Oe have made great strides in England in terms of acceptance and knowledge of mental health issues. But have our basic services also improved in tandem? We are told that clinical approaches to mental health are improving: that the coercive control of the asylum era is over, heralding care in the community; that the blossoming of interest in well-being means that psychiatric care is no longer the second-class citizen of medicine. But some facts, unfortunately, tell a more poignant story, reflecting a problem as much of ideology as of funding.
Over the past few months, scandal after scandal has brought to light the appalling state of care for mental health inpatients (i.e. those who must stay at least one night). First, we had a Panorama investigation into the Edenfield Centre, a secure NHS-run psychiatric hospital in Manchester, which alleged vulnerable patients were being ridiculed and restrained inappropriately. Then a secret Dispatches investigation showed wards in Essex where patients appeared to have been cruelly treated, despite repeated inquiries into a series of suicides between 2004 and 2015, hauntingly depicted in the continued agony of members of family interviewed. Over the past week we have heard of more than 20 teenagers allegedly abused in wards run by the private sector Huntercombe Group, followed by an independent investigation into a hospital in Middlesbrough, outlining the failures preceding the suicides of three young women.
The same themes come up again and again. Excessive use of restraint, which can turn into violence from being dragged down the halls; setting arbitrary and sometimes punitive limits; a lack of understanding of autism, eating disorders and self-harm; suicidal patients left at high risk; a lack of compassion.
It’s easy to blame ‘bad apples’ for protecting our collective fantasy from angelic NHS staff. But life is more complicated than that, and so are the dynamics of health systems. Teams can and do become toxic, caught up in coercive and cruel practices into which new members are socialized. We are all vulnerable to these processes, even if it scares us to think so, and never more so than in a system that is brutally underfunded and over-pressurized.
England has fewer psychiatric beds than ever before, with the number falling by a quarter since 2010, from 23,447 to 17,610. Such a drop would still be catastrophic, let alone in a time of growing demand and community services significantly underfunded. The wellness agenda, which focuses on lighter issues, can lead to great statistics in a way that doesn’t work for serious mental illnesses; longer-term needs are pushed aside and our patients increasingly oscillate between neglect in the community and mistreatment in services.
Good care has simple principles that we forget too quickly. As patients, we benefit from a trauma-informed environment – a paradigm shift from our obsession with labeling what’s wrong to the question, “What happened to you?” – it’s welcoming and not too sensory overwhelming. We need a kind word and a listening ear from familiar staff who know us. Sometimes we need medicine to dull the pain or boost our mood; activity or rest in bed, depending on the state in which we arrived and nourishing soul food. Lacking the philosophy to provide this type of care, staff are caught up in increasingly brutal protocols aimed at extinguishing surface issues rather than deeper exploration.
Everyone loses in this equation. I am in contact with two fellow activists who are in hospital and they report that staff are in tears over the gap between what they want to do and what they can do. A worse fate awaits patients who experience excessively restrictive practices that directly repeat how society or primary caregivers have treated them; a particular problem for black men and survivors of abuse.
Beyond the obvious things required – recover the millions spent on beds from private providers; specialized units for people with autism; the end of the most armed diagnosis against patients, borderline personality disorder; and self-harm training – we need the kinds of non-carceral approaches, those that are not based on a logic of incarceration, that grassroots organizations have long been calling for.
Ask any consultant where they would most like to have a breakdown, and the answer is probably Trieste. This Italian city is recognized by the World Health Organization as a center of excellence, with few involuntary treatments and few hospitalizations. Trieste emphasizes principles dear to patients: dignity and respect; inclusion in daily city activities; an emphasis on the social relationships that define us; access to nature, and that great enemy of anxiety, gambling. Deinstitutionalization works in Trieste; once there were 1,200 beds for a population of 240,000 citizens, now there are only six general hospital beds and 30 overnight community center beds. But it only works because there’s a community scaffolding there to support it.
We can take that leap in England, investing in emerging projects such as Bristol’s Link House and London’s Open Dialogue that emphasize the importance of human connections in responding to mental health crises. Today’s well-intentioned efforts to create parity between mental and physical health must not lose sight of this. We don’t apply a physical procedure, like dressing a wound, but hope to create relationships in which the sick person can heal. This is what we can no longer afford to ignore.
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