I'm still happy to meet and talk to anyone about any aspect of mental health, but it has to be in a public place and not a mental health facility (as has been my 'policy' for 18 months now). However, due to caring responsibilities (and also to fit-in with my usual flaneuring activities), 'cafe conferences' and 'street therapy' now have a more or less fixed timetable - Monday, Totnes; Wednesday, Newton Abbot; Friday, Torquay; Saturday, Exeter. Tuesday/ Thursday part-day, Teignmouth.
Usual contact arrangements, or just hit on me at one of my regular 'offices'.
Saturday, 3 December 2011
Saturday, 9 April 2011
'..the best is yet to come...'
It was my intention when I started this blog a little over a year ago to have said everything I wanted to say about mental health by now. Yet I still have a mountain of half-written material. And I must go on, what’s to come is my best work, and builds on the foundations of everything posted so far. I guess I still have about a year to go (assuming my other responsibilities stay the same) before I can leave here, cross to my other blog Hunter-gatherer - the past in us ( http://hunter-gathers.blogspot.com/ ) and begin on the subject that really drives me - evolutionary anthropology. So, I thought I’d just write a short piece about where all the previous posts are leading to.
What is still to come, is first The Recovery Movement (part three); the final article on the Recovery approach looking at two local attempts to put it into practice. That should be followed by my completing an essay (about 6000 words) on my last experience of being an inpatient in 2005, a period for which I have complete medical, nursing, ambulance and police records. It’s working title is I Know, Because I Was There - health records and personal recall, two versions of a ‘psychotic’ episode. Once completed it can then be reformatted into three or four (not too long) blog posts. Following that is another essay for which I’ve allowed my myself 6000 words, and called Challenging Expertise - my misadventures in mental health education; which charts and reflects upon my experience of being a service user in education, being a service user undertaking training in mental health work, and on how academia (at all levels) trains it’s workforce and researches it’s subject. Hopefully it too will convert to three or four reasonable sized posts. This should be rapidly followed by ‘the thesis that never was’, Ways Of Being With - rethinking expertise in mental health. This was the research project which was rejected by a local university and caused me not to complete my M.Sc in Mental Health. It will run to about 12,000 words (half that already) but, minus the stuff I’ve written about before, it should be dividable into six post-sized chunks. It explores the wealth of tacit knowledge involved with being with people in mental distress, then offers a radically different (compared with current practice that is) way of thinking and behaving when trying to be an effective helper. In fact if offers a lot of ancient heuristics which are being re-emphasised as a result of the findings of neuroscience. Then comes The Sound Of Water - on the possibility of an ecotherapy. This piece is a critical exploration of the idea that there can be an ecopsychology and by extension, ecotherapy. Though many practicing green care claim that it amounts to ecotherapy, very little has been written or researched about it. It will also include an application of the principles of Ways Of Being With. Again another four or so posts. Finally Natural Mental Health, a post which asserts that there is such a thing as normal, or better still natural, mental and physical fitness (you can’t really separate mind and body) and that there is excellence in living, which can and should be emulated. After all, imitation is, what is special about human learning.
Needless to say these six projects (amounting to about twenty more posts) have been progressing in parallel for sometime (they need to, if they’re all to fit together!) The final piece should, at one and the same time, become the first post on the new blog about pre-agricultural ‘forms of life’ - how we have spent 95% of our real history as hunter-gatherers, and how that legacy is still with us.
What is still to come, is first The Recovery Movement (part three); the final article on the Recovery approach looking at two local attempts to put it into practice. That should be followed by my completing an essay (about 6000 words) on my last experience of being an inpatient in 2005, a period for which I have complete medical, nursing, ambulance and police records. It’s working title is I Know, Because I Was There - health records and personal recall, two versions of a ‘psychotic’ episode. Once completed it can then be reformatted into three or four (not too long) blog posts. Following that is another essay for which I’ve allowed my myself 6000 words, and called Challenging Expertise - my misadventures in mental health education; which charts and reflects upon my experience of being a service user in education, being a service user undertaking training in mental health work, and on how academia (at all levels) trains it’s workforce and researches it’s subject. Hopefully it too will convert to three or four reasonable sized posts. This should be rapidly followed by ‘the thesis that never was’, Ways Of Being With - rethinking expertise in mental health. This was the research project which was rejected by a local university and caused me not to complete my M.Sc in Mental Health. It will run to about 12,000 words (half that already) but, minus the stuff I’ve written about before, it should be dividable into six post-sized chunks. It explores the wealth of tacit knowledge involved with being with people in mental distress, then offers a radically different (compared with current practice that is) way of thinking and behaving when trying to be an effective helper. In fact if offers a lot of ancient heuristics which are being re-emphasised as a result of the findings of neuroscience. Then comes The Sound Of Water - on the possibility of an ecotherapy. This piece is a critical exploration of the idea that there can be an ecopsychology and by extension, ecotherapy. Though many practicing green care claim that it amounts to ecotherapy, very little has been written or researched about it. It will also include an application of the principles of Ways Of Being With. Again another four or so posts. Finally Natural Mental Health, a post which asserts that there is such a thing as normal, or better still natural, mental and physical fitness (you can’t really separate mind and body) and that there is excellence in living, which can and should be emulated. After all, imitation is, what is special about human learning.
Needless to say these six projects (amounting to about twenty more posts) have been progressing in parallel for sometime (they need to, if they’re all to fit together!) The final piece should, at one and the same time, become the first post on the new blog about pre-agricultural ‘forms of life’ - how we have spent 95% of our real history as hunter-gatherers, and how that legacy is still with us.
Saturday, 20 November 2010
Universal emotional expression
Anyone familiar with the television drama Lie to me, now in it’s third session on FOX/ Sky, will know something of the work of Paul Ekman, upon who’s research it is based. Ekman has given his support to the programme, but maintains a blog on the FOX website to point out where and when he sees fiction portrayed as fact (http://community.fox.com/drpaulekman/blog/). Lie to me draws mainly on Ekman’s work on micro facial expressions and their connection with deception - emotional expressions which show for about one fifth of a second before a person can consciously try to disguise them. But it is Ekman’s work on facial expressions as a whole, and their role in expressing universal emotions (as well as individual variations) which concerns me here.
