Monthly Archives: December 2013

Emma Watson ~ Exciting Times for Peer Support

Over the past decade, the employment of peer support workers (PSWs) within mental health services has taken off. The distinctive element of peer support is that it draws on personal lived experience of emotional distress to support others going through similar experience.  However, peer support is not just about sharing lived experience of mental health problems; it can also be about mutual experiences of trauma, education, culture, shared age group, sexuality and life experiences. It is about drawing on all of our roles and strengths to promote and provide whatever support a person requires to help them move closer to their ambitions.

The ability to harness one’s own lived experience and combine this with positive communication and listening skills is at the core of peer support. As a peer support training team, these are the skills that we hope to harness and develop through training for potential Peer Support Workers. With this ambition, so far we have trained over 400 students to become PSWs across the country. Reaching this milestone has been a roller coaster for us and along the way we have learnt a huge amount, not only about what is helpful in delivering training and supporting organisations, but about the incredible strength and inspiring journeys of all the people we have trained.

In 2009, our training team had no idea of the snowball effect they were about to witness surrounding recovery and peer support training. We developed our PSW training module at a time when Peer Support activity was relatively new within the UK but the importance of peer support is gradually becoming more recognised within mental health services.

As we have continued to facilitate PSW training, we have become aware of other areas where specific training might benefit the workforce. We have begun to offer additional training courses based on the emerging needs of organisations, current trends in policy and specific requests from organisations/service user groups. These new projects have now become equally as important as our core PSW training. All the courses which we have expanded to offer are advertised in our new prospectus.

Alongside our advertised courses we have had the opportunity to design bespoke courses and consultancy packages for particular service areas where peer support roles are tailored for a new client group. One such example is our delivery of a bespoke course for Child and Adolescent Mental Health Services (CAMHS) to support the use of PSWs in helping people transition to adult services. During this project, the training team offered bespoke Peer Support Training to the prospective PSWs as well as training to prepare staff teams, help in developing an implementation strategy, and support in discussions with commissioners to explain the importance of peer support work in this specific role. This was provided using a firm base of recovery values and appreciative enquiry meaning that consultancy was supportive, strengths-based and non-directive.

This year, the team has also been thrilled to have been invited to present their work at national conferences. Presentations have included to the 25th World Hearing Voices Congress in Cardiff and the first Narrative Future for Healthcare conference in London. We have used these conferences as a way of sharing our experiences of what works as trainers. Regular presenting has helped the team to become aware of the level of practical understanding and knowledge which we have developed over 5 years. We have been able to present on themes of peer support, story sharing and disclosure, and co-production to name a few. These opportunities have enabled us not only to share our experiences but also to continue learning from a wide range of audiences, co-facilitators and other conference speakers.

Peer support has always been hugely important not only to us as trainers but to us as people in recovery too. There have been times for all of us when the support of a peer has provided us with the understanding and strength we have needed to take our next few steps. As a team this has made us incredibly passionate about recovery and peer support. We hope that in training we pass this passion onto others to spur them on in their individually inspiring paths of recovery.

Emma Watson
Institute of Mental Health (Nottingham)

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Rodney Yates ~ Open Dialogue: Why does the Open Dialogue approach work so well?

Tread softly because you tread on my dreams
W.B. Yeats

Schizophrenia is never being able to trust your senses: we see things which ‘are not there’; we hear what no one else does. We therefore live precariously, with a terrific amount of uncertainty and confusion for long periods of time. This is also an experience particular to individuals.

The Open Dialogue approach gives due recognition to this and seeks to tentatively explore exactly what is happening in the lives of individual clients and to find ways forward which grow out of current predicaments, evolving solutions to expressed difficulties and weighing each tread-fall with care and attention.

This is done through the medium of ongoing exploratory treatment meetings which are convened with all the people connected in the social network of the client in attendance and contributing from their perspectives, with as many meetings as it takes to evolve and become the solution and resolution of the difficulties expressed and experienced, finding a way forward launched from the dialogue taking place. This open and thorough dialogue finds a language to best express the realities of life from client-perspectives, exploring these towards outcomes which everyone present can approve and give consent to.

This is a true and meaningful discernment of what is happening in the life of the client. The care taken in achieving this accuracy is well-rewarded in rendering complex issues accessible to practical solutions and removing scope for mis-understanding and discord later; maybe this process of ascertaing the facts will not have to be visited and revisited again, having uncovered the truth at first onset.

