The Retirement of 'Mental Health'
Other than the hovercrafts and T-shirts, things look pretty much as they do now, with alarming inequalities in health and the ever present threat of war and migration crises. However, a few things have changed, and most specifically, some of the issues that concern us in this book. A social democratic government had been in power for 15 years, and proportional representation is now the order of the day. What in 2016 was once quaintly referred to as ‘mental health’ is no more in 2050. Indeed, the term has as much relevance as other strange describers of distress from bygone ages like ‘hysteria’ and ‘schizophrenia’. Misery, which had previously been the remit of health professionals like GPs, psychiatrists and psychologists, was completely deinstitutionalised. The seeds were sown by some academic psychiatrists themselves. Arthur Kleinman in 20123 said that for all the efforts in neuroscience, genetic research and neuroimaging, there was no better understanding of what was still referred to as ‘mental illnesses’ and that academic psychiatry still acted like the breakthrough was just round the corner. This failure had already clearly been apprehended by the pharmaceutical industry which had begun to move away from mental disorders, towards treatments for the neurodegenerative diseases so prevalent in an aging population.3
Kleinman was a key figure and many listened when he said that ‘if by 2030 we still have no useful biological test for mental disorders and little in way of new therapeutic agents, academic psychiatry will be consigned to irrelevancy’. It turned out that many absorbed this prescient warning. When a year later the National Survivor User Network4 noted that ‘nearly all of the members who responded to their survey said that the governments’ mental health strategy was failing’, there appeared to develop a small but significant movement towards questioning the psy disciplines (psychiatry and psychology) and how useful they really were. Soon everyone had something to say on the matter.
Clinical psychologists like Colin Feltham5 openly noted that ‘Counsellors cannot do much directly about the upstream causes of mental health problems’, and Pat Bracken et al6 in 2012 warned that psychiatry faced challenges it couldn’t ignore—a need to move beyond its own paradigm and more importantly, the growing evidence of the primary importance of ‘nontechnical aspects of mental healthcare’. There was a growing acceptance that improvements in people’s misery could come from simple human interactions, very often with people who had no training or expertise. These notions gradually gained momentum and a consensus slowly formed, albeit one that many service users had known for many years—that people were entrained to see themselves as ‘mentally ill’.
That’s not to say that they did not suffer horresdously- it simply meant that understanding this suffering as a biological illness was no longer good enough. Moreover, the consensus grew that receiving alienating ‘treatments’ from remote professionals paid many times their own salaries in environments that were lifeless and completely removed from their own families, friends and communities was not perhaps the best way to address misery. The pain of stigma didn’t come from ignorance or a lack of education in the public but from the diagnostic labours of the psy institutions who had inadvertently worked so hard on a social segregation that enforced ‘mental health’ identity niches that almost demanded that people were stigmatised.7
And those were seeds. But they were seeds that soon flourished into discussions about values-based commissioning of services8 that was underpinned by the realisation that the values and experiences of everyday people could be put at the forefront of helping rather than a reliance on problematic evidence-based medicine (EBM).9 EBM was an enticing idea in name but one where the technicality of knowledge was irrevocably tied up with professionals’ claims to autonomy and status. EBM had more value in strengthening the authoritative voices of clinical experts than in helping people with their misery. There was a growing acceptance that there needed to be a more nuanced awareness of humanity, one where people were understood not as fixed carriers of disorders but as fluid and plural subjects that couldn’t simply be captured by scientific rational and objective forms of knowledge. That was best left to the physicists working on the memory machines and the invisibility cloaks.
At its worst, at the turn of the century nearly 20 % of British people had consulted a counsellor as counselling had come to be the answer for all manner of personal and social problems10 —boredom, loneliness, overexcitement, rejection, unattractiveness, workplace change and marital infidelity. There was a growing understanding that antidepressants didn’t treat, they sedated (although such sedation was certainly useful for some in the throes of suffering), and that the evidence base for trials of medications and psychological therapies was so flawed as to leave little but placebo. And there was a growing acceptance from within the discipline that psychiatry was scientifically bankrupt—it was a collusion of good will, self-interest, inappropriate understanding of people and complex social environments,10 and more importantly that suffering was social, not personal. The World Health Organization11 released a report that said as much, stating that what was really needed for mental health was an increase in the number of people with a living wage; that what was needed more than anything was government action on the social determinants of mental health in order to achieve advances in health equity.