It may come as a surprise to some that there are universal emotions and that they are overwhelmingly displayed on the face, of everyone - supported to varying degrees by tone of voice, and some body movement. It may be even more surprising to learn that Ekman and his colleagues mapped the human face (43 muscles, up to 10,000 possible expressions, about a third of which are expressed emotions) and demonstrated the way emotions are transmitted through interaction, including the universals, over 30 years ago! (FACs - Facial Action Coding System 1978) A heaven sent gift you might think for mental health professionals, but how many have ever been taught them? (The CD-Rom for micro-expressions alone has been learnt by many in just one hour). Indeed one might well think that such ignorance of science by psychiatry is positively negligent, yet as Ekman has explained, it even took the Department of Psychiatry which employed him 20 years to put his research on the medical curriculum! Such things only serve to fuel one’s contempt for the world of mental health. This was one of the issues he reflected upon in an hour-long interview for the University of California at Berkeley - available on You Tube via the UC channel (http://www.youtube.com/watch?v=IA8nYZg4VnI)
Another, was how during the process of mapping the face and identifying muscles, many hours were required in front of a hand mirror. A consequence of which was the disturbing realisation of just how easily the repeated making of an emotional facial expression can cue the persistence of that emotion, how it induced a change in mood, whether it be fear or sadness.
I stumbled upon Ekman’s work about 3 years ago quite by chance, no one ever directed me to it. I found the easiest way to digest it was through two books Unmasking The Face, and Emotions Revealed. Much of it was a shock, I simply hadn’t learnt unconsciously as a child what faces show - not unrelated I’ve come to realise, to the fact that I later spent 20 years as a client of mental health services. However, for a fast introduction, go to Ekman’s website (http://www.paulekman.com/).
Darwin said it first, of course! He identified six universal expressions of emotion and implied that it is in the act of making the expression, in response to another human, that the emotion is felt. Ekman set-out to prove it and in the process added contempt. At the outset of Ekman’s career the ‘blank slate’ or ‘culturally relative’ view of almost all human behaviour held sway. What Ekman has demonstrated is that what is personal, is specific to the context an individual finds themselves in, and is always a variation built upon the structure of universal emotional expression. What remains up for debate is the extent to which emotion can be said to be made in the moment that you physically feel the shape of your face change, how much felt emotion is cued by others, how much effective communication depends on correctly learning what you are feeling, being able to communicate it to others, and make a correct interpretation of what others are showing you. Put another way, the windows through which we can understand another’s mental distress, the extent to which we can be said to ‘have empathy’ (feel what others feel) are; the facial expressions of emotion, the tone of voice, plus some supporting cues found in the gestures which support them. But when it comes to meaning, to what a particular emotion refers to, then gestures display their principal role - and that is to support language. Nonetheless, the work of people like Paul Ekman demonstrates that non-verbal behaviour and so called ‘inter-personal skills’ should really be the spine of any training in mental health, upon which all else can be hung. The pre-occupation with non-action, with non-physical cognitive skills - is just so much talk.
The first time I tested myself for recognition of emotions I scored just four out of the seven universals, let alone anything else! How many other clients like me need a program of active learning. After the anger, it occurred to me that the lack of emotional expression amongst many in mental distress may not be so much about shutting down, blocking-out, hiding or lacking emotion but simply a failure at recognition of emotion! In fact I’m more than contemptuous of some services I’m disgusted.
Thursday, 18 November 2010
The Recovery Movement (part two)
This is the second of three posts on the Recovery movement (part 1 - 17th January) and offers a brief history of what I’ve come to regard as a social movement - an attempt to introduce a particular set of moral, ethical and political values into the behaviour of those in the world of mental health. Here I look at the nature of the Recovery approach itself, whilst the third part will deal with it’s impact on the day to day practice of individuals and organisations. For those entirely unfamiliar with Recovery please read part one and follow the links.
As far as I am aware, I am the only person locally, who having been a recipient or ‘product’ of Recovery-focused care, has then gone on to become a critic. Bemused workers and managers have responded to my observations almost as if they were acts of disloyalty - since my mental health obviously improved over that period. My contention, as hopefully the content of this blog has begun to show, is that it was factors other than those identified by the Recovery approach which were of real importance in improving my life. Nonetheless I believe the Recovery movement is important, not least because it helps to stop some of the damage psychiatry and clinical psychology continue to do.
It needs to be asserted at the outset that the Recovery approach to date has not generated any new theory of human behaviour, understanding of mental distress, of emotions or unusual behaviour, nor has it advocated specific therapeutic interventions. It is principally about the better management and delivery of care, but in this area too, it does not challenge the legitimacy of any of the existing occupational groups within mental health. In essence the Recovery approach sets out to change the way mental health services are organised and delivered in order to be more responsive to the stated needs of clients and their supporters. A set of Recovery values has emerged that are intended to inform the personal conduct of workers in their interactions with clients.
However the way the Recovery approach is experienced or encountered by the worker, client or supporter is self-reported in highly individualistic ways, only later do some appreciate the sources of their new insights or beliefs. Many talk about a journey of recovery, and of who or what placed them on that journey (see the recovery stories at http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf ) in a way that is reminiscent of many narrative approaches throughout history, particularly the notion of spiritual or religious pilgrimage - albeit with a very secular favour - as if it were a novel and unique experience. But it was never that way for me. My growing ‘wellness’ made me increasingly an outsider looking-in on the Recovery movement, which seemed to be socially constructed by people talking a language of networking.
As yet there is only a very modest evidence base for Recovery-focused care and little that could be claimed as evidence based practice. But there are many ‘interested parties’, committed to Recovery values, who are only too anxious to create an evidence base. Equally there appears to be no systematic critique of Recovery other than the reassertion of more traditional approaches - extraordinary given how pervasive the ideas have become. It is also remarkable given the context of the highly contested nature of knowledge in mental health; within and between the disciplines of psychiatry, clinical psychology, nursing and now Recovery, between competing theories of learning, and the contrasting perceptions of the providers and users of services.
With the exception of the current UK REFOCUS research project ( http://www.iop.kcl.ac.uk/departments/?locator=1073 ) almost all investigations globally have been service evaluations, and almost exclusively quantitative. A recent local example being Alison Moores Report Of The Standards And Outcomes Pilot Project 2008/9 ( http://www.communitycaretrust.org/attachments/File/Standardsandoutcomes2008-9FINAL.pdf ). Qualitative data has been overwhelmingly restricted to collections of users’ writing. The involvement of service users as ‘researchers’ in such quantitative service evaluations is a sensitive and problematic issue in the UK and America. It remains to be seen how much influence they can assert over the current REFOCUS project.
The concept of Recovery may yet turn out to be an example of reification, but nonetheless many people do act ‘in the name of’ Recovery and in that sense it is having a very real impact on everybody’s ‘outcomes’.