No one jumps to conclusions or imposes stock remedies or solutions, because it is better not to have answers than to apply the wrong ones. When the whole topic is explored with everyone present and conferring, the way forward can become much clearer, with all possibilities explored and only the feasible solutions ruled in. Any sense of compulsion is banished from the proceedings and the approach is sensitive, commensurate and quite beautiful in its simplicity. Why would it not work!

So instead of discounting and disregarding the words of people with schizophrenia, these have taken centre-stage. Open Dialogue practitioners are listening carefully and non-judgmentally to the narratives of people with first-onset schizophrenia in a quest to ascertain appropriate care and treatment – without naming it. Is this a Revolution? What do we all think of this?

Rodney Yates
Open Dialogue Nottingham
December 2013


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Dr Arun Chopra ~ Are our mental health services in crisis?

This post, ‘Are our mental health services in crisis?’, originally appeared on The Fabian Society on 5 November 2013 and is re-posted with permission from the author.

There is an increased demand for mental health services in Britain, but we are failing some of our most unwell and vulnerable people.

Last week, the Health and Social Care Information Centre published its annual report into the use of the Mental Health Act. In 2012/13, for the first time, the number of people detained under the Mental Health Act crossed 50,000 (a 4 per cent increase on 2011/12, continuing a rising trend).

The NHS bed crisis

And yet since 2008, bed numbers for the mentally ill have been cut by 36 per cent. In the last year alone, 1,700 beds were cut, representing a 10 per cent reduction in bed numbers.  This massive reduction in the capacity to care for our most unwell has led to the stories that have emerged in recent weeks of people having to be admitted 200 miles away from home and; tragically, those who have killed themselves while awaiting a bed.

In August 2013, the Health Select Committee reported that Approved Mental Health Practitioners were having to detain people under the Mental Health Act, illegally, in order to secure a bed as it was almost impossible to admit people who agreed to come into hospital.

In my own practice, I’ve heard of several days in the last few months when there has been no NHS bed left in the country. The system has been stretched beyond breaking and it’s perhaps no surprise that the average city inpatient ward is a place seething with anger, threats and chaos. Small wonder that in these environments, demoralised and overworked staff are reduced to focusing on immediate risk reduction with the unwell, rather than supporting their recovery in a therapeutic environment.

In October Dr Martin Baggaley, the medical director of the South London and Maudsley Trust and one of the leading psychiatrists in the country said that mental health services in England are in a state of crisis. The Care Minister, Norman Lamb, acknowledged that there are problems, but still there is a lack of action.

How did things get so bad for mental health services in Britain, and what underlies our inability to act?

Suicide rates and austerity

Suicide rates are an indicator of the strengths and weaknesses of the system. Falling year by year since 1997, they started to rise again after 2009. The Office for National Statistics reported that 2011 saw a further ‘significant’ rise in suicide numbers, 6045 people took their own lives that year.

The idea that a nation’s mental health will inevitably suffer as a consequence of the economic recession is flawed. Both Iceland and Greece suffered with the collapse of their economies. However, Iceland rejected bailouts – with austerity strings attached, invested in health and social care, and its population has not suffered a change in health status. On the other hand, Greece’s austerity drive has led to a worsening of a host of health indicators including a 30 per cent increase in suicides.

Based on some economic indicators, the Coalition is claiming success for austerity-based policies. But viewed from a health perspective, there is little to be joyous about.

A perfect storm

Within the health service, the conditions of the ‘Nicholson Challenge’ for the NHS to find £20 billion savings by 2015 and the first disinvestment in mental health services for working age adults since 2001 (according to the Department of Health’s National Survey of Mental Health Investment) have contributed to the current crisis. Other factors include cuts to Local Authority budgets that have led to social workers being ‘redeployed’ away from mental health teams into more traditional social worker roles and cuts to voluntary sector funding that has led to the closure of many of the programmes that supported severely unwell people to find purpose in their lives.

It’s within this ‘perfect storm’ that services are cutting, slicing and re-disorganising to meet cost improvement challenges.  Hidden behind politically correct jargon of ‘treatment at home’ and ‘care in the community’ beds are being cut to meet the financial pressures.

