Annette de la Cour
A mental health social worker and family therapist
who worked in London mental health services for over two decades, including
in the first community crisis intervention service based at
Napsbury Hospital. She was a Mental Health Act Commissioner from
2004 to 2011 (seven years) and has been
an Associate Hospital Manager for Worcester Health and Care Trust since
2008.
ANNETTE DE LA COUR:
I would like first of all to pay tribute to Barbara's courageous account of
her years of mental illness, journey to recovery, and her reflection on the
history of asylums in Britain and the state of mental health services as
she experienced them in the 1980s and how they are now.
I also think we can all be grateful to her for the contribution she is
making to stimulating debate over the current state of our mental health
services of which this evening is a part.
How would Barbara fare today?
Barbara poses an important question in her book, how would she fare in
today's mental health system were she to be unwell now?
I would say the answer depended then, to a degree, on good fortune. It
depends on it now to a far greater extent, and infinitely more than it
should on where you happen to live. There do exist places of truly
excellent care, but they are now few and further and further between.
I will not dwell on the nature and scale of the crisis in community mental
health care. We know about the cuts and closures, lack of beds and
increasing coercion by the use of the Mental Health Act.
The state we are in is not what we was envisaged when a policy to close the
old asylum was a supposed to be coupled with better, more humane, less
socially excluded care provided in the community. The scandal of
institutional patients, languishing in backwards and lying there was to be
no more and neither would be the horrors associated with all these old
institutions.
What went wrong and what does it tell us now about what needs to be done to
put things right.?
It is clear that the true cost of post asylum mental health care is far
greater than was thought. Closing the asylums clearly became an
opportunity to save money and since that time services have been subject to
cuts at different times, and never more than under the present government.
So much for the promise of parity between services.
Three features contributing to our problems.
However, money is only part of the story, important though it is. I would
like to highlight three features of what has happened since the asylums
closed which I feel have contributed to many of the problems we now face
and which need to change if we are to develop the kind of services users
need and want.
Firstly community care
After the asylums, it was community mental health services which were meant
to form the corner stone of service provision. However, based on no
particular coherent or consistent model, but instead developed in response
to the latest government policies, a bewildering array of different teams
has come into being throughout the past thirty years, characterised mainly
by a lack of co-ordination and poorly understood by service users and their
carers.
Typically, with each mental health trust, such as my own one, there will be
a crisis team, home treatment team, assertive outreach team, early
intervention team, recovery team and a general community mental health
team, each with their own entry criteria and assessment procedures.
Service users journey forwards and backwards through these teams, even
during a single episode of illness and often many times as their mental
health needs vary, subject to frequent assessments and equally frequent
changes of personnel. This is not a system of care, but more one of people
processing. It places no real value on relationships and is devoid of
psychological thinking.
Care takes place between people in the context of relationships between
service users and mental health workers which are allowed to develop and
exist over time. Sadly, resolving mental health problems takes not days or
weeks, but often months and even years, and continuity of care is
fundamental.
Our current fragmented services, and the state of flux on the agenda,
serves to mirror the fragmented state of service users themselves, and so
utterly fails to offer the emotional and psychological containment that
people need in order to recover and to remain well. Given the absence of
the walls of the asylum - in Barbara Taylor's memorable phrase, "stone
mother" - and our failure to provide any meaningful virtual containment,
small wonder so many service users feel abandoned and carers neglected and
that hospitals cannot cope with the resulting, ever increasing pressures on
beds.
If all my years as a social worker on the frontline, so to speak, of
community mental health services have taught me anything, it is never,
ever, to underestimate the value to service users of simply being there and
being known to be there, whether or not needed at any particular moment.
This we have largely lost and the consequences, as we have been hearing,
speak for themselves.
Secondly risk
This brings me to my second point, which is about risk. Mental health
services are full of it nowadays, measuring it, evaluating it and managing
it: Risk is at the top of everybody's agenda. However, never before has
risk felt so risky. It is why the use of the Mental Health Act continues to
rise inexorably and why it was felt necessary to introduce community
treatment orders. Undoubtedly the reasons for this situation are many and
complex. The shut down of the range of housing and social care facilities
has a huge part to play, but the ones that are to do with the nature of the
services that do exist are often overlooked. Good risk management requires
trust and sadly there is not nearly enough of it around. It is my belief
not only that the fragmentation of the services which I have described
increases levels of risk in users due to absence of trusting relationships
between them and staff, but also it is far harder for doctors, nurses and
others working in the community to tolerate acceptable levels of risk when
they themselves do not know their patients well enough, only have
responsibility for them for segments of time and, very importantly, are
often not working collaboratively in stable and supportive teams.
Working in these conditions understandably leads to a flight to safety, and
this I believe is an important aspect of what we are seeing now.
Thirdly the biomedical model
The years since the closure of the asylums have seen the growing dominance
of the biomedical model, within mental health services, despite the absence
of evidence to prove it. Barbara Taylor describes in her book how it came
to increasingly influence British psychiatry from the first world war
onward and how that affects effective treatment, at least in some parts of
system. Now, symptoms, diagnosis and medical treatment matter most,
whereas personal history, social context and individuality count for
little. Understanding is not necessary - only treatment to eradicate the
symptoms.
Following this medical model, the alternatives offered to the old asylums
are based on the same model as physical healthcare: Patients only require
brief in-patient stays, quick fixes were to be the order of the day and
still are. To me one of the most damning and disheartening features of the
post asylum world is that, as a result of this medicalised approach, we are
still creating new generations of chronic patients at a dismaying young
age, leading lives frequently damage by the sometimes life threatening
physical and mental affects of long-term treatment. This is not what was
anticipated by those of us who argued for the asylums to be closed. As
long as services adhere to this flawed model we will not achieve the
provision of services which will enable users to recover, in the true
meaning of the word, and lead the lives that they would wish for and for as
long as the rest of the population.
Due to criticism and pressure brought to bear, particularly by the service
user movement, mental health services have responded more recently by
adopting the recovery approach. Consequently, while some parts of services
now march to the drum of collaboration, choice and shared decision making;
in others, even within the same Trust, the ethos is still one of expert,
patient, doctor knows best, compliance and the treatment pessimism of much
diagnostic labelling.
What, one wonders, are service users to make of this extraordinary
conceptual muddle and fundamental contradiction which now lies at the
centre of our services?
Conclusion
In conclusion I would say that, in mental health services particularly, no
one size fits all. This is the situation we have been heading towards,
based on the prevailing paradigm of care and treatment. What works for one
person is not the same as what works for the next, and it varies over time.
Service users need a range of services available to them to cater for a
variety of needs at different times of what is often a long journey. These
include housing, financial, social, therapeutic and medical services. The
need for containment and refuge has not gone away, but is rarely to be
found in our over-crowded acute wards nor, as I have indicated, in the care
provided by our community mental health teams or in the other few services
left.
This need existed in Barbara's time and as in hers so still in ours.
Antony Garelick
Antony Garelick, who trained at the
Maudsley Hospital, is a Consultant
Psychiatrist/Psychotherapist who worked for 25 years at
Claybury Hospital
in Essex, one of the largest therapeutic communities in the UK. He was the
first Clinical Director at Claybury, and was heavily involved in its
eventