A Practice Future
Well what to do is to build on the primary innovations associated with the notion of enabling places—that is, the privileging of a relational account of place that acknowledges the resources for the ‘everyday work of recovery’.9 Such an understanding of place would include an acknowledgement for the diverse objects, assets and benefits that circulate in and through local communities. These include intangibles like companionship, empathy, atmosphere, hope and non-judgementalism, and more tangible things like practical support, advice and advocacy. A focus on practice—not on expertise or experts, immutable clinical categories, technologies and fixed knowledges—might allow us to appreciate that knowledge, status, relief, atmosphere and solidarity are constituted in practice.10 Knowledge is not a tangible asset that can be moved between organisations or individuals. Instead it manifests itself as actors engaged in practices with other human and non-human agents.10
A practice lens might help us to strip away what happens, from what is supposed to happen, in clinical settings and to articulate with a little more surety what is useful and why. Within the dominant knowledge paradigm of distress, there are clearly constituted caregivers and care- receivers and certain forms of care are recognised, practised and legitimised as care. But we need to think about the way that we recognise these care practices. If multiple care practices are only talked about in terms that are not appropriate to their specificities, they will be submitted to rules and regulations that are alien to them.11 If care can only be understood as ‘care’ if practised by the correct people (e.g. psychologists, therapists or psychiatrists), then we miss the practices that happen both in formal and informal settings.
Our current fascination with the static rationalist knowledge regime of positivistic biocognitivism not only misses care practices and fluid knowledges articulated in various informal settings, but it also does scant justice to the spaces of psy practitioners themselves. Moreover, when taken to its extreme, a strict adherence to this rationalist knowledge paradigm presents an altogether warped, inflexible and frankly bizarre set of arrangements between those deemed to be ‘professionals’ and ‘patients’ (particularly bizarre for psychotherapists who receive psychotherapy by another practitioner to help them deal with the distress experienced from having to listen to the distress of others). A focus on care practices moves us away from rationalist versions of the human being with the understanding that, in enacting solutions together, people collaboratively shape what the problem is, what form it takes and how it can be addressed.12
If we use a questionnaire for depression, in the presence of a medical professional, immediately following the time spent in a waiting room that transitioned the individual from ‘person’ to ‘patient’,13 this tells people how to talk about their distress and what terms to use; subsequently we enact an illness requiring treatment. Alternately if the same persons ring up the advice line of the local support organisation to discuss the desperation they feel because of the lack of sleep they have had and because they don’t feel they are being listened to by their children’s school or doctors, then different problems may be attended to in different ways.
If we want to recognise the fluid and innovative nature of the many variegated care practices, then a future course for a social science of distress is to develop and celebrate methods that are sensitive to this fluidity. It is difficult to recognise fluidity using the static snapshots enabled by all quantitative and many qualitative methods. Care practices can be done, rather than known or told, and they may be silent and implicit, as well as explicit and recognisable.14 So it appears that there is a need for a social relational approach that embraces the fluid complexity of misery and eschews the careerism that tends to enclose, fix, hold static and monopolise rationalist forms of knowledge, knowledge that can too often displace, colonise and damage care practices which are less formal.14
The tendency of capitalism to colonise new areas of social and psychic life15 has privileged models of care that cannot recognise well-being as anything other than a set of internalised qualities to be produced via financially rewarded technologies and treatments. However, we can also think about well-being as sets of effects produced in specific times and places, and as something that happens through the interface of complex assemblages of people, places, material objects16 and other intangibles that we recognise and often crave, but can barely define—things like atmosphere, shared histories, sense of place, values and feeling safe.
When you look at a setting like the Brighton Unemployed Centre Families Project, where people eat a decent meal together, feel a sense of safety, stillness and space, and feel enabled to enact some form of change in their lives, you can see that while the social materialist realities of distress are complex, the enabling practices of recovery can be relatively straightforward. Here we can recognise the ordinary humanity of the care relationship, between people and people, places, atmospheres, activities and things. Ordinary is the key word but not because we need some oversimplified, anti-intellectual drive to strip care to some artificial edifice that anyone can do, but because both simple and complex care practices exist within and outside the formal settings. A key element, however, is a general recognition in informal care settings that recovery cannot be done to a person. Rather it is something emergent from the complex set of transactions between a person and his or her broader socio-environmental setting.17 In our fishing chapter, the authors discussed the value of ‘learning through country’ and how in so doing, the boundaries of expert and instructor dissolved. In these spaces people combined their ways of knowing in a situated experience of loss, rebirth and hope. Such experiences can act as valued counterpoints to the intensity of their home setting, provide platforms where people could assert themselves differently at home and could have power because of what they are not, as much as what they are.