The Health Select Committee report raised the alarm that it was more than just anecdotal evidence that suggested illegal detentions. People are killing themselves while awaiting a bed. If this was happening to people with heart disease or cancer, there would be an outrage. Why is it taking so long for any action to be taken?

Private concerns

Perhaps the answer lies in the dramatic increase (32 per cent) in the number of admissions of the mentally ill to private sector beds, which is a consequence of the NHS bed crisis.

In October, the Health Service Journal reported that these admissions often cost £3000 a week in the private sector. A spokesperson for Cygnet Healthcare, a private provider, has even said in an interview reported in Community Care that the reduction in NHS beds has been one of the main drivers for a 30 per cent increase in the number of service users it had supported in 2011/2013.

These beds are often not local to the patient. At a time when someone is most unwell creating distances from family and friends is the opposite of what many people need. Similarly, the loss of the continuity of care between the NHS community team and the inpatient private provider will extend the duration of an admission and worsen therapeutic engagement.

This is the opposite of high-quality care. Whereas community mental health teams support patients as much as they can to try an avoid unnecessary admissions and there is often a discussion between the inpatient and community teams of the local NHS service about the need and expected outcome of an admission – what are the incentives that operate within the private sector and will this make clinical care better in the long term? Is this economically effective?

There are also concerns about transparency. The Health and Social Care Information Centre raises concerns that although the independent sector are now looking after a quarter of inpatients, some of the major providers are not providing required information (the mental health minimum data set) for monitoring.

We’ve been fighting a battle to keep the NHS public, and yet a portion of the NHS that supports the most vulnerable is being dismantled in this crisis. Conservative politician, Oliver Letwin, said in 2004, within 5 years of a Tory government there would be no NHS. I can’t help but wonder if the dramatic privatisation of the care of the mentally ill is more than an unintended consequence.

Stigma and discrimination

The stigma and discrimination that people with mental illness continue to face partly explains the lack of action. According to YouGov research in early October, the mentally ill are widely seen as the most discriminated group in Britain. Attitudes have hardened towards the mentally ill, and the narrative of deserving and undeserving poor has hit this group hard.

This is despite £21 million lottery and DH funded anti-stigma campaign led by leading mental health charities. Stigma can be a difficult concept to understand, but the fact that this is a group of people with relatively less power and that attracts little public sympathy has allowed this crisis to continue.

The road ahead

There is much that needs to be done. We must galvanise public support; research into the impact of privatisation on care pathways and audit the costs; and develop a workable plan to reverse or at least halt further bed closures until capacity for community support can be expanded and its safety and effectiveness demonstrated. And this needs strong leadership – both clinical and political.

Encouragingly, at Labour party conference this year Ed Miliband showed that he gets it. He described mental illness as a one nation problem – but one that we don’t talk about, that’s been swept under the carpet and how that needed to change.

In an excellent speech on mental health and illness to the Royal College of Psychiatrists last year, Miliband announced setting up a Labour Mental Health Taskforce. Now is the time for that taskforce to act.

Arun Chopra
Consultant Psychiatrist

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The Birth Project ~ An oppurtunity to participate in reserach

The Birth Project, an IMH collaborative research project with the University of Derby, is looking to recruit both midwives (students, practising, retired) and women who have given birth in the past 5 years  for ‘The Birth Project, researching the birth event through visual methods’.  More details, including how to get involved,  are below:

Midwives (students, practising, retired)

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Women who have given birth in the past 5 years

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Dr Arun Chopra ~ ‘Time to Change’: is it time to change?

All of us who work within or who use mental health services are well-aware of the stigma that continues to surround mental health conditions and how it affects patients and their carers, preventing them from accessing support, making it difficult for them to enter or re-enter the workforce and how it saps at quality of life in a way that can make the stigma around mental  illness almost as disabling, and perhaps at times worse, than the illness itself.

At the same time, we are facing austerity drives that are leading to cuts and closures to mental health services. There is a national adult inpatient crisis. Against this background, we have to ask whether the generously funded anti-stigma campaign ‘Time to Change’ is working and whether it is value for money. This is not a popular question to ask. However, the analysis that ‘Time to Change’ has been subject to makes it easier to address.

