Hearing voices

Embarking on this journey, I'd hoped to not only be exposed to indigenous traditional practices that might serve to enhance mental health and empower communities, but to also gain insight into how the native culture and belief system itself influences the perception and management of psychological distress. Little did I know that the latter would become such a central feature of the work I'm doing and a foundation on which every other finding must be laid.

Let me explain why...

Come back in time with me if you will to Maine and the Wabanaki Clinic, the multi-faceted operation serving the local Penobscot tribal community and the site of my infamous beading humiliation. It offers many services; from medical to social to behavioural health but Wabanaki's heart, in my opinion, lies in it's health and wellbeing centre on the third floor.

Here is where the magic happens; where old blends with new and where culture and tradition are used as tools for healing. Nicknamed 'the Wab', the principles behind its well-subscribed Sobriety programme line the walls as a reminder of the transformation potential for everyone stepping through the door.

I had the privilege of spending a morning there, talking to staff and some of the community members who frequented the clinic. Unknowingly and not really meaning to, I took my 'British NHS doctor hat' into the room with me, so used to having to define people by their symptoms and whether they fit criteria in our current system, and on being shown the centre's list of group sessions and activities found myself asking the peer support workers about their 'roles and training' and the 'common diagnoses' they see. I could have kicked myself as soon as I'd said it as it quickly became apparent those things weren't of importance here. My reaction was met with patience but firmness: 'those questions aren't asked at the centre and the answers aren't relevant'.

It's generally accepted that people coming to the Wabanaki Clinic will have experienced some form of trauma and may in conjunction be suffering with addiction. I won't go into the details of that having done so in a previous blog but suffice to say all forms of distress are expected and in turn tolerated.

People are not defined by these details when they walk through the door; they are seen as a person needing to tell a story, not a patient with an illness.

I've heard this so many times over the last three weeks; the idea that we all have a story and that our very being and sense of wellness relies on our ability and the opportunity to tell it. While I know I would have claimed to have been a believer in this idea before and an impassioned campaigner for a person-centred approach when talking to patients, my initial reaction to the centre's style tells me that certainly in my professional life I am not used to the luxury of being able to treat patients in this way, not really. I want to know their story, believe me, but in the current way we have to work finding a way of allowing them to tell that story in full can sometimes seem impossible.

As conversations continued in the centre my attention was drawn to a group on the schedule called 'sharing visions'. I assumed this was a group for people experiencing psychotic hallucinations but again my western mindset was met with the explanation that that was not how the group was seen; I was advised that it was not about defining people in terms of a diagnosis but about seeing them as people with a certain kind of story who might benefit from sharing that experience with others. Help for them, they explained, didn't come in a 'one-size fits all' package, it came in a variety of forms, unique to each individual. The agenda wasn't to 'fix people' but to help them live their lives in a meaningful way.

I can't really explain what it feels like, though I'm sure many of you can relate, to be told something that makes so much utter sense. It feels like an overwhelming bubble of excitement or like that perfect meeting with someone who's on exactly the same plane as you. In that moment, it suddenly seemed much clearer than it ever had before that how we perceive psychological distress; as part of our story, as a series of experiences, as a set of symptoms, as a illness or as some combination of the above heavily influences our response to it and the 'treatment' we seek from others.

But, while excited and in general agreement with most of their ethos, I couldn't help but get stuck on the idea of symptoms such as auditory hallucinations not being attached in any way to a diagnosis of mental illness. Having grown up with Schizophrenic twin uncles I'm not a stranger to the chaos and dysfunction such features can bring about and whilst I completely agree that for many people in distress medical diagnoses are made where, in my opinion, looking at the influence and causation of traumatic life events would be more useful, I can't help but think that in the case of severe psychosis there is a need for the term 'illness' and the response that that triggers.

So if not deemed 'illness' per se, I wanted to know a bit more about how such experiences might be framed in Native American culture...

Let's think about that for a second... Schizophrenia as a 'spiritual emergence' and not a 'mental illness'. I can hear some ruffling of feathers and some sharp intakes of breath... believe me, I was challenged by the idea too.

The concept of psychotic features really being the communication of spirits is hard for us to swallow, of course it is; most of us have not been brought up in the Native American culture. But the seed this idea plants, the encouragement to think bigger and more 'out of the box' when it comes to mental health is a useful one. The value in being at the centre, for me, was not necessarily in learning about the idea of voices as spirits trying to emerge but in the reminder that how we frame a 'symptom' or 'experience' in our minds directly influences how we respond to it. Through the framing of auditory hallucinations within a cultural context in this way, the distress associated with them was lessened. They were an accepted subject to discuss and through the sharing of these experiences people were able to be open to actual tangible help that made a difference in their lives. 'Treatment' for them wasn't simply about 'stopping voices', it was about improving their quality of life in other ways. Wabanaki focuses on this idea of quality of life and, for those still looking for meaning behind their experiences, draws on traditional and cultural beliefs to serve as an anchor to give them hope.

Reconnecting people to their roots also opens up opportunities for other avenues of healing, processes such as ceremony that actively bring people together and promote connection, forgiveness and acceptance. Regardless of what our own belief systems are, I think most people would agree on the importance of these aspects when responding to any mental health problem, no matter how 'severe'. Yet when we look at how we treat Schizophrenia in the UK even today, and certainly in the past, I would argue little priority has been given to such ideas...

Fundamentally, by calling visions or hallucinations a 'spiritual emergence' or deeming people 'holy men' or 'seers' you allow something to be expressed, whatever that might be, via a story that makes sense to a person at that time. As I mentioned before and will, I'm sure, talk about many times in the future Native American culture is all about sharing story and while I'm still getting my head around the framing of psychosis, how they use story to frame and interpret less 'severe' forms of emotional distress is something I'm fully on board with.

Emotional distress is deemed part of the story of the person experiencing it; a product of and response to the things they have been through. Depression, anxiety, suicidal ideation are all very real and sadly incredibly prevalent in native culture but in the traditional view they are not seen as isolated 'illnesses', but as reactions and coping mechanisms around trauma. This acknowledgement of what many people have been through coupled with a lingering sense of the 'community protecting its own', something I experienced during my time in Orkney, leads to a higher tolerance and acceptance of distress and a reduction in otracisation and stigma.

I wanted to know more about this and managed to pin Lewis and Barbara down one evening to discuss. Both working as therapists in the native community they are very familiar with the challenges people face and how they manifest in terms of mental health problems...

Later in that conversation, we moved on to talking about non-native populations and Lewis said a wonderful thing when trying to describe the constant challenge we face as physicians in drawing the line between human life experience and pathology: 'How do we tell people this isn't a mental illness but simply the slings and arrows of an outrageous life?'. In that moment I knew we were on that same plane, bubbling with excitement and thinking exactly the same thing.

When our own trauma is less obvious, it can be difficult to link it to the way we are feeling, leading us to overthink and pathologise 'normal' feelings of sadness and distress. When one has suffered trauma to a greater or more obvious degree, the problems that occur following are interestingly deemed more acceptable than for the rest of us. But whether we have endured poverty or abuse or violence or nothing of the sort we are still reacting every day to the things we have experienced, our own 'traumas', and coping in whatever way we can.

But how do I tell my patients this? How do I tell the father of four who 'should be fine' or the teenage girl with the 'perfect' life who doesn't understand why she cries all the time? How do I tell them that there probably is a reason for it if we look close enough and that dealing with it might mean medication and a diagnosis but it might also mean something else?

The only place I can think of to start?

'Tell me your story...'

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