Exceptional Clients and Disaffected Workers
The concept which became known as Recovery (in mental health) has its origins amongst a small number of individual consumers (users) in the US in the late 1980’s and early 90’s. Contrary to the folklore of Recovery they appear not to have rejected the medical or disease model itself, but the pessimistic prognosis offered by psychiatry. What they refused was the ‘sick role’ and the notion that they need be ‘disabled’ by mental illness. The client might continue to live with mental distress but it need not limit their ‘life chances’ or opportunities to fulfil goals or wishes. A few exceptional clients emerged who were able to wear as a ‘badge of honour’ both their ‘lived experience’ as well as their educational and work achievements. Readers may care to ‘google’ the following exceptional clients from the US - Patricia Deegan, Priscilla Ridgeway, Shery Mead and Mary Ellen Copeland. Deegan asserted in 1988 that:
‘Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. ..At times our course is erratic and we falter, slide back, regroup and start again. ..the aspiration is to live, work, and love in a community in which one makes a significant contribution’.
Even now, well over 20 years since it’s emergence there is only the broadest of agreed definitions of what Recovery is, allowing for a wide interpretation - and many welcome that. Ironically some also insist that Recovery is, what the individual decides it is. Last year Mike Slade, in the UK’s first textbook on the approach, Personal Recovery And Mental Illness ( http://www.amazon.co.uk/Personal-Recovery-Mental-Illness-Professionals/dp/0521746582/ref=sr_1_1?ie=UTF8&qid=1290062155&sr=1-1 ) selected the following quote from William Anthony in 1993 to serve as a working definition.
‘…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/ or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’.
Unlike the anti-psychiatry movement of the late 1950’s and 60’s however, which offered new theory and practice (though now largely rejected) and the user/ survivor groups of the 1970’s and 80’s, who in their complaining and campaigning focussed on rights and entitlements - Recovery approaches were, and remain highly individualistic. Not only is it assumed, in a moral or political sense, that individuals should be able to determine their own futures, but also in terms of theory - individual determinism is taken for granted, as opposed to more social forms of learning and agency. Part of the approach is for workers to be extremely client-centred with a clear moral imperative to take what clients say at face value. This is one of the senses in which the Recovery movement is best understood as a reaction against previous forms of care, rather than a positive assertion of new insights into mental distress. It emerged in the historical context of public perceptions of what constitutes abuse becoming much wider, and in parallel with a growing sensitivity of government and academia to the use of discriminatory and gender-based language, commonly referred to as ‘political correctness’.
Individual charismatic clients were joined by mental health workers who had gravitated towards community services, having become disaffected by the rigidity of the formal mental health system. The Recovery movement spread outwards from the USA to New Zealand (google Frank Bristol, Mary O’Hagan) and the UK (Ron Coleman). By the turn of the millennium, Recovery approaches were beginning to be considered for inclusion in the formal structures of health care in most western countries.
Recovery Values
From my observations of how the values and ethos of the Recovery approach have been embodied in practice, three underlying themes have emerged, and although their meaning is not made explicit or self-evident in the discourse of workers, they seem increasingly to be taken for granted in their actions. There is of course also a contrast between policy documents (again follow the links in part one) and practice. These are social processes, of working through different ways of being with clients.
What is explicit is the language of Recovery. In the UK, ‘hope’, ‘opportunities’ and ‘social inclusion’ seem to be the emerging concepts around which the Recovery dialogue is structuring itself - indeed advocates are often quite prescriptive about individual choice and freedom of action! From the general conversation of workers I would add; 'active listening’, ‘lived experience’, ‘empowerment’, ‘self-management’, ‘personal journey’, ‘goals’, ‘control’, ‘coaching’, ‘personal story’, ‘choice’ and ‘peer support’ as key words. But the underlying processes I observe are as follows:
Having a future orientation - (hope, goals, opportunities) the promise that tomorrow will be better than today and of acceptance, sometime in the unknowable future, by a society which has rejected them. Yet alarmingly workers often appear not to realise mental distress is only experienced in the present moment and must therefore be confronted today. Hopes and expectations need to be matched to the current situation and current capabilities, otherwise the expectations of others, come to be seen as further evidence of failure. Equally motivation can only come from others, and persists only as long as the client feels some emotional attachment to that person.
The pursuit of individualism - (self-management, personal journey, lived experience, choice, goals, peer support, social inclusion) an essentially anti-social bias; seeking equality in individual rights, entitlements and personal decision making and the formalising of relationships with peers. Clients are urged to set their own goals and needs and take responsibility - if they fail they appear to have ‘chosen’ and relieve others of responsibility. Wellbeing is judged not on the actual outcome of client’s activities, but the story or narrative they tell themselves. Individual merit and skill may be recognised but it is not given value or rewarded, everyone is made an expert to maintain an illusion of equally. Even those exceptional clients and workers who provide charismatic leadership - deny it! The social nature of learning goes unrecognised. Some claim Recovery is about social relationships, but when positive emotional attachments form between workers, clients and carers it is often seen as dependency and a failure to move on.
The illusion of a ‘self’ in control - (control, choice, empowerment, lived experience, self-management) it is one thing to argue that the client should take control back from mental health services and be in control, but this is what clients have always tried to do and been knocked-back by the reality of their situation - by evidence of not being in control. It is the ability to live with doubt, uncertainty, and not being in control, and be able to respond in a flexible way to change, that is mental health.
In short, Recovery values are the embodiment of our commonsense understandings about the place of individuals in modern western societies. They reflect the ideology of liberal democracies built upon a capitalistic economy. In so far as Recovery can be said to have intellectual antecedents then they lie in American humanistic psychology from the 1940’s and 50’s. Indeed at various times Recovery has made an uncritical use of Maslow’s ‘hierarchy of needs’! What the Recovery movement offers is highly conventional, but is offered to the one client group who are most psychologically and emotional alienated from society, the most aware of the difference between ideological valves and practical realities. The characteristics of the client continue to be seen, not as a reflection of modern society’s inability to genuinely accept difference, but of their failure to live within it. We are offered time and support to become more sophisticated conformists.
The clients I speak to every day do not speak the language of Recovery; if the subject is our own mental distress (and most often it isn’t) then we speak of the reality of the present moment and the inadequacies (or occasional virtues) of mental health services. We are suspicious of anything not grounded in the practicalities of everyday life. Workers in their stated attitudes often appear ignorant of our limited life choices. Workers wish to give hope, but do so in a situation where they get little back from the client. Equally they are anxious not to undermine the fragile confidence of the client. Yet in reality, as low paid, low status workers, they must be only too well aware of the limited opportunities of the client. As the number of workers with varying degrees of lived experience increases then the gap between potential life chances (as demonstrated by exceptional clients) and the reality of limited opportunities for most, can only become more visible.
