotions, such as fear, can feel like anger.

Sometimes anger can lead to you lashing out and becoming aggressive, which is fairly understandable if you are stuck in such a confined and powerless situation. Aggression might not necessarily be interpreted in this way, unfortunately, and may lead to further restrictive interventions or negative staff attitudes towards you, making you more angry and creating a cycle.

3. Afraid

You may not even be sure what is happening, know where you are, or know who these people are who are stopping you from doing what you want to do. You might be scared of the other patients, or the staff, or what you think is going on.

The way you feel and act when you are afraid can often feel and look the same as anger.

4. Ashamed

No one should have to feel ashamed if their health has led to them needing urgent mental health treatment or support, but stigma in society around serious mental health problems continues, so it is not surprising if you do feel this way.

Your feelings might be about how you perceive yourself, and also about what other people might think about you.

5. Alone

You may only be able to see or speak to your loved ones at certain times or for short periods. You might not get along with any of the other patients, or be interested in them, so you spend a lot of time on your own.

If you are moved to a hospital out of the area, it may be impossible for you to have anyone visit you, and you may feel very far from anything and anyone familiar.

You might not even want anyone to visit or call if you are feeling ashamed, or if you are angry with them seemingly playing a part in your current situation.

You can still feel lonely, even if you have purposely decided that you don’t want to see or speak to anyone.

6. Irritated

When you are feeling irritable, you can get annoyed or stressed out at things very easily. This can happen for many reasons, such as in response to outside stress, or because you feel bored and fed up.

Psychiatric wards are often not calm places. They can be noisy and uncomfortable, and also boring if there are few activities, or if you don’t feel like joining in.

Other patients can be noisy or disruptive because they aren’t very well. Being stuck in a fairly small area, with people you would not normally choose to be with, can lead to you feeling irritable and agitated.

7. Worried

You may have children, a partner, or pets, and be worried about how you being away from them is affecting them. You might be worried about how being sectioned will affect your life in terms of your job or your reputation.

8. Trapped

If you are an informal patient on a mental health patient, you will often be allowed to come and go as you please throughout the day.

As a patient on a section, however, you cannot go out for leave unless it is legally agreed to and signed off by a psychiatrist. This is called section 17 leave. If the psychiatrist is not in over the weekend to do it, or if they decide you won’t be allowed it yet, then you cannot leave the unit.

This means spending all your time in just a few spaces – a bedroom, hallway, lounge area, dining room, a small yard, maybe a quiet room, and occasionally activity rooms – sometimes for months on end.

Feeling trapped can make you feel irritable, stressed, and angry, and more likely to feel aggressive towards others.

It can also have lasting effects on you mentally because of the stress it can cause.


These feelings are all very natural responses to the experience of being detained under a section of the Mental Health Act.

Although I have set them out individually here, these emotions do not happen separately, but are all entwined with each other. Feeling one will often make you also feel many of the others.

You may not even be able to tell which of them you are feeling because they all get so easily tangled and jumbled up together.

Your stress levels can affect the way you act and how you come across, which in turn might affect the way others respond to you and the care that you receive.

All of this can lead to an extremely stressful experience, the effects of which you might carry with you sometime into the future.

It is quite normal to feel any of these emotions, or any others, when you are in this situation.


If you are currently on a section on a mental health ward of any kind, it is highly likely that you are legally entitled to an advocate.

This is someone impartial, who is not part of the staff who are caring you, that will listen to you and support you to be able to express your views, and who will help you stand up for your rights.

If you would like to speak to an advocate, let a member of staff on your ward know. They will be able to organise that for you.

Alternatively, you can find one and contact them directly by searching online.


Here are some great UK charities with resources to get you started:

Mind

Rethink

Voiceability

POhWER


You might also like to read 10 ways you might feel LONG AFTER being sectioned under the Mental Health Act, which looks at how the experience of being sectioned can still affect you some time afterwards.