During our National Lottery Community Fund supported Living Well UK programme, we have had the chance to work with pioneering people and places from across England and Scotland on the shared task of transforming mental health support. For our sites across the UK including Edinburgh, Salford and Tameside and Glossop, this has been a journey of revealing the often invisible power that our imagination has in determining what might be possible for our mental health systems. 

 

So, how does our imagination shape what is possible for mental health systems? 

 

For many of us, we often think about imagination as something disconnected from the here and now. We might see it as the faculty we use when we make up fantastical stories or come up with whacky ideas. We might therefore associate imagination as something we grow out of, or a skill and ability only for Hollywood film-makers and Turner prize artists. 

 

In fact, imagination is a  powerful force, not just in dreaming about tomorrow, but in how we understand our mental health systems today. 

 

Let’s explore this concept of imagination a little further. We generally experience our imagination as something personal and intimate to our thoughts, yet according to leading academics,  our imagination is “deeply cultural (1)” and specific to our community and context. This is because “the contents of our imagination utilise cultural resources”; imagination draws on existing ways in which a society understands itself - its images, stories, ideas and importantly its language. What this means is that  “most of our imagination flows quite predictably along the current of contemporary culture.”

This understanding of imagination was core to the thinking of 20th century Greek-French psychoanalyst Cornelius Castoriadis, who recognised how our imagination is often something we have collectively or socially created and we draw on it to “explain the world to ourselves”. However, when we begin to experience a failure in how our current ways of understanding the world no longer meet our individual and collective needs or desires, a creative ‘friction’ is created between what is and what we wish to be. Castoriadis described this friction as our ‘radical imagination’; a capacity that can only be found when we acknowledge the way the world is imagined now in relation to the way we wish the world to be. It is with this capacity of radical imagination that we can begin to create the new. 

 

Mental Health systems are a uniquely important context for understanding the power of imagination as both a force to maintain things as they are and to transform them when the ways we imagine the world no longer fit with our needs and aspirations. Historically, mental health support has reflected the ideas and understanding of a society and it is most powerfully represented in the language we use to define people with poor mental health. 

 

For over a thousand years, the term for someone experiencing significant poor mental health was a ‘lunatic’. This label appears in the bible and refers to the idea that mental disorders were the influence of the moon (Luna being Latin for moon). Support for these ‘lunatics’ was given - when at all - in ‘asylums’; places where people were held as ‘inmates’ and given refuge and protection from society and indeed society refuge and protection from them.  

 

In the 1800s, ‘enlightenment’ science began to develop a biomedical understanding of many mental health conditions. These changes evolved British society’s ideas of mental health and were made concrete by the 1845 Lunacy Act, which defined mental health as something that required ‘treatment’, and that those experiencing mental health should be defined as ‘patients’. 

 

The label of ‘patient’ was powerful and was marked in the 1930s by the Mental Treatment Act that legally replaced the definition "asylum" with "mental hospital".  It evolved the public’s imagination that mental health was something, like a disease, that could be diagnosed and treated. This led to mental health support being developed to mirror the ideas, architectures and treatments of institutions to treat the physically unwell.  

 

Today, we still often term people with mental health conditions as patients. However, in the 1980s a new language began to evolve that mirrored a wider change. As the confidence and power of a new global economy began to take hold, we began to recognise and celebrate the power of the consumer to drive improvements in our lives. Attitudes to social systems of support were shaped by this idea and we began to believe that public institutions should be there to serve our needs; that they should be services to us as users and clients.

 

These terms of user and client began to infiltrate mental health support. Instead of being problems to be diagnosed and treated, we should instead have the rights of customers of services that are there to provide solutions to our poor mental health. As the idea and language of ‘patient’ and hospitals’ had, so the language of user and service began to shape the ways in which mental health support was organised and delivered.  

 

When viewed from a contemporary perspective, we might see that the terms inmate, patient and user share a common belief; that somehow people experiencing mental health challenges are a deficit to society; people we need protecting from, people who need to be removed and treated or people who need to take and consume from society. In essence, a belief that positions people with poor mental health, as a group, as devalued and feared by the rest of society (2).

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

 

 

 

 

What this rapid history illustrates is the powerful ways in which language shapes perceptions of the world and significantly influences how we think - our cognitive processes (3). It acts to reinforce what we understand to be ‘good’ and ‘right’ for those experiencing poor mental health and shapes what we imagine better mental health support might be. This is what we might call a collective mind-set or mental model, in this case one that shapes our perception to see and understand people experiencing poor mental health as a deficit, which in turn means we will only ever conceive of new services of support that act to treat them as such. 