A useful way of making sense of the activity of the Recovery movement is to see it as an example of ‘ideological work’. The late sociologist Bennett Berger ( http://www.amazon.co.uk/Survival-Counterculture-Ideological-Everyday-Communards/dp/0765808056/ref=sr_1_1?s=books&ie=UTF8&qid=1290063625&sr=1-1 ) introduced the concept - for him it was both his object of study and his method. Like myself he was initially personally involved with, and committed to, the subjects of his research, and like them wanting to provoke social change. He was interested in the tension between peoples ideals and the reality of their material existence. How the publicly stated goals of individuals or groups, realised themselves in actual behaviour. But he was also acutely aware of such a tension within himself; between his personal beliefs about the world, and what the results of his research told him. He argued that much of culture was becoming increasingly ideological, but that such symbolic structures were rarely translated into social structures. He studied people with ‘green’ values who wished to pursue a self-sufficient and communal lifestyle, but were confronted by the practical realities of agricultural labour and subsistence farming. He wanted to study the inevitable gap between what they professed and the way they behaved as they adapted to the changing circumstances of their lives.
‘…when groups are caught in contradictions between the ideas they profess to believe in and their day-to-day behavior, is their hurried ideological repair work best understood in an ironic, contemptuous, and cynical manner?’
In part three I consider how ideals have been turned into action in the Recovery movement.
As far as I am aware, I am the only person locally, who having been a recipient or ‘product’ of Recovery-focused care, has then gone on to become a critic. Bemused workers and managers have responded to my observations almost as if they were acts of disloyalty - since my mental health obviously improved over that period. My contention, as hopefully the content of this blog has begun to show, is that it was factors other than those identified by the Recovery approach which were of real importance in improving my life. Nonetheless I believe the Recovery movement is important, not least because it helps to stop some of the damage psychiatry and clinical psychology continue to do.
It needs to be asserted at the outset that the Recovery approach to date has not generated any new theory of human behaviour, understanding of mental distress, of emotions or unusual behaviour, nor has it advocated specific therapeutic interventions. It is principally about the better management and delivery of care, but in this area too, it does not challenge the legitimacy of any of the existing occupational groups within mental health. In essence the Recovery approach sets out to change the way mental health services are organised and delivered in order to be more responsive to the stated needs of clients and their supporters. A set of Recovery values has emerged that are intended to inform the personal conduct of workers in their interactions with clients.
However the way the Recovery approach is experienced or encountered by the worker, client or supporter is self-reported in highly individualistic ways, only later do some appreciate the sources of their new insights or beliefs. Many talk about a journey of recovery, and of who or what placed them on that journey (see the recovery stories at http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf ) in a way that is reminiscent of many narrative approaches throughout history, particularly the notion of spiritual or religious pilgrimage - albeit with a very secular favour - as if it were a novel and unique experience. But it was never that way for me. My growing ‘wellness’ made me increasingly an outsider looking-in on the Recovery movement, which seemed to be socially constructed by people talking a language of networking.
As yet there is only a very modest evidence base for Recovery-focused care and little that could be claimed as evidence based practice. But there are many ‘interested parties’, committed to Recovery values, who are only too anxious to create an evidence base. Equally there appears to be no systematic critique of Recovery other than the reassertion of more traditional approaches - extraordinary given how pervasive the ideas have become. It is also remarkable given the context of the highly contested nature of knowledge in mental health; within and between the disciplines of psychiatry, clinical psychology, nursing and now Recovery, between competing theories of learning, and the contrasting perceptions of the providers and users of services.
With the exception of the current UK REFOCUS research project ( http://www.iop.kcl.ac.uk/departments/?locator=1073 ) almost all investigations globally have been service evaluations, and almost exclusively quantitative. A recent local example being Alison Moores Report Of The Standards And Outcomes Pilot Project 2008/9 ( http://www.communitycaretrust.org/attachments/File/Standardsandoutcomes2008-9FINAL.pdf ). Qualitative data has been overwhelmingly restricted to collections of users’ writing. The involvement of service users as ‘researchers’ in such quantitative service evaluations is a sensitive and problematic issue in the UK and America. It remains to be seen how much influence they can assert over the current REFOCUS project.
The concept of Recovery may yet turn out to be an example of reification, but nonetheless many people do act ‘in the name of’ Recovery and in that sense it is having a very real impact on everybody’s ‘outcomes’.
Exceptional Clients and Disaffected Workers
The concept which became known as Recovery (in mental health) has its origins amongst a small number of individual consumers (users) in the US in the late 1980’s and early 90’s. Contrary to the folklore of Recovery they appear not to have rejected the medical or disease model itself, but the pessimistic prognosis offered by psychiatry. What they refused was the ‘sick role’ and the notion that they need be ‘disabled’ by mental illness. The client might continue to live with mental distress but it need not limit their ‘life chances’ or opportunities to fulfil goals or wishes. A few exceptional clients emerged who were able to wear as a ‘badge of honour’ both their ‘lived experience’ as well as their educational and work achievements. Readers may care to ‘google’ the following exceptional clients from the US - Patricia Deegan, Priscilla Ridgeway, Shery Mead and Mary Ellen Copeland. Deegan asserted in 1988 that:
‘Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. ..At times our course is erratic and we falter, slide back, regroup and start again. ..the aspiration is to live, work, and love in a community in which one makes a significant contribution’.
Even now, well over 20 years since it’s emergence there is only the broadest of agreed definitions of what Recovery is, allowing for a wide interpretation - and many welcome that. Ironically some also insist that Recovery is, what the individual decides it is. Last year Mike Slade, in the UK’s first textbook on the approach, Personal Recovery And Mental Illness ( http://www.amazon.co.uk/Personal-Recovery-Mental-Illness-Professionals/dp/0521746582/ref=sr_1_1?ie=UTF8&qid=1290062155&sr=1-1 ) selected the following quote from William Anthony in 1993 to serve as a working definition.
‘…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/ or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’.
