Support health and well-being, don't treat 'illness'

There is a purpose and a reason for arguing that mental health care, including psychiatry, should be located in the social services of local authorities. A mere change in the line of management would be pointless without a change in ethos and practice. The point of bringing mental health care under local authority control is to shift from a service based on a disease-model ethos to one based on a person-centred ethos: from one designed to treat mental illness to one designed to foster human well-being.

This isn't really too much to wish for. And it should also be close to the aspiration of psychiatrists. The 1948 founding Charter of the World Health Organization describes health as ' ... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. The European Commission takes a step further, describing mental health as: 'a resource which enables them to realise their intellectual and emotional potential, and to find and fulfil their roles in social, school and working life. For societies, good mental health of citizens contributes to prosperity, solidarity and social justice'. Interestingly, the European Commission also suggests that: 'the mental condition of people is determined by a multiplicity of factors including biological

(e.g., genetics, gender), individual (e.g., personal experiences), family and social (e.g., social support) and economic and environmental (e.g., social status and living conditions)'.

The consequences of bullying and abuse in childhood can be far- reaching and lifelong. Children form their views about themselves and their futures during their adolescence, and all manner of negative life events can lead to significant future distress. The impact of childhood abuse - emotional abuse, neglect and both physical and sexual abuse - is huge. Children also spend a very significant amount of their time interacting with peers (with other children, usually in school or with school friends). Any observer of children will see how hierarchies and patterns of in-group and out-group behaviour are quickly established. These serve as frameworks within which children begin to understand their skills and talents, how others see them, and what patterns of friendship they can expect. These complex relationships are vital to their healthy emotional and psychological development . .. and bullying is therefore traumatic and has long-lasting consequences.

In our mental health services as they are currently constituted, these children tend to come to our attention when 'disorders' or 'illnesses' are diagnosed - whether as children or later as adults. Many colleagues working both in child and adolescent mental health services (CAMHS) and in adult psychiatric services stress the social determinants of later emotional problems, and most colleagues working in child psychiatry services are fully aware of the impact of social circumstances and traumatic life events on children's emotional well-being. Similarly, many social psychiatrists are fully aware that emotional distress in adult life frequently stems from experiences in childhood. But nevertheless, and despite their close working relationships, the mental health system is currently somewhat separate from education and children's services and, crucially, based on different assumptions and ethos.

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