From inclusivity

One step on from when you called me

Tree of Hands

In this month’s Lancet Psychiatry I’ve written a comment piece Agony, misery, woe: a new role for media advice columns about the history and purpose of media advice giving, the changing role of the agony aunt/uncle, and the agony aunt as witness to the crisis around austerity and poverty and the harms these bring.

Expanding on the comment piece I am joined by Lancet Psychiatry Editor Niall Boyce and journalist Anna Raeburn in a podcast where we talk about how advice giving has changed (or not), what it can deliver, and why practitioners may be missing this important media resource and the tools and experiences it may hold.

Anna starts the podcast talking about how advice columns have developed, with a particular focus on radio and the power of the voice in reaching out to others. In addition Anna touches on the problems posed to modern media due to financial cuts and a lack of investment in community programming/features and particularly local radio and press. Explaining that the need for advice and information is higher than before but the opportunity for advice givers to work effectively is “significantly less”.

From this Anna moves to talk about advice giving as storytelling, sharing experiences, and how it’s okay to say you aren’t sure about a person’s situation. While discussing the strengths and weakness of advice giving on television, newspapers, magazines and new media.

When asked what role agony aunts fulfill, Anna replies:
“I would describe myself as a bridge….I have a very modest idea of what I can do. I want you to walk over me to the next stage of your life….I want, very modestly, to move you one step on from when you called me”

This is helpful in the context of advice giving as it sets out very simply what advice giving can achieve. And highlights where it may be a bridge between individuals and services but also part of a wider chain of help seeking behaviours people engage in. We don’t assume agony aunts have all the answers, or advice columns can solve all our problems, but if we consider it as a small step forward it reminds us that advice columns should never be excluded or forgotten about in wider conversations on physical or psychological health, help seeking or behaviour change.

In the second part of the podcast Niall asks me about evidence and whether we can we be evidence based around advice giving? This echoes other questions I’m increasingly asked about how agony aunts know they are doing a good job – something I’ll be returning to in future blog posts.

I reflect in the podcast on what agony aunts and audiences think evidence means when it comes to media advice giving. Plus what we already know about media advice giving, what we don’t know, and where we can draw parallels of evaluated work on self-help and public health campaigns. I have a bit of a grumble about how academic and journalistic snobbery can lead to advice giving being overlooked or denigrated – and why this is improvident.

For me the crux of the podcast focuses on the issue of how cuts to benefits, austerity measures, poverty and funding problems within the NHS are leading to staff and patients/service users feeling increasingly pressured, distressed and excluded. This may be an area where agony aunts and mental health services might work together, particularly in poor communities who are far less likely to be able to access and use mental health services. Another agony aunt Denise Robertson had previously suggested to me one role of the agony aunt in modern times was to bear witness to the damage caused by poverty, inequalities, and the blaming and shaming of those in need. The podcast explores more on why this has happened and whether there is a role for advice columnists and NHS staff and patients to work together to highlight theses issues and consider possible solutions.

This brings us to what form advice might take and how the traditional focus of the advice column has often been to refer people to a charity or a GP (Family Practitioner/Doctor), or helpline. But how in these cash-strapped times people are arriving at their conversation with advice columnists by telling them what services they have already tried – and failed – to access. The podcast reflects on why this is and what we might do about it in ways that do not further denigrate either those in need or health/social care staff who are also under huge pressure and struggling to do their job.

Rather than just seeing advice giving as asking for help, reaching out or being supported by others the podcast considers advice giving as advocating models of activism and resistance using the example of Focus E15 Mothers campaigning for housing and rights.

By contrast examples from the global south where advice giving through radio, TV, text and newspapers has had particular success are shared as examples of good practice. Particularly around the ideas of citizen journalism and self-care. I talk about trailblazers such as Hesperian and BBC Media Action within this context (although other examples of good practice can be found within this site).