Unlike the anti-psychiatry movement of the late 1950’s and 60’s however, which offered new theory and practice (though now largely rejected) and the user/ survivor groups of the 1970’s and 80’s, who in their complaining and campaigning focussed on rights and entitlements - Recovery approaches were, and remain highly individualistic. Not only is it assumed, in a moral or political sense, that individuals should be able to determine their own futures, but also in terms of theory - individual determinism is taken for granted, as opposed to more social forms of learning and agency. Part of the approach is for workers to be extremely client-centred with a clear moral imperative to take what clients say at face value. This is one of the senses in which the Recovery movement is best understood as a reaction against previous forms of care, rather than a positive assertion of new insights into mental distress. It emerged in the historical context of public perceptions of what constitutes abuse becoming much wider, and in parallel with a growing sensitivity of government and academia to the use of discriminatory and gender-based language, commonly referred to as ‘political correctness’.
Individual charismatic clients were joined by mental health workers who had gravitated towards community services, having become disaffected by the rigidity of the formal mental health system. The Recovery movement spread outwards from the USA to New Zealand (google Frank Bristol, Mary O’Hagan) and the UK (Ron Coleman). By the turn of the millennium, Recovery approaches were beginning to be considered for inclusion in the formal structures of health care in most western countries.
Recovery Values
From my observations of how the values and ethos of the Recovery approach have been embodied in practice, three underlying themes have emerged, and although their meaning is not made explicit or self-evident in the discourse of workers, they seem increasingly to be taken for granted in their actions. There is of course also a contrast between policy documents (again follow the links in part one) and practice. These are social processes, of working through different ways of being with clients.
What is explicit is the language of Recovery. In the UK, ‘hope’, ‘opportunities’ and ‘social inclusion’ seem to be the emerging concepts around which the Recovery dialogue is structuring itself - indeed advocates are often quite prescriptive about individual choice and freedom of action! From the general conversation of workers I would add; 'active listening’, ‘lived experience’, ‘empowerment’, ‘self-management’, ‘personal journey’, ‘goals’, ‘control’, ‘coaching’, ‘personal story’, ‘choice’ and ‘peer support’ as key words. But the underlying processes I observe are as follows:
Having a future orientation - (hope, goals, opportunities) the promise that tomorrow will be better than today and of acceptance, sometime in the unknowable future, by a society which has rejected them. Yet alarmingly workers often appear not to realise mental distress is only experienced in the present moment and must therefore be confronted today. Hopes and expectations need to be matched to the current situation and current capabilities, otherwise the expectations of others, come to be seen as further evidence of failure. Equally motivation can only come from others, and persists only as long as the client feels some emotional attachment to that person.
The pursuit of individualism - (self-management, personal journey, lived experience, choice, goals, peer support, social inclusion) an essentially anti-social bias; seeking equality in individual rights, entitlements and personal decision making and the formalising of relationships with peers. Clients are urged to set their own goals and needs and take responsibility - if they fail they appear to have ‘chosen’ and relieve others of responsibility. Wellbeing is judged not on the actual outcome of client’s activities, but the story or narrative they tell themselves. Individual merit and skill may be recognised but it is not given value or rewarded, everyone is made an expert to maintain an illusion of equally. Even those exceptional clients and workers who provide charismatic leadership - deny it! The social nature of learning goes unrecognised. Some claim Recovery is about social relationships, but when positive emotional attachments form between workers, clients and carers it is often seen as dependency and a failure to move on.
The illusion of a ‘self’ in control - (control, choice, empowerment, lived experience, self-management) it is one thing to argue that the client should take control back from mental health services and be in control, but this is what clients have always tried to do and been knocked-back by the reality of their situation - by evidence of not being in control. It is the ability to live with doubt, uncertainty, and not being in control, and be able to respond in a flexible way to change, that is mental health.
In short, Recovery values are the embodiment of our commonsense understandings about the place of individuals in modern western societies. They reflect the ideology of liberal democracies built upon a capitalistic economy. In so far as Recovery can be said to have intellectual antecedents then they lie in American humanistic psychology from the 1940’s and 50’s. Indeed at various times Recovery has made an uncritical use of Maslow’s ‘hierarchy of needs’! What the Recovery movement offers is highly conventional, but is offered to the one client group who are most psychologically and emotional alienated from society, the most aware of the difference between ideological valves and practical realities. The characteristics of the client continue to be seen, not as a reflection of modern society’s inability to genuinely accept difference, but of their failure to live within it. We are offered time and support to become more sophisticated conformists.
The clients I speak to every day do not speak the language of Recovery; if the subject is our own mental distress (and most often it isn’t) then we speak of the reality of the present moment and the inadequacies (or occasional virtues) of mental health services. We are suspicious of anything not grounded in the practicalities of everyday life. Workers in their stated attitudes often appear ignorant of our limited life choices. Workers wish to give hope, but do so in a situation where they get little back from the client. Equally they are anxious not to undermine the fragile confidence of the client. Yet in reality, as low paid, low status workers, they must be only too well aware of the limited opportunities of the client. As the number of workers with varying degrees of lived experience increases then the gap between potential life chances (as demonstrated by exceptional clients) and the reality of limited opportunities for most, can only become more visible.
A useful way of making sense of the activity of the Recovery movement is to see it as an example of ‘ideological work’. The late sociologist Bennett Berger ( http://www.amazon.co.uk/Survival-Counterculture-Ideological-Everyday-Communards/dp/0765808056/ref=sr_1_1?s=books&ie=UTF8&qid=1290063625&sr=1-1 ) introduced the concept - for him it was both his object of study and his method. Like myself he was initially personally involved with, and committed to, the subjects of his research, and like them wanting to provoke social change. He was interested in the tension between peoples ideals and the reality of their material existence. How the publicly stated goals of individuals or groups, realised themselves in actual behaviour. But he was also acutely aware of such a tension within himself; between his personal beliefs about the world, and what the results of his research told him. He argued that much of culture was becoming increasingly ideological, but that such symbolic structures were rarely translated into social structures. He studied people with ‘green’ values who wished to pursue a self-sufficient and communal lifestyle, but were confronted by the practical realities of agricultural labour and subsistence farming. He wanted to study the inevitable gap between what they professed and the way they behaved as they adapted to the changing circumstances of their lives.
‘…when groups are caught in contradictions between the ideas they profess to believe in and their day-to-day behavior, is their hurried ideological repair work best understood in an ironic, contemptuous, and cynical manner?’
In part three I consider how ideals have been turned into action in the Recovery movement.
Thursday, 11 November 2010
Mental health services - the future
The future is unknowable, but hopefully this one-off excursion into ‘futurology’ will be of use in raising awareness and informed debate.
All the issues raised here have already been discussed on the web, but many in the world of mental health appear to have either little knowledge of them, or only just begun to consider them. Reaction within ‘health and social care’ to the coalition government has been almost exclusively negative, focusing on budget cuts and the idea of services being taken away. The development of Conservative social policy over the last five years, has been largely ignored.