A relevant starting point might be to ask whether any anti-stigma campaign has ever worked in mental health. The history of systematic attempts to de-stigmatise mental illness goes back to the 1950s when a psychiatrist and sociologist couple attempted to change the views of the folk of a Canadian town by presenting information about mental illness – unfortunately rather than de-stigmatise the condition they found that their attempts attracted hostility. 25 years later – another research group found that attitudes towards the mentally ill in that town had not shifted in that time. The World Psychiatric Associated launched an anti-stigma campaign, ‘Open the Doors’ in the 1990s – again with Canada being a pilot site. They found that there was no change in attitudes even if knowledge about mental health conditions increased. More large-scale projects followed. In the UK, the Royal College of Psychiatrist’s Changing Minds campaign between 1997- 2003 didn’t lead to a change in attitudes and the Scottish ‘See Me….’ campaign of 2002 was difficult to evaluate.

A question that could be asked is if these studies were adequately funded and if their effects were properly analysed. ‘Time to Change’ is the largest ever programme in England that aims to reduce stigma and discrimination against people with mental illness. The first phase between 2008 and 2011 was relatively well funded – £21million pounds from the DH and Lottery funds, led by leading mental health charities and evaluated by the Institute of Psychiatry in London.

The evaluation of the first phase was reported in a British Journal of Psychiatry supplement in April 2013. My reading of this evaluation and the associated editorials is that the project has not been a success.

With regards to public knowledge and reported behaviour the evaluation showed that there was no change. Although mental health service users reported a reduction in discrimination, the target of a 5% reduction was not met, and the percentage of service users who responded to this question was low – around 9%- and White British and women were overrepresented in the respondents. There was no change in the attitudes of professionals and a short-term improvement of the attitudes of medical students didn’t last. The economic evaluation is uncertain with model-estimates ranging from a net-cost to a net benefit of £223 million!

In my, much closer to home, evaluation – on a day in Mid November 2013, not one of the 20 patients admitted on my inpatient ward had heard of the Time to Change campaign and only one member of staff had heard about it (out of about 10 who I asked). Indeed in the past 3 years, not a single patient or carer had ever mentioned the Time to Change campaign to me. The only person who did was a visiting politician.

I’m not sure that TTC had an underlying theory that underlined their campaign and informed their attempts to change attitudes and reduce discrimination. I haven’t seen one published.

In a recent issue of the New Republic I came across the work of Daniel Kahneman, an American academic who has explored the process in which people distort knowledge to fit their world-view. Cultural cognition theory might explain why mental health stigma campaigns fail to shift attitudes. Culture shapes world views and just a cursory glance at what’s been happening in our world and how the media reports this demonstrates the scale of the challenge. Media portals of mental illness remain dominated by accounts of violence – the Sun’s recent headline of ‘1200 killed by mental patients’ is a good example of this. But also, a recent You Gov poll (October 2013) showed that the public consider the mentally ill as the most discriminated group in Britain. The dominant political narrative has been of ‘benefit scroungers’ and whether the mentally ill are portrayed as ‘deserving or un-deserving poor’ depends on which newspaper you choose to read. Around Halloween our largest supermarkets marketed costumes based on negative stereotypes of the mentally ill as deranged killers. Although the outcry that followed forced them to apologise – the fact that these products managed to hit the shelves shows how Time to Change message has failed to penetrate. There has been no perceptible shift in the cultural attitudes towards mental illness.

Time To Change isn’t sufficiently nuanced – the public equate mental illness with severe depression and psychosis and that’s why the ‘1 in 4’ message that it has championed fails to resonate, indeed I wonder whether it alienates. Perhaps we need to be more specific about what we mean by ‘mental health conditions’ and more sophisticated in targeting the stigma that surrounds each condition rather than try and address all as one group.

Susan Sontag’s work around the myths and metaphors that surround illness is also instructive here – when better treatments for TB, Cancer and HIV became available and accessible the myths that surrounded these illnesses started to clear and stigma reduced.

Mass anti-stigma campaigns against mental illness don’t work. We need a more sophisticated approach, targeting particular illnesses. And more research into treatment; and into the support that works to ensure that people with these conditions are given a voice, enabled to enter work and take part in public life. Locally presented stories are far more powerful in capturing and changing minds than national campaigns. Treating people and helping them get better to pursue their goals might be a better use of available resources and a better advert for anti-stigma work.

Is it time to change how we think about anti-stigma campaigns?