The podcast ends with a reflection that if services across media, health and social care and the third sector are massively stretched. And where there is no immediate change to the current climate then we need to think about ways to help ourselves

“No-one is going to help us at the moment. That’s quite obvious. So how do we help ourselves and what do we do together to make things a bit easier for those in need where there may not be immediate help available?”

The resources below are ones I use myself within these limitations, and may help those who want to know more about working effectively where barriers exist.

Although broadcast after this podcast the actor Michael Sheen also picks up on some of the problems around the NHS and ways for us to defend and stand up for it.

Further Reading
Psychological First Aid
In or Out?
Community Psychology
Augusto Boal
Paulo Friere
Kerry Frizelle 2011 What is critical community psychology?
Carolyn Kagan et al 2011 Critical community psychology. Critical action and social change

 

Psychological First Aid

Cartoon - giving someone PFA
Cartoon – Giving someone PFA

Psychological First Aid, or PFA, may not be a term you’re familiar with, but it may well be something you’ve given or received. The Australian Psychological Society explain it as a “humane, supportive response to a fellow human being who is suffering and who may need support”. And while developed for people who’ve survived disasters (floods, fires, war, forced migration, earthquakes, mass shootings, or disease) it is effectively a set of tools that may benefit anyone who has experienced trauma. That may include civilians of all ages, journalists, healthcare staff, aid workers or others dealing with disaster.

The aim of PFA is to appropriately respond to another person’s needs to help them, when needed, at any point following a traumatic event. That may be around enabling them to feel safe and supported immediately after a disaster, allowing them to talk if they want to, and to reduce distress at any point following trauma. Importantly the point of PFA is to help people identify what services and facilities may benefit them during and after a crisis, enable them to connect with social support, assist them to feel in control, and empowered to try and recover from what has happened to them. Rather than telling people what they should do or how they ought to feel, the aim of PFA is to allow people to prioritise and address their own needs in their own time.

Following large and small-scale disasters we may focus on the physical injuries and deaths that may occur. We may not consider the impact of trauma on individuals who have lived through an event or the effects this may have on those who are front line or support service staff. PFA is used here to both reduce the likelihood of post traumatic stress disorder (PTSD) developing, and to give people the strength to cope at a time when they may feel bewildered, afraid or angry.

In focusing on words like ‘disaster’ we may assume the only time PFA can be employed is by mental health professionals following something huge and devastating happening to a community or country. Whereas PFA may be used be individuals and smaller groups and following any situation that might result in grief or trauma. That could include a relationship breaking down, following a bereavement, dealing with a chonic illness, if someone’s lost their job, or after a traumatic birth. Or supporting friends, loved ones or strangers in the disaster situations outlined above (e.g. during war, when coping with widespread infections, or if you are a refugee or supporting refugee communities). You don’t have to be a trained professional to deliver PFA.

This is easier to understand by noting the five goals of PFA. To provide people with: safety, calm and comfort, connectedness, self-empowerment, and hope. A practical guide on the steps you might want to cover in delivering PFA can be found here (courtesy of the National Centre for PTSD, US). Not all of these are always possible to deliver at the same time, but being able to provide some of them may still be beneficial.

How can media advice givers make use of PFA?
For agony aunts and uncles, we may often be a first port of call when someone is in crisis, or be expected to provide emotional and practical support to those who want advice. Advice columns and programmes can fill an immediate role following disasters or conflict – particularly in the case of radio. But on a general level for those wanting to provide advice via media, learning about the principles and applications of PFA can greatly help when offering advice that empowers and enables others to manage their situations.

This 40-minute talk from the Australian Institute of Professional Counsellors outlines some of the basics of PFA and how to use it

On being a good Psychological First Aider
Following any crisis we may want to take care of others, and as with physical first aid there’s the chance we could save a life if we administer psychological first aid correctly. And equally that we could cause more harm if we get it wrong. To that end it is worth noting what PFA is not. It isn’t: debriefing; taking details of traumatic experiences and losses; offering any kind of treatment, counselling or therapy; or imposing labels or diagnoses.

You don’t have to be a professional to offer PFA. However whether you’re a professional (in healthcare, media or so on) or offering care to a loved one, friend or family member it is vital to remember not to impose any kind of care without asking first. If someone’s experienced a trauma they may want to deal with it in diverse ways and not everyone affected by an emergency will require assistance from you or any other support service. If you’re reaching out to people who are different to you in terms of age, sexualities, genders, culture, faith etc they may understand and respond to their trauma in ways that are not like yours. That is okay and being respectful of this and not pushing your way of coping onto them is important. Just as it is vital to ensure you’re not excluding people from help because you don’t know what to do with them or don’t particularly like who/what they represent. There is an excellent discussion of how trauma and care differs globally (and what can go wrong when we try and impose Western approaches onto other cultures) covered here.

Given how common traumatic events are, it is worth finding out more about what PFA is and how we could use it in our own lives. Links to useful resources and guides can be found at the end of this post. To read through, listen to and reflect on everything here will probably take 15-20 hours so you may want to set aside time to do this or come back to it as and when time permits. Professionals may already be offered PFA as part of their work or may want to take this free online training from John Hopkins University (I would include agony aunts and uncles in this group). Returning to the idea of who may be included or excluded by care, it is worth critiquing all of the references and support materials here to think about who created them, who benefits from them, what models of care are being promoted, and who may be brought in or left out by the way PFA is discussed.

If you’ve used PFA in your own work please share your experiences in the comments – whether it’s helped you or not been effective or if you’ve examples of good practice I’d love to hear them. Particularly from communities across the world, and especially if you can help others help themselves during and after any kind of trauma.

Further reading
Minnesota Department of Health has a useful website with links to additional support materials and apps for PFA. While the University of Minnesota also has a selection of training options on PFA.

National Centre for PTSD (US) Operations Guide for PFA while the National Centre for Child Traumatic stress have this adapted guide for delivering PFA to children and young people alongside this guide from ready.gov (US) for teachers about working with pupils following trauma, and these multi-language training resources for those working with children and young people by Save The Children.

Vikram Patel’s Where there is no psychiatrist is also worth reading in conjunction with some of the resources listed here.

This paper “The Johns Hopkins Model of Psychological First Aid (RAPID – PFA): Curriculum Development and Content Validation” (starts on p.95) explains more of the evidence base behind PFA teaching. While this one ‘First responders and psychological first aid’ details more of how it works and the history of PFA.

WHO’s Psychological First Aid: A guide for field workers also available in multiple languages. And with a pdf of a talk explaining PFA here.

Alongside these tools, if you are health professional dealing with physical health as well as psychological health following disasters or crises you may find the resources from Evidence Aid and Hesperian may benefit you and the communities you work with.

InSocialWork’s podcast has an episode on psychological capacity building in response to disasters.

New evidence reviewing PFA guidelines suggests that, following a review of existing guidance, there is no strong evidence currently to show the effectiveness of PFA. This does not mean PFA has no place, more that based on the available evidence cannot pinpoint which is the most effective intervention we might use. Given the aims of PFA are about adapting ideas for individual and community support based on circumstance, culture and place it may be sensible for now to critically use and adapt the resources listed above; while noting potential limitations and finding ways to document any interventions and practices so the process of PFA can continue to be improved upon.

25 reasons why advice columns fail

Stock photo to illustrate 'depression'

Recently I blogged about 25 reasons why advice columns are amazing.

As an agony aunt it’s obvious I’m going to defend advice columns. They’re not just a popular source of entertainment, people do find them genuinely useful. Sometimes even life saving.

However it would be completely wrong to suggest advice columns are all benign or even helpful. It’s worth supporting them when they get things right, and being aware they can get things very wrong.

Here are some of the ways that happens.

1. The advice given tells you what to do but not how to do it. While “luggage label” (very short) replies don’t give enough information to help do anything about your situation.

2. You may write or call in for advice but receive either a standardized answer that doesn’t address your situation. Or get no response at all. Leaving you anxious about whether you’ll ever get reply and potentially feeling rejected and afraid to reach out again, not just to advice columns but to other sources of help and care. This also means a media company is making a profit from your problem.