The most worrying aspect however is watching workers simply waiting to be told what to do by managers from failing providers and commissioners (who’s current role will soon cease to exist) little realising that the new government want them to take the initiative at local level, and transform their own work in a more autonomous way. There will be a Conservative led, or majority government for the foreseeable future, so time and money spent resisting reform, or endorsing the efforts of others to do so, is wasted and a disservice to clients.
The ‘new’ Conservatives do have a considered mental health policy developed over many years - explore The Centre For Social Justice ( http://www.centreforsocialjustice.org.uk/default.asp?pageRef=418 ). They do not ‘cut’ for the sake of cutting or just to reduce public borrowing. As a result there are new directions which any mental health organisation can take which will receive encouragement and support from reformers in national and local government. For a fast introduction see David Cameron’s 20 minute presentation at TED last February ( http://www.ted.com/talks/lang/eng/david_cameron.html ) and this article for The Observer from April ( http://www.guardian.co.uk/commentisfree/2010/apr/18/david-cameron-my-big-society ).
There are a few simple principles behind new Conservative thinking, which though often confused with Thatcherism actually come from an older tradition, and provide a certain logic to forthcoming policy:
a) You impose as little as possible on people’s freedom to act, minimising legislation and the bureaucracy it creates.
b) Governments do not seek to lead change in society, but enable individuals, communities and business enterprises in their chosen pursuits. There are no inherent, or permanent, ‘rights’ or ‘entitlements’ which people have, and which it is a government’s duty to bestow or uphold - rather it is expected that individuals and groups will lobby, vote and negotiate in their own interests to change the law to fit current social needs.
c) Governments tax and spend as little as possible, leaving the maximum amount of wealth and resources for people to use as they please.
d) You encourage anything that will sustain family and existing communities and devolve decision making to the lowest level possible.
e) Work (purposeful, productive or contributory activity) is undertaken on behalf of families and the community and is the principal way in which people maintain their self-esteem, achieve status and reward. It ought to lead to a fair exchange of labour, goods, services and education such that the costs and rewards match the real demand within a community - rather than being dictated by government.
f) You don’t reward failure, or reward people for doing the wrong thing (so in 2008 it was wrong to bail-out the banks, but right to guarantee personal savings). Equally risk (and a willingness to fail) is accepted as an inherent part of creating both wellbeing as well as wealth. Therefore seeking to regulate for most risks is folly, leading to a false sense of security, greater vulnerability and a less flexible response when the unexpected happens.
Social enterprise and social entrepreneurship
The idea of shared ownership amongst the workers and users of a business plus the principal of not taking profits out of an organisation has been around for a long time and taken many forms. The new Conservatives enthusiasm for social enterprises to take over services previously provided by national or local authorities is not so much ideological, since ‘public service‘ has always been part of their ethic, rather a result of it becoming lost in public bodies through the seemingly unstoppable process of bureaucratisation. Public organisations which set out with equality in mind, have ended-up offering a hugely inefficient and impersonal service, and often the people working within such organisations don’t realise how rule-governed, inflexible and risk-averse they have become. For an explanation of what is meant by social enterprise and social entrepreneurship see the website of Oxford University’s Skoll Centre for Social Entrepreneurship ( http://www.sbs.ox.ac.uk/centres/skoll/Pages/default.aspx ).
The new Conservatives don’t seek to impose how much health and social care is provided - that’s a matter for individuals, families and communities to decide. Nor indeed how it is financed, what mix of public and private, as long as it is responsive to public demand, and the public get value for money. What is paramount is an equitable relationship between provider and consumer. Therefore any form of business organisation may provide the best service in a particular location if it is responsive to local needs.
The idea that general practitioners should oversee the commissioning of health services in their locality arises solely from the observation that they are in the best position to assess need. It is a re-assertion of the idea of a family practitioner and an acknowledgement that a GP already acts as a ‘gatekeeper’ to services. Even today the most important decision affecting the outcome for a person in mental distress is probably their choice of G.P. Mental health professionals often assert that the average GP knows very little about mental health. Well - yes and no. A GP knows that many of their patients present with psychological problems, and they know about the psychology involved in the doctor-patient relationship. What they know little of is how mental health services are organised and what they actually do. What little they have seen, usually some parts of NHS mental health trusts, they don’t much care for - they know services rarely deliver because their patients tell them so. More worrying still, they know they’re boxed-in - forced to refer to services they have little confidence in because they know their patients have problems that go beyond their own level of expertise to treat. And herein lies the greatest opportunity for mental health organisations that are willing, and flexible enough, to go with the government rather than against it.
Mental health organisations
Despite being over-worked general practitioners do want to influence commissioning in their local area, they know of local needs but lack quality information about alternative providers.
(The principal purpose of making available government and local authority information and statistics, is to give anyone the opportunity to bid for contracts to provide public services).
Voluntary and ‘third sector’ providers, given that they tend to be smaller, more community based, flexible, efficient and the first to try-out more innovative practice, may well be better placed to form direct relationships with general practitioners and later the commissioning consortia they oversee, than the existing statutory providers. However a third sector organisation needs to pause and think twice about it’s existing collaborative practices in what will become a more competitive environment; existing open sharing of information and expertise, the informal ‘hands-off’ agreements based on geographical areas, deferring to the presumed expertise of statutory NHS mental health trusts etc. Smaller providers have often taken on trust the information and priorities handed down by commissioners. However there is already the opportunity for more equitable relationships given the amount of existing information and data placed on the web - but often their lack connectivity, coupled with an attitude of not needing to know, means they just don’t know they don’t know.
The larger statutory organisations have repeatedly shown over the last twenty-five years their lack of ability to reform themselves. The managerial bureaucracy cannot imagine that much of what they do is unnecessary. Eventually the only option is to cut-off the money. However, one common strategy of NHS managers to avoid reforming themselves is to ‘mothball’ one service in order to introduce another, with the consequence that the only increase in actually activity is amongst themselves. For the observant client the hypocrisy is staggering, for mental health professionals will daily be encouraging them to take more risks, be pro-active, and drop the routines and habits that have failed them!
The answer being proposed is in essence to personalise the process, whereby the person taking a decision at any level (in smaller, more local and devolved organisations), is placed in direct face-to-face contact with the people affected by their decisions - where the consumer has access to the same information as the provider. To be personally connected to an outcome. This also implies a radical change in the concept of expertise - which will be the subject of future posts on this blog.