The Mental Health Foundation12 reported that psychiatry needed to be moved into the community for fresh ways of working in mental health. When in 2013 Whitely13 called the publication of DSM-V, previously understood as the ‘psychiatric bible’, an exercise in blatant disease-mongering where normal human behaviours were pathologised and medicalised, even he could little have known DSM-IX would, in 2029, contain ‘leaving your house without locking the door syndrome’ and ‘Bad hovercraft use disorder’. Social prescribing, that is, the prescribing of non-medical community-oriented services for immiserated people visiting their GPs, began to take off under the early century neoliberal governments that saw in this model a way to promote ‘patient choice’ and cut state medical costs in one fell swoop. A financially besieged community and voluntary sector was increasingly ready to be recognised for much of the work that it was already doing.
And so things changed—not overnight but slowly and irrevocably. The National Service User Movement’s ‘It’s often bollocks’ campaign drew more and more supporters through the ever-developing social media. That campaign morphed into the ‘Community Options’ movement. It was clumsy at first. Well-being shops opened up on high streets around the country but were often backed by private equity firms. These largely virtual environments scored a bit of an own goal. But eventually and slowly they got there. ‘Options in the Community’ programmes developed around the country to help support people who were experiencing what was no longer referred to as mental health problems. Psychologists and psychotherapists who had always been keen to differentiate themselves from the biomedical psychiatrists, yet often who had reproduced and benefitted from the conceptual tools of psychiatry (DSM, disorders, illnesses, treatments), were quick to respond and rebrand themselves as ‘community psych workers’ and then eventually ‘community supporters’.
People like James and company, introduced at the beginning of this chapter, who were experiencing embodied suffering, and often as very clear and understandable responses to life histories, losses, abuses, dislocations, humiliations and pressures, were no longer seen as ‘abnormal’ or ‘different’. They were just people going through a period of change (albeit a period which felt excruciating) much like other periods of life change. Many people continued to experience distress as a result of coming to terms with difficult things that they had experienced, such as housing, benefits and legal issues, with work difficulties and debt. These people were no longer automatically sucked into the institutions of medicine to be sedated or inappropriately counselled when in many cases they just needed help with the specific life circumstances that were causing their distress. Instead, an ‘Options in the Community’ programme, staffed by volunteers who did a fixed term in the programme to avoid the building of professional enclaves and interests, pointed them to a vastly expanded array of networks of community organisations whose incredible distress work, often carried out by non-trained staff and volunteers, was finally recognised with funding by parliament of the Community Options Programme nationwide in 2050. People still had facility to talk to the rebranded psychologists who had become ‘community friends’, many of whom had come through the volunteer ranks and had never had any psychological or medical training. However, that wasn’t deemed important.
For some of those whose acute distress took the form of hearing voices, a vastly expanded series of Soteria houses were integrated with the ‘Community Options Programme’ and served as community spaces for people experiencing mental distress or crisis. The Soteria approach included non-medical staffing and worked by preserving residents’ personal power, social networks and communal responsibilities; finding meaning in the subjective experience of hearing voices by ‘being with’ clients; and involving no or very little use of antipsychotic medication. Staff members at the house were encouraged to treat residents as peers and to share household chores. The programme was designed to create a quiet, calming environment that respected and tolerated individual differences and autonomy. They were initially heavily criticised as irresponsible or ineffective by what had become the Nike College of Psychiatrists, but came to be widely established across the country.
And for those whose period of acute crisis meant that they were considered to be in danger of taking their own lives or harming others, the institutional baby wasn’t completely thrown out with the psy bathwater. Safe zones, shorn of the biomedical and diagnostic pretensions that had engulfed the old inpatient hospitals, were used to hold people in these forms of crisis. As with Soteria houses, non-medical staffing and a focus on preserving residents’ personal power, social networks and communal responsibilities were emphasised. The sedatives that had previously laboured under the guise of treatments were sometimes used here. And as with the old inpatient hospitals, they failed in the eyes of many to hold the uneasy tension between crisis and liberty.