3. The advice given may not suit your culture, circumstances or situation. For example recommending a relaxing bubble bath as an answer to a serious problem and to someone who has limited access to affordable/hot water. Or recommending someone must immediately and publicly come out as bisexual, lesbian or gay when they’re living in a country where this is illegal and potentially punishable with prison or death.

4. Advice may be outdated, wrong, or dangerous. For example suggesting those who’re depressed just need to ‘think positive’. Or stating those with mental health problems are possessed. Or claiming masturbation causes infertility. Or encouraging people on medication for chronic or life limiting illness to stop taking it. Or recommending people don’t vaccinate their children.

5. Advice can fail to account for difference or diversity – e.g. recommending sex positions unsuitable to someone with mobility problems or chronic pain. Or telling people to make individualistic choices while not noticing they’re in a situation where state, faith or familial control would make this difficult and dangerous, if not impossible.

6. The tone of the advice, or the format of the advice giving column or programme can shame, blame or ridicule those seeking help. If the advice columnist seems judgemental, unsympathetic or overly harsh this can lead to similar reactions from wider audiences towards those in difficulty.

7. The advice columnist may be more interested in promoting their products and services than offering realistic and useful advice for you. While their messages may be commercialized and focused on solutions that are reliant on you having the money to be able to pay. Whether that is in the form of healthcare, therapy, or purchasing products to enhance your relationship (date nights, trips away, sex toys, designer lingerie, expensive bedlinen).

8. The advice columnist may not be paid nor adequately supported or supervised to do their job.

9. Those seeking help may be treated as passive recipients of expert-led (top down) advice rather than giving them tools to find their own solutions to problems or peer-led approaches that actively engage with any advice being given. A focus on all problems as being a huge crisis in need of multiple support interventions may overlook how some people perhaps don’t feel the need for solutions that automatically include follow-up care or to talk widely and in-depth about their experiences. For example the woman who’s had multiple miscarriages that have all upset her to a greater or lesser degree and who wants to share that experience but does not necessarily feel the need to see a therapist about it nor join a self-help group.

10. Examples may be used in advice that are triggering or upsetting (e.g. talking about child abuse recovery by using graphic anecdotes about child sexual behaviour). While images used may reinforce, rather than challenge, problematic ideas about people’s issues. For example the image used at the start of this post is a stock ‘head in hands’ image for ‘depression’.

11. Cases featured, particularly on television (and especially on tabloid talk shows) can demonize those who are poor, from particular racial or tribal groups, who are socially disadvantaged, inarticulate and who may have additional physical or mental health problems or learning difficulties. Rather than offer support for people they may serve to reinforce wider cultural and political views of those in need of assistance as being feckless, immoral, scroungers.

12. Problem pages can change identifiable information but they may not always get this right and potentially you could be identified. For advice programmes on radio and particularly TV you may be easily identifiable if care is not taken to avoid this.

13. Tabloid talk programmes (Maury, Jeremy Kyle etc) may encourage guests to ‘act out’ in ways that may be regretted during and after the programme. Guests may be exposed to stressful, abusive and violent situations, or forced into making choices they don’t feel included in (e.g. ‘choose now to go into therapy or we won’t help you any more’). While aftercare for advice columns and programmes is mostly non-existent and where it does exist it varies in quality and has never been evaluated for effectiveness. Services used within programmes may compound people’s difficulties. For example using lie detectors or ‘interventions’ (where friends or family confront a person to tell them how much of a problem their problems are causing).

14. Some agony aunts are more interested in being famous and/or talking about their own issues than those of their audience.

15. Increasingly advice giving happens via email, online, or through smart phones. If you don’t have access to the right technology you may not be able to ask for the help you need.