A relatively good example of a current third sector provider, with which I was personally connected as a client, is the Community Care Trust ( http://www.community-care-trust.co.uk/ ) Although still unknown to many local general practitioners, it has a track record of reforming itself towards a recovery-focused approach, of being cheaper and smaller (more efficient) than it’s competitors, of understanding social networks (though it lacks knowledge of just how the web can facilitate this), and of introducing more flexible working practices that respond more to an individual client’s needs. It’s major weakness however is the lack of up-to-date IT skills and personal connectivity amongst most staff, plus a few who remain habituated to deferring to traditional expertise in mental health.
Mental health clients and carers
There is a common myth that most mental health clients don’t use the Internet, that they would be at a major disadvantage if they did because many lack conventional ‘functional skills’ (numeracy, literacy and IT) and besides they’re ‘vulnerable’ when online. This of course just tells us about the ignorance of mental professionals and the eagerness of conventional educationalists to make work. I’ll just note in passing that there is no reason why the technology which produces World of Warcraft cannot teach mentally healthy skills - fast! See Pandora’s twitter list for a sample of (200+) global mental health service users online ( http://twitter.com/serialinsomniac/mentalists ).
Public reaction amongst UK users of mental health services to the new government has been largely one of fear, panic, anger and outrage at the perceived desire of the coalition to take away financial benefits and services they believe they have an inherent right or entitlement to based upon a diagnosis of mental illness for which they believe there is limited treatment and from which they are likely to suffer for the rest of their lives. They believe themselves to be amongst the most vulnerable in society and that government has a permanent and comprehensive duty of care towards them. But they also believe that their disability should not prevent them from fully participating in society and that any government has a duty to facilitate this.
One objective of those who think in a new Conservative way is to reconnect the users and beneficiaries of public services with the people in society who’s productive work has paid for them. Many clients and carers do not seem to make the connection that other people's tax payments, combined with loans secured with that tax revenue, has in relatively recent history, allowed for the benefit payments, services and housing they consider to be their’s by right. Some younger clients seem to believe that a government has a free hand to provide or take away a public service, or indeed the power to create a prosperous economy. Equally, the protests of clients and carers in recent months appear to take no account of the fact that the entire population is facing cutbacks.
The new Conservatives believe the mentally ill need not be permanently dis-abled and dependant - that it’s financial support should be an incentive to be more independent from the state, more in the community. For them the tragedy of de-institutionalisation has been that unconditional financial benefits, better services and social housing have had an unintended disabling effect, a deskilling of social skills, leaving individuals isolated ‘in the community’. Their ‘model’ of provision comes from observation of people with physical disabilities, whose work prospectus and integration into the social life of the community has proved greater over the past 30 years than that of people with mental health problems. They have no problem with paying DLA for transport and to provide support at home to someone who is already doing some form of contributory work, paid or not, for just a few hours or full-time - which will boost the moral of a client, their acceptance by others, and be a public demonstration of a willingness to contribute to the wellbeing of all.
All of the above is of course my attempt to get inside the ‘mindset’ of new Conservative thinking. My own political views, as someone who has been permanently ‘on the sick’ for sixteen years and was a client of mental health services for twenty years, I’ll leave for another time.
All the issues raised here have already been discussed on the web, but many in the world of mental health appear to have either little knowledge of them, or only just begun to consider them. Reaction within ‘health and social care’ to the coalition government has been almost exclusively negative, focusing on budget cuts and the idea of services being taken away. The development of Conservative social policy over the last five years, has been largely ignored.
The most worrying aspect however is watching workers simply waiting to be told what to do by managers from failing providers and commissioners (who’s current role will soon cease to exist) little realising that the new government want them to take the initiative at local level, and transform their own work in a more autonomous way. There will be a Conservative led, or majority government for the foreseeable future, so time and money spent resisting reform, or endorsing the efforts of others to do so, is wasted and a disservice to clients.
The ‘new’ Conservatives do have a considered mental health policy developed over many years - explore The Centre For Social Justice ( http://www.centreforsocialjustice.org.uk/default.asp?pageRef=418 ). They do not ‘cut’ for the sake of cutting or just to reduce public borrowing. As a result there are new directions which any mental health organisation can take which will receive encouragement and support from reformers in national and local government. For a fast introduction see David Cameron’s 20 minute presentation at TED last February ( http://www.ted.com/talks/lang/eng/david_cameron.html ) and this article for The Observer from April ( http://www.guardian.co.uk/commentisfree/2010/apr/18/david-cameron-my-big-society ).
There are a few simple principles behind new Conservative thinking, which though often confused with Thatcherism actually come from an older tradition, and provide a certain logic to forthcoming policy:
a) You impose as little as possible on people’s freedom to act, minimising legislation and the bureaucracy it creates.
b) Governments do not seek to lead change in society, but enable individuals, communities and business enterprises in their chosen pursuits. There are no inherent, or permanent, ‘rights’ or ‘entitlements’ which people have, and which it is a government’s duty to bestow or uphold - rather it is expected that individuals and groups will lobby, vote and negotiate in their own interests to change the law to fit current social needs.
c) Governments tax and spend as little as possible, leaving the maximum amount of wealth and resources for people to use as they please.
d) You encourage anything that will sustain family and existing communities and devolve decision making to the lowest level possible.
e) Work (purposeful, productive or contributory activity) is undertaken on behalf of families and the community and is the principal way in which people maintain their self-esteem, achieve status and reward. It ought to lead to a fair exchange of labour, goods, services and education such that the costs and rewards match the real demand within a community - rather than being dictated by government.
f) You don’t reward failure, or reward people for doing the wrong thing (so in 2008 it was wrong to bail-out the banks, but right to guarantee personal savings). Equally risk (and a willingness to fail) is accepted as an inherent part of creating both wellbeing as well as wealth. Therefore seeking to regulate for most risks is folly, leading to a false sense of security, greater vulnerability and a less flexible response when the unexpected happens.
Social enterprise and social entrepreneurship
The idea of shared ownership amongst the workers and users of a business plus the principal of not taking profits out of an organisation has been around for a long time and taken many forms. The new Conservatives enthusiasm for social enterprises to take over services previously provided by national or local authorities is not so much ideological, since ‘public service‘ has always been part of their ethic, rather a result of it becoming lost in public bodies through the seemingly unstoppable process of bureaucratisation. Public organisations which set out with equality in mind, have ended-up offering a hugely inefficient and impersonal service, and often the people working within such organisations don’t realise how rule-governed, inflexible and risk-averse they have become. For an explanation of what is meant by social enterprise and social entrepreneurship see the website of Oxford University’s Skoll Centre for Social Entrepreneurship ( http://www.sbs.ox.ac.uk/centres/skoll/Pages/default.aspx ).
