We are changing—and improving—the ways in which we plan and deliver mental health services. But if we are to continue to improve, we need to change the way we think about mental health. Instead of a ‘disease model’, which assumes that emotional distress is merely a symptom of biological illness, we would all benefit if we were to embrace and implement a social and psychological approach to mental health and wellbeing that recognises our essential and shared humanity.
I am an optimist. Our mental health services are far from perfect. But if we elect the right kinds of politicians and implement the right kinds of policies, change is possible.
In 1967, Martin Luther King said that: ‘…there are some things in our society, some things in our world, to which we… must always be maladjusted if we are to be people of good will…. There comes a time when one must take a stand that is neither safe, nor politic, nor popular. But one must take it because it is right’. 1 When we look at our current approach to mental health care, we still have a lot about which we should be ‘maladjusted’, and there is a lot about which we must take a stand. As I was making final preparations for the publication of this book, a doctoral student was interviewing people on mental health wards in the North–West of the UK about their views on the protection of their human rights. One participant reported that she didn’t feel safe on her psychiatric ward (a damning comment in itself). She reported how she had woken up the night before to see one of the other residents with her hands around another woman’s neck. ‘It’s a risk…’, she said, ‘… but, I’ve learned to cope. I smear Vaseline on my neck; it means their hands can’t get a grip’. What an indictment. In the fifth largest economy in the world, and in a nation that prides itself on its values, a woman in our mental health care system has to use Vaseline to protect herself from assault.
Many of the horrors of previous generations’ attempts to offer ‘care’ are thankfully behind us. My generation have not had to run the risk of lobotomy or insulin coma therapy. The people I love have not been forced to weigh up the possible risk and benefits of having an ice pick hammered into their brains through the thin bone just above the orbit of the eye, and then wiggled from side to side to destroy the delicate nerve tissue in the frontal lobes of the brain. We are lucky. Around 66,000 people were subjected to lobotomies before the Soviet Union banned the practice (which had won its inventor a Nobel Prize in 1949) in 1950 on moral grounds and the use of lobotomy declined worldwide.
But we have absolutely no reasons to rest on our laurels. As I was preparing this book, some of my colleagues were preparing for a twenty-first-century version of lobotomy. At the 2018 Annual Conference of the UK’s Royal College of Psychiatrists, delegates promoted the benefits of localised destruction of brain tissue. The claim (in the words of one colleague via a personal email) is that ‘…precise lesioning… interrupts the neural circuits that drive obsessional thoughts …’ There is something chilling, incidentally, in the use of the words ‘precise lesioning’. The now notorious ‘ice pick’ lobotomy technique used in the past was euphemistically called the ‘precision method’. I don’t doubt the motivations of my colleagues looking to help people with serious and even life-threatening problems. But I do doubt the wisdom of approaching things from such a reductionist biomedical perspective.
A short time ago, I accompanied a friend to a stressful appointment with her family doctor. My friend wanted to discuss an ‘advance directive’, a quasi-legal summary of her wishes as to how she expected to be cared for if she became unable to make decisions for herself. Because of aversive experiences with mental health care in the past, my friend made it clear that, under no circumstances whatsoever would she accept psychiatric care. And she knew that the law, in the form of the Mental Health Act, was insufficient to protect her. Rather than ensuring that her needs are met, my friend feared that the Mental Health Act gives unprecedented powers to mental health professionals, without any immediate need to seek judicial approval, to detain and medicate any person whom they believe to be ‘ill’, despite—or, more properly, against—the wishes of that person.
Care rather than Containment
In the UK, we spend around 10% of our (substantial) national wealth on health care, a figure which has risen steadily over the years (although substantially dependent on which politicians we elect). 2 In general, we spend that investment efficiently, because we have a nationalised healthcare system, the National Health Service (NHS). And we spend a relatively high proportion of that healthcare budget on mental health, around 12% in the UK, compared to only 5.5% as the European average. That’s all good, but we have a long way to go.
I am not in any sense undermining the efforts of my hard-working colleagues, but the care that people receive, both in community and residential care settings, is inadequate. In 2011, the charity and pressure-group Rethink Mental Illness established the independent Schizophrenia Commission and in 2012 published the report ‘Schizophrenia—The Abandoned Illness’. 3 The Commission recognised that there will always be a need for some form of residential care for people in acute distress. It seems clear that there will always be individuals within even the most advanced and democratic societies whose problems leave them desperate, at risk of harm from neglect or self-harm, or very occasionally so distressed and angry that they pose a risk to others. Among some excellent recommendations (which echo many of my own views, e.g., in calling for greater access to psychological therapies, a right to a second opinion on medication, greater reliance on the skills of pharmacists and general practitioners, etc.), the Commission called for ‘a radical overhaul of poor acute care units’. The Commission’s chair, Professor Sir Robin Murray, concluded: ‘… the message that comes through loud and clear is that people are being badly let down by the system in every area of their lives’.
Recently, in the UK, there has been extensive media coverage (appropriately) of the challenges faced by clinicians needing crisis care for children. Our front-line colleagues have found it so difficult to find residential care that children have been placed in residential care only in settings so far from their homes that their parents were practically unable to visit; journalists reported cases where children in serious distress could only be found suitable accommodation 200 miles from home, and a 400 mile round trip, even if parents could afford and had access to transport, takes the whole day. 4 In a remarkable outburst, Sir Justice James Munby, President of the English High Court’s family division, ruled that a (normally private) judgement should be made public. The case concerned a girl who had made ‘determined’ attempts to kill herself since being detained, and desperately needed a safe, therapeutic, place to live. For legal reasons, the place in which she was resident was no longer suitable, but the staff caring for her reported that they had simply been unable to find a suitable alternative. Sir James Mumby used his power as a judge to warn of ‘blood on our hands’ and to order (because judges make ‘orders’) that the news should not only be made public but also sent to senior government ministers to expose the ‘outrage’ over the ‘lack of proper provision for X – and, one fears, too many like her’. The upshot, through the combined influences of a high court judge, the media and government ministers, was that (fortunately) a suitable place was then swiftly found. 5
We’re faced with an unenviable choice. When in acute distress (and perhap...