16. Problems can be individualized through advice giving. Solutions offered are around the person with a problem either seeking further care or looking to improve themselves. Rather than encouraging audiences to look at wider cultural, structural or social issues that are causing or exacerbating their problems. You may well feel unhappy and a course of counselling might help, but it won’t change much if you are still living in a damp home where you cannot afford food and are struggling with breathing difficulties.

17. Supporters of advice columns argue they challenge or subvert the status quo. In many cases they may maintain it, or worse still present a commercialized and aspirational view of the world where those in crisis are there to be laughed at, pitied, shamed or punished.

18. If you’ve literacy or communication problems reading or contacting advice columns may be particularly difficult.

19. Searching for information or asking for help on taboo topics may be highly risky in some cultures – for example asking for advice about sexuality, or abortion, simply trying to access reproductive health services if you are a young person or unmarried, searching for information about domestic violence, or trying to get help without your husband or in-law’s permission.

20. Writing about your experiences or expressing them on radio or TV may leave you feeling more upset or anxious than before you asked for help.

21. You may simply not have the reserves, energy or confidence to act on the advice given. Which in turn may leave you feeling more helpless and hopeless.

22. Although it’s often recommended, particularly when justifying the importance of advice columns, passing your secrets on to someone else doesn’t always make you feel better, nor lead to anything changing in your life.

23. You may feel cheated if the person you ask for help from doesn’t give you the answers you want. And sometimes there are no immediate solutions to problems.

24. Problems are often presented in a narrative of hope and recovery where audiences are expected to ‘get better’ or ‘change’. But where no notice is given to how difficult this may be, and how other social, cultural and historical factors may prevent this. For example the person upset about being single is expected to try harder and transform themselves into dating material. The alcoholic or drug user is expected to want to stop using immediately and get sober. The person in an abusive relationship is expected to recognize abuse and to leave, quickly. Where people resist or find this hard they are seen as being difficult, weak or unwilling to want to help themselves. And therefore completely to blame for their situation.

25. If your situation is not represented in advice giving (because it often doesn’t deal in diversity) you may feel more alienated and afraid.

In or out?

Picture from Cory Silverberg's 'What Makes A Baby?'
Picture from Cory Silverberg’s ‘What Makes A Baby?’

Advice columns in print, online and broadcast media are promoted as places where anyone who needs help can get it.

In reality, this isn’t always the case. For starters pretty much all advice columns, wherever they exist, will have more people getting in touch than can be included in any programme or page. Some media outlets and advice columnists have a policy of answering everyone regardless of what is published or transmitted, but that doesn’t apply everywhere.

Right from the entry point of asking for advice there will be people who may not get a reply to their letter or call.

You’re more likely to be featured in a column or programme if you’ve a compelling story, something that’s not been addressed for a while, or that fits a topical issue. Those who are willing to have their problems broadcast or perform their difficulties to wider audiences have a better chance of getting a response. As do people who can describe their situation coherently. Or who have the access, ability and freedom to write, email, or call an advice column or programme.

While plenty of people get in touch with agony aunts or uncles seeking assistance and advice, there are wider audiences tuning in who never actively ask for advice but are still using the advice column or programme to get information, help and ideas.

The way in which we then describe people and problems can make some people or topics seem ‘normal’, make others appear strange or unusual, and render some invisible. By what we decide to focus on and how we choose to do this we have the power to make people feel included, supported and safe. Or to further demonize, judge and shame them. And put them at risk.

Try this exercise
Whether you are making, watching or reading advice columns, think about how they talk about, or don’t talk about, people or problems based around their:
Age
Gender
Sexuality
Ethnicity
Relationship status
Income
Location
Work
Faith
Dependents
Housing
Physical/mental health
Friends and family
Disability

You may be able to think of more areas of our lives that are included or excluded in our advice giving.

What can we learn from this?
Looking critically at advice giving we can see
– what conversations or topics are we opening up, and what ones are we closing down?
– who are we bringing in, and who are we leaving out?
– what are the things we say clearly, and what is left unsaid?

From this we can think about how effectively information is offered to audiences. And who is harmed or hurt by what we do and don’t discuss.