The new Conservatives don’t seek to impose how much health and social care is provided - that’s a matter for individuals, families and communities to decide. Nor indeed how it is financed, what mix of public and private, as long as it is responsive to public demand, and the public get value for money. What is paramount is an equitable relationship between provider and consumer. Therefore any form of business organisation may provide the best service in a particular location if it is responsive to local needs.
The idea that general practitioners should oversee the commissioning of health services in their locality arises solely from the observation that they are in the best position to assess need. It is a re-assertion of the idea of a family practitioner and an acknowledgement that a GP already acts as a ‘gatekeeper’ to services. Even today the most important decision affecting the outcome for a person in mental distress is probably their choice of G.P. Mental health professionals often assert that the average GP knows very little about mental health. Well - yes and no. A GP knows that many of their patients present with psychological problems, and they know about the psychology involved in the doctor-patient relationship. What they know little of is how mental health services are organised and what they actually do. What little they have seen, usually some parts of NHS mental health trusts, they don’t much care for - they know services rarely deliver because their patients tell them so. More worrying still, they know they’re boxed-in - forced to refer to services they have little confidence in because they know their patients have problems that go beyond their own level of expertise to treat. And herein lies the greatest opportunity for mental health organisations that are willing, and flexible enough, to go with the government rather than against it.
Mental health organisations
Despite being over-worked general practitioners do want to influence commissioning in their local area, they know of local needs but lack quality information about alternative providers.
(The principal purpose of making available government and local authority information and statistics, is to give anyone the opportunity to bid for contracts to provide public services).
Voluntary and ‘third sector’ providers, given that they tend to be smaller, more community based, flexible, efficient and the first to try-out more innovative practice, may well be better placed to form direct relationships with general practitioners and later the commissioning consortia they oversee, than the existing statutory providers. However a third sector organisation needs to pause and think twice about it’s existing collaborative practices in what will become a more competitive environment; existing open sharing of information and expertise, the informal ‘hands-off’ agreements based on geographical areas, deferring to the presumed expertise of statutory NHS mental health trusts etc. Smaller providers have often taken on trust the information and priorities handed down by commissioners. However there is already the opportunity for more equitable relationships given the amount of existing information and data placed on the web - but often their lack connectivity, coupled with an attitude of not needing to know, means they just don’t know they don’t know.
The larger statutory organisations have repeatedly shown over the last twenty-five years their lack of ability to reform themselves. The managerial bureaucracy cannot imagine that much of what they do is unnecessary. Eventually the only option is to cut-off the money. However, one common strategy of NHS managers to avoid reforming themselves is to ‘mothball’ one service in order to introduce another, with the consequence that the only increase in actually activity is amongst themselves. For the observant client the hypocrisy is staggering, for mental health professionals will daily be encouraging them to take more risks, be pro-active, and drop the routines and habits that have failed them!
The answer being proposed is in essence to personalise the process, whereby the person taking a decision at any level (in smaller, more local and devolved organisations), is placed in direct face-to-face contact with the people affected by their decisions - where the consumer has access to the same information as the provider. To be personally connected to an outcome. This also implies a radical change in the concept of expertise - which will be the subject of future posts on this blog.
A relatively good example of a current third sector provider, with which I was personally connected as a client, is the Community Care Trust ( http://www.community-care-trust.co.uk/ ) Although still unknown to many local general practitioners, it has a track record of reforming itself towards a recovery-focused approach, of being cheaper and smaller (more efficient) than it’s competitors, of understanding social networks (though it lacks knowledge of just how the web can facilitate this), and of introducing more flexible working practices that respond more to an individual client’s needs. It’s major weakness however is the lack of up-to-date IT skills and personal connectivity amongst most staff, plus a few who remain habituated to deferring to traditional expertise in mental health.
Mental health clients and carers
There is a common myth that most mental health clients don’t use the Internet, that they would be at a major disadvantage if they did because many lack conventional ‘functional skills’ (numeracy, literacy and IT) and besides they’re ‘vulnerable’ when online. This of course just tells us about the ignorance of mental professionals and the eagerness of conventional educationalists to make work. I’ll just note in passing that there is no reason why the technology which produces World of Warcraft cannot teach mentally healthy skills - fast! See Pandora’s twitter list for a sample of (200+) global mental health service users online ( http://twitter.com/serialinsomniac/mentalists ).
Public reaction amongst UK users of mental health services to the new government has been largely one of fear, panic, anger and outrage at the perceived desire of the coalition to take away financial benefits and services they believe they have an inherent right or entitlement to based upon a diagnosis of mental illness for which they believe there is limited treatment and from which they are likely to suffer for the rest of their lives. They believe themselves to be amongst the most vulnerable in society and that government has a permanent and comprehensive duty of care towards them. But they also believe that their disability should not prevent them from fully participating in society and that any government has a duty to facilitate this.
One objective of those who think in a new Conservative way is to reconnect the users and beneficiaries of public services with the people in society who’s productive work has paid for them. Many clients and carers do not seem to make the connection that other people's tax payments, combined with loans secured with that tax revenue, has in relatively recent history, allowed for the benefit payments, services and housing they consider to be their’s by right. Some younger clients seem to believe that a government has a free hand to provide or take away a public service, or indeed the power to create a prosperous economy. Equally, the protests of clients and carers in recent months appear to take no account of the fact that the entire population is facing cutbacks.
The new Conservatives believe the mentally ill need not be permanently dis-abled and dependant - that it’s financial support should be an incentive to be more independent from the state, more in the community. For them the tragedy of de-institutionalisation has been that unconditional financial benefits, better services and social housing have had an unintended disabling effect, a deskilling of social skills, leaving individuals isolated ‘in the community’. Their ‘model’ of provision comes from observation of people with physical disabilities, whose work prospectus and integration into the social life of the community has proved greater over the past 30 years than that of people with mental health problems. They have no problem with paying DLA for transport and to provide support at home to someone who is already doing some form of contributory work, paid or not, for just a few hours or full-time - which will boost the moral of a client, their acceptance by others, and be a public demonstration of a willingness to contribute to the wellbeing of all.
All of the above is of course my attempt to get inside the ‘mindset’ of new Conservative thinking. My own political views, as someone who has been permanently ‘on the sick’ for sixteen years and was a client of mental health services for twenty years, I’ll leave for another time.
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