 

This power of imagination to drive us to maintain the world as we currently see and understand it needs to be acknowledged if we wish to truly transform mental health support and outcomes. We need to recognise the influence of the mental models that we hold that are so often expressed through our language. These mental models can blinker us from seeing the possibilities that already exist around us and we can even end up deploying them to protect and reinforce the very things we are trying to change. We are unlikely to have a human and collaborative relationship with those people whose mental health we are supporting, if, for example, we continue to use the language of ‘front-line services’ (front-line coming from those soldiers closest to the enemy and service deriving from the Latin ‘Servitium’ meaning slave) and the mental model that it activates. 

 

Imagining new alternatives

 

In our Living Well UK sites, we have been paying close attention to this power of imagination. Our sites have been fostering a mindset that sees those with poor mental health as people first and foremost. Such people-first language is not new, having emerged in response to labels that appear to promote bias, devalue others, and express negative attitudes (4). However, applying this idea of being people-centred as a core and central principle, not just in the language we use for mental health, but in how we design and develop support, has revealed possibilities for radically different systems of support.

 

One of the most powerful resources to unlocking this radical imagination is stories of lived experience. Listening to these have helped our sites to acknowledge the limiting effect of seeing someone solely through a lens of their diagnosis, their ‘deficits’, or as a user that requires treatment or a service. Instead, these stories have helped reveal the untapped possibilities when we see those with poor mental health as a ‘person’ who exists in relationships with others and in a specific context. Revealing these mental models has enabled our sites to imagine and develop ways of organising support within and through ‘community’ and ‘place’, rather than solely inside the walls of a hospital or service. 

 

As simple as it might seem, this shift from the value of support being in role and services, to understanding the value of relationships and community, is transformational for mental health systems. It helps acknowledge a deficit view of people with poor mental health as consumers of services and reveals the possibilities when we see them as co-producers who hold an abundance of potential for improving theirs and others’ mental health. 

 

We have seen new language emerging in our sites to reflect this shift: sites now ‘introduce people’, rather than ‘refer a case’; they have ‘conversations’, rather than carry out ‘assessments’; they focus on ‘aspirations’, rather than solely on ‘needs’. Furthermore, it has led to places like Tameside & Glossop moving away from seeing specialist support as a destination to be referred to and instead seeing it as a resource to draw up and into communities. This has helped them to begin to reimagine the ways in which important specialist expertise in their system is differently distributed to ensure that it can be most effectively used.  

 

​

 

 

 

 

 

 

​

 

 

 

​

​

​

​

​

​

​

​

 

 

 

 

 

 

 

 

​

 

Into the realm of the possible

 

As we continue to work towards transforming our mental health systems, the power of imagination continues to be revealed.  By mobilising and harnessing our imagination, we acknowledge what already is and question how that might be different. We realise how limiting the ways we see ourselves and the world might be and how tethered we are to how things are today. It is only by giving voice to our imagination that we are able to see the power that our imagination has over us and, in turn, to mobilise our capacity for Castoriadis’s idea of radical imagination, as a faculty to imagine something alternative. 

 

Truly fostering the possibilities of a deeply person-centred approach is just the beginning in revealing new possibilities in mental health systems. As we continue to deepen our understanding of how our imagination shapes the way we see the world today, new ways of seeing are revealed that might offer even greater and more radical possibilities for the 21st Century. For example, in the last 20 years we have seen a growing recognition of neurodiversity as a value rather than a deficit. Movements like Mad Pride revealed the need for a more ‘radical acceptance of all types of human diversity” and for ‘anti-normalisation’ and ideas of “‘human nature’ that privilege majority and historically dominant groups’”(5). Acknowledging neurodiversity as difference rather than ‘impairment’ reveals the possibility of alternative mental health systems that aims to support and leverage this capacity, rather than treat and cure it.  Another example might actually challenge the very idea of person-centredness that we have described here. There is increasing challenge to person-centred ideas for continuing to propagate an idea of human domination over nature, a mental model that is argued to have led us into the crisis of climate change. There is also an important and growing argument that a person-centred approach fails to recognise power relationships born from deep rooted colonial mindsets that determine what and who has legitimate needs.

 

When we acknowledge the hold our collective and dominant mindsets have over what can be imagined and reach out to explore others, we expand our potential. Seeking out perspectives and ideas from the margins of our systems is the fuel to an imaginative power that has no limits. 

 

Jo Harrington

​

​

​

(1) Imagination in Societal Development, Zittoun and Gillespie, LSE 2016.

(2) Martinez, Piff, Mendoz-Denton, & Hinshaw, 2011.

(3) Linguistic relativity, Wolff & Holmes, 2011

(4) US, Committee on Disability Issues in Psychology, 1992

(5) Graby, S. 2015. “Neurodiversity: Bridging the Gap between the Disabled People’s Movement and the Mental Health System Survivors’ Movement?”

​

​