So what might a focus on practice look like? Well one might say the social prescribing model could edge us in that direction.18 Here we have examples of primary care settings collating information on local groups and community-based support. This uses agreed referral routes and criteria, requiring up-to-date information on the local community and voluntary sector organisations. And of course it can only work if a vibrant community and voluntary sector exists. Social prescribing as a model has its challenges, not least an insistence on primary care as the primary mode of expertise determining people’s direction of travel. Moreover, as this book is being written (2016), the sustained funding squeeze for local authorities in the UK, and by proxy the community and voluntary sector, means that our public infrastructures are being savaged with an unparalleled ferocity. As a result, the rich and varied forms of local innovative expertise which have arisen through communities to be able to respond to critically important local needs are being dismantled. The crushingly obvious impact of this is that more and more people are being driven towards woefully overstretched health services. For any of this to work, this situation needs to be addressed fast.
Other work in recent years in East Sussex, UK, namely the ‘Options’ programme, was predicated on a similar notion where, instead of receiving traditional counselling, meetings between people in distress and two ‘options practitioners’ heralded a discussion which sought to open up multiple perspectives on difficulties in order to develop a different, and potentially liberating, understanding of the issue. Here the person in distress was an active part of the discussion rather than a passive recipient of care. Such a service sat somewhere between signposting and traditional forms of psychotherapy. In this way it can provide a timely opportunity for people to explore whether they can find their own ways forward, without the need for counselling or longer-term intervention or support. Organising such a service located in a community hub and staffed not necessarily by psy practitioners, but by a range of people, could have potential as a gateway service for people in distress.
There are other encouraging practices emerging right now. Even in more formal therapeutic contexts, activities like gardening and mindfulness have become part of the fabric of ‘treatment’. And the Recovery College model, in which service users are paid to co-deliver mental health courses to anybody who wants them, alongside health care professionals, is gaining ground. Granted they are mostly attended by other service users, rather than by other members of the community. And granted the service users aren’t paid as much as the professionals for their teaching input. But it is a start that might never have been imagined a few years ago.
The 2013 joint commissioning panel for mental health, in their ‘values- based commissioning in mental health’ moved the commissioning debate some way to where it needs to be in order that care practices—rather than clinical institutions and forms of expertise—become the focus of orientation.19 They privilege the perspectives and values of people in distress and their carers. However, the emphasis is still on clinical expertise and there is some way to go before a commissioning that is oriented to mental distress values aspects such as diverse beneficial care practices, enabling places and a relational account of care places. A key element for the future will be, not only to privilege the recognition of such enabling places and practices, but to link the everyday work of recovery to community-based services and develop brokering access to such enabling places. Service users should be central in the creation of peer support and mentoring programmes to foster access to local enabling places and resources.9 Here, peer mentors could assist with the task of enhancing the quality of an individual’s existing care practice sites and to open up novel but possibly useful care practice sites.
It will need collaborative work with commissioning frameworks that allow for the use of scarce funds to privilege the multiple forms of different practice that foreground the everyday work of distressed people and the people and things around them, that they find useful. And we need to work towards developing ways to think through what constitutes ‘useful’ within such a value-based approach if we are to make a convincing case for sacrificing the rational atomised ‘before and after’ archetype that has missed all but the most mechanistic of care journeys. If people want to bring fluid innovative care practices to the fore, then not only do we need methods sensitive to this fluidity,12 but we need such methods to be understood as having value in the commissioning arenas of the future.
Doing this requires us to move from the narrow captivations of science, but it should not leave us foundering in the new age fascinations of anti-science, where as Smail puts it, ‘rhyme is preferred to reason’.5 Such an approach should not, however, be seen as a rendition of the neoliberal orthodoxy of public services cuts in search for some mythical version of the big society. To begin to operationalise the modest radicalism we advocate in knowing, naming and privileging practices of care for those in distress, we need an authentic common solution beyond the market that will see the redistribution of resources and power through smaller, local contexts, and then scale up. And it will need a radical investment in public service and the community and voluntary sector settings that make many of these variegated encounters in care possible. Care practices are, after all, knowledgeable collective actions that forge relations and connections despite the constraints present.20
When we started this book we rather optimistically started with a vision of the future that was replete with the many tropes of science fiction which have enlivened films for the last 50 years. We were throwing hoverboards, unbearable land temperatures and corporate dystopian exemplars around like they were going out of fashion. We can’t of course say with any certainty whether the future is going to be marked by teenage hoverboard enthusiasts. But we do think that a path towards a radically different mental health world can be charted where there is a welcoming of the ‘human paradigm’6) into the care practices, spaces and settings of mental well-being. This must honour the capacity for human beings to deeply absorb, interpret and appropriately respond to the stories of others. Where an embodied moral practice, grounded in material and cultural circumstances, personal histories, and relationships, edges out the technologies and rationalist knowledge focus as the authoritative paradigm.6 This means we need to focus on what is actually done in practice and to remember that the practicalities of actually doing distress work and receiving support in everyday contexts need to be made visible and nurtured.8 This is what we have tried to do in this book.