The blog was based on arguments presented at a debate at the Royal College of Psychiatrists Trent Division Annual Conference on 20 November 2013.

Arun Chopra
Consultant Psychiatrist



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Angela Gilchrist ~ Wounded healer? A qualification without ceremony

The post below was originally posted on the Discursive of Tunbridge Wells, The Salomons blog: Views and commentary on psychology, mental health and other stuff on 29 November 2013 and reposted with permission from the author.

Do professionals always have to wear a mask? Image:

Do professionals always have to wear a mask?

I innocently posted an item on Twitter the other day about Marsha Linehan, one of the world’s best known clinical psychologists and the creator of Dialectical Behaviour Therapy (DBT). Linehan caused a stir a little over two years ago when she announced that she, like so many of the people she has tried to help, had suffered from the experiences labelled as ‘borderline personality disorder’ (BPD). Admittedly, Twitter is a volatile medium in which people say many things free of the restraints that a less anonymous conversation might impose. But, even so, I was unprepared for the vitriol with which my tweet was greeted.

Service-users responded immediately and their views were unequivocal.

‘It only took her 30 years to come out!’ complained one, while another said that surely she could have helped more if she had revealed her own history of mental illness sooner. An attack followed on the merits of DBT, created by Linehan with the aid of insights provided by her own struggle.

Whatever you think of DBT, it’s clear that when a mental health professional ‘comes out’, it will not necessarily go down well. The issue provokes interesting questions. Why don’t professionals with so called ‘lived experience’ of mental illness and other difficult or traumatising experiences make known their histories more often or more easily? What might make them ‘come out’ and why would they choose to do so after many years of silent practice?

Linehan apparently spilled the beans after a service-user had asked whether she was ‘one of us’. Linehan it seems, was used to answering such questions. But something about that question on that particular day got to her, and she let her secret be known. Her confession included details of frequent and protracted hospitalisation as a young woman, a misdiagnosis of schizophrenia and multiple electroconvulsive treatments. It was a risky admission.

More recently, the CEO of one of our local partner NHS trusts, Lisa Rodrigues, chose to make public her history of bipolar mood swings. Her confession received broad applause from what we might call ‘the mental health community’. Nonetheless it was not without its detractors. Some service-users predictably thought it too little, too late. Others, including professionals, pointed to the fact that her imminent retirement meant that now was a safe time for coming clean.

The reasons for concealment might seem obvious. Stigma is frightening, and nobody wishes to invite it. But it’s a sad fact that mental health professionals stand accused of colluding with it. Stephen Hinshaw in his book, Breaking the Silence suggests there is a status differential between those who give and those who receive care. The result is a tendency for those in professional and scientific roles to hold to an ‘us versus them’ approach in which users and survivors have the one-down position. Many professionals hide behind a facade of invulnerability and those with histories thus remain ‘other’. The fact that any one of us can develop a mental health problem given the right circumstances, may get lost.

There are many traps the other way, though.  While there may be merit in making wounds explicit, referring to a label can be a tricky business. Using it may invite others, including fellow professionals, to view user/survivor professionals through a particular lens. Do people think you understand their pain better? Or will they confer insight on you that you might not have? Psychiatrists might take the view that the disease is in remission. Once labelled, always labelled and that’s it. Do you then have the strength and resilience to cope with the work you do? As well as unease in the professional world, it may sometimes be difficult to be taken seriously as a user-activist if you’ve enjoyed the privilege of recovery and professional training. Both professionals and service-users may attempt to position a dual status professional in ways that can be both unhelpful and unrealistic.

Some of the most difficult dilemmas may arise from within wounded healers themselves. For some, the gift of recovery exerts what is felt as a responsibility to help those in distress, while for others it is an attempt at making peace with the past. However noble such agendas may be, dual status professionals will need to pay attention to motivations that may lead to unhelpful pressures from either themselves or colleagues. Hinshaw suggests that many individuals who enter the mental health professions do so at least in part to examine their own (or their family’s) psychological issues, vulnerability and pain. The psychologist Jung, who suffered serious breakdown, believed that it was a healer’s own wounds that made the curative therapeutic journey possible. Wounds, he maintained, potentially bore within them transformative and curative power. Indeed, some believe that a therapist cannot necessarily guide a client anywhere they haven’t been themselves.

Of course, this is a complex issue. Those with a history do not necessarily have the wherewithal to be healers, nor are they always ready to contemplate the rigours of clinical practice. Those who bear their own wounds may be terrified of being seen as too vulnerable, and training schemes may be afraid to take on those who confess to significant histories. What if they become a liability? At times I’ve heard colleagues say that it’s okay to confess to a history of mental health problems so long as you were never hospitalised. Ironically, this ludicrous logic reveals that many don’t have much faith in recovery, or indeed the healing power of their own methods. The result is that many of those who could be most valuable to services are either kept out, or kept quiet. The controversial clinical psychologist, Rufus May, confessed to a history of psychosis only once he had qualified. Other wounded healers believe they need to clock up considerable years of practice and a record of reliability before it is ‘safe’ to reveal their dual status. It is a travesty that those who potentially have the most to contribute are pressured into lives of subterfuge. Arguably, successful transformation of one’s own wounds is the highest qualification of all.

Survivors and service-users know this, hence their feelings of betrayal when a wounded healer belatedly ‘comes out’. Professionals know it too, despite their collusion with an us-them hierarchy. As a wounded healer myself, I believe aiding others is most potent when practised from a position of common humanity where all are regarded as fellow travellers on this difficult journey of life. This is no easy task, for it requires that we not only gain intimacy with our vulnerabilities, but ceaselessly and courageously confront them. It is the only standpoint that is genuinely authentic in a world in which suffering is inevitable. What we need is an honest appraisal of the issues, so that clinicians like Marsha Linehan and executives like Lisa Rodrigues needn’t risk censure when they make known what might be of profound value.

You can follow Angela on Twitter @cyberwhispers.

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Paperback Book by Professor Paul Crawford Now Available: Nothing Purple, Nothing Black

The IMH Blog is pleased to announce that Professor Paul Crawford’s fictional novel Nothing Purple, Nothing Black, is now available in paperback:

An intriguing debut novel that deserves a closer look. The lives of two seemingly disparate characters are fascinatingly juxtaposed in this confident debut novel: one is a Roman Catholic bishop on the run from his diocese and the Church; the other, an ex-mental patient on the street, haunted by voices and under the command of sinister beings visible only to him. When the tramp prevents the bishop from catching a train to an uncertain freedom, and offers shelter and a bolt-hole, the pair are set on an inextricable course that can only lead to a tragic climax. With an intricate and masterly narrative, Nothing Purple, Nothing Black casts the reader into a world where the old certainties of order, faith and morality are cast away.

…I really enjoyed it…it is very well plotted…it is humane and somehow tender’ Sara Maitland

‘Three bizarre lives become intertwined in this strange and intriguing tale: Harvey, a bishop with carnal yearnings, Crystal, a psychotic tramp, and Olwyn, the object of Harvey’s yearning. Cleverly told with some touches of black humour, an unexpected finale and not a moment of boredom – I found it a great read.’ Rula Lenska

‘Nothing Purple, Nothing Black draws you in and holds you suspended. A psychologically powerful study.’ Roy Porter

‘Paul Crawford has written with clarity and chastity about the anguish of institutional celibacy…The desperate loneliness of the isolated priest is conveyed with Greene-like insight. A parallel theme is the alienation of the insane… Delusions, hallucinations and compulsions are vividly portrayed. There is no idealisation of the deranged – madness and its expectations are depicted with an insider’s knowledge.’ Dr Maurice Lipsedge

‘Written with wit and a strong feeling for his protagonists… Crawford’s fictional debut is impressive, and his depiction of the “mad and the sane” sharing “the same bathwater of life” lingers in the mind long after you turn the final page.’ Paul Sayer

‘No other novel explores the painful dilemmas of the vow of chastity as this one does. Anyone who wants to know about the state of the Catholic Church, both from inside and out, must read Nothing Purple, Nothing Black.’ Theodore Dalrymple/Anthony Daniels

‘This is a very powerful and touching novel in which the two worlds of the church and the laity are so well portrayed and poetically united. Crawford merges Graham Greene and Patrick Hamilton into the best of both – an obsessive internal landscape set against a murky dusk of a deadly town and a railway station going no-where.’ Stephen Lowe

“Nothing Purple Nothing Black is an unusual, and unusually promising first novel. It is an intriguing, topical story, and Paul Crawford tells it with passion, wit and a boldly metaphorical style.” David Lodge

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