'What about People in Extreme Crisis?'

Well a good place to start with this is to think through what is happening currently with, or to, people in extreme crisis. All three of us have an awful lot of experience, both personal and professional, of being inside acute inpatient treatment facilities in recent years, and of trying to support people to keep out of them. There is one such acute facility not far from where we live. It sits in a relatively leafy area just off a main road. The acute wards emerge into sight after what seems like a prolonged walk through an array of dark and winding corridors that would leave a rabbit begging for a compass.

And so the question is, what is the magic that happens once we emerge from the corridors? What is happening inside this heartland of biomedical care for those in severe distress that means that it is the only way to address severe crisis? Well when you go into these centres what you see is the following. The first thing is incarceration. For some at least; other people are in there voluntarily. Sometimes people experience both—at some points they will be incarcerated and at others they may ask to go there. Second, the people who are being treated there will be given medications, often different types of different doses, to try to find something that ‘stabilises’ them. Some academics will weave the beneficial activity of these drugs around a narrative of medical pharmacology,1 others will posit that they are little more than broad brush sedatives2 (albeit effective ones), while it is also important to note that up to two-thirds of medicated schizophrenic patients relapse, despite being constantly treated.3

By ‘stabilise’ this often means stopping the uncontrolled flourishing of mania, to reduce or dim the frequencies of voices they hear, and/or to manage the delusions and hallucinations in order to bring such people back in touch with reality. Inpatient pharmacological practice often looks more like trial and error than a carefully crafted evidence-based intervention, although it will almost certainly be informed by experience. Other than this a core activity is sitting around smoking cigarettes. A lot of people watch TV, some sit in their rooms, most smoke prodigiously and there are many quite sentient conversations between the people being treated and staff and between each other. You could even argue that therapeutic encounters sometimes take place. These spaces can be frighteningly loud and hectic and also quiet and relatively still.

You could characterise them as places where people try different sedatives, smoke cigarettes, and watch television in slightly grotty surroundings until they transition out of immediate crisis. Or you could say that they receive expert medical care, supervision and space in which to build towards a recovery. Part of the reason for the prevalence of different narratives, discourses and institutions surrounding distress and suffering is that, thus far, we have tended to enclose distress well but yet haven’t really captured it.

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