April 6, 2016, by Centre for Applied Social Research
Why is a more socially oriented approach to mental health difficulties so hard to embrace?
The BBC’s recent series on mental health, ‘In the Mind‘ drew mixed reactions. In particular Stephen Fry’s exploration of manic depression was both praised on account of his attempts to destigmatize mental illness, and criticised because it presented a very narrow biomedical understanding of mental illness. Richard Bentall, a respected leader in the field responded in the form of an open letter to Stephen Fry. They were at school together. Amongst other places it was published on the Mad in America website. It challenges some of Fry’s assumptions about mental illness and can be found here.
Earlier this year an independent Mental Health Taskforce assembled by NHS England published a potentially influential report; The Five Year Forward View for Mental Health. It begins with a rounded criticism of NHS mental health services: “The NHS needs a far more proactive and preventative approach to reduce the long term impact for people experiencing mental health problems and for their families, and to reduce costs for the NHS and emergency services”. It goes on to develop this criticism and make a series of recommendations. It is clear from the report that the taskforce is advocating a much less medical and a much more socially oriented approach to mental health difficulties, but the recent history of high level statements like this reveals some of the challenges such a shift in thinking has to confront.
In 2009 the Department of Health published New Horizons. A Shared Vision for Mental Health which was endorsed by the then Prime Minister Gordon Brown and his Secretary of State for Health, Andy Burnham. New Horizons described itself as “a cross government programme of action with the twin aims to: improve the mental health and well-being of the population and improve the quality and accessibility of services for people with poor mental health”. Those keen to see a more socially oriented approach to mental health difficulties found it encouraging. It refers to a need for closer attention to early intervention, to the need to address stigma, for a focus upon life’s transitions, and innovations that could support recovery, personal autonomy and well-being. These were defined not as symptom control, but as “A positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment”.
What happened? Nothing. There was a change of government and none of these recommendations saw the light of day. Over the last seven years mental health services have become more coercive, with a steadily rising proportion of inpatients on a detention order. We have a bed crisis as a result of which individuals might find themselves hospitalised miles from their homes and loved ones. We are seeing more and more suicides. The rate of pointless prescriptions for antidepressants, antipsychotics and so-called mood stabilisers has continued to rise and once again we have falling levels of morale amongst the NHS mental health workforce with consequent difficulties over recruitment and retention.
The  Five Year Forward View for Mental Health makes absolutely no reference to its 2009 predecessor, but it does make very much the same recommendations. It openly acknowledges that current NHS mental health services are unsatisfactory and firmly recommends enhanced crisis care, easier access to psychological therapies and preventive work, especially amongst young people. It encourages attempting to achieve recovery, as in enabling people to lead better lives as equal citizens, and the building of healthy communities through the provision of suitable housing and the reduction of stigma. It has been lauded by the Royal College of Psychiatrists who were party to its authorship and have produced their own briefing paper outlining its implications for the profession. Again there is little here about medication or symptom reduction and much about even better access to psychological therapies, vulnerable minorities and recovery. The central role of services user experiences is respected: “Co-production with clinicians and experts-by-experience will be at the heart of commissioning and service design, and involve working in partnership with voluntary and community sector organisations…” page 5.
These are not the earnest pleadings of a radical minority. These are establishment publications. It is fascinating that the same views are reiterated following a change of government. 2009 was the dying year of the Labour government and 2015 saw the election of a majority Conservative government after a period of transition. Despite these changes at the top, on the face of it, the UK health policy establishment has remained faithful to a vision of NHS mental health services that gives more weight to talking therapies than medicines, appears to understand “recovery”, recognises that well-being is dependent upon opportunities of employment, appropriate housing and acceptance, and that all of this can’t be provided for free. It will be even more fascinating to see what the fate of a renewed commitment to these aims turns out to be. Not only is it a welcome vision for those who would like to see change and improvement in mental health services, it is also a blueprint for a more caring and accepting society.
That is probably where these aspirations run into the sand. It is a widely acknowledged truism, that the way a society responds to its most vulnerable is a reasonably accurate reflection of its core values. It is easy to be charitable and supportive towards people with mental health difficulties if they are seen to be suffering an “illness” that has developed as a result of otherwise inexplicable changes in brain chemistry. It is much more difficult to do so if they are understood as vulnerable because of adverse developmental experiences, suffering the consequences of difficult social circumstances or simply misunderstood. This requires a genuine commitment to others’ welfare across the board and acknowledgment of societal imperfections.
It will be interesting to see whether the establishment figures who have responded to the blindingly obvious in relation to NHS mental health services are really joined up with those who are charged with realising a neo-liberal ideology in other government departments. The medical focus the BBC followed in the form of Stephen Fry’s contribution and the failure of New Horizons to make any palpable different suggests not, but re-iteration of its views in the form of The Five Year Forward View suggests that this is collective blind spot which isn’t going to go away easily.
Hugh Middleton. April, 2016.
Hugh Middleton is both an Associate Professor of the School of Sociology and Social Policy and an NHS Consultant Psychiatrist. Hugh’s latest book ‘Psychiatry Reconsidered: From Medical Treatment to Supportive Understanding’ was published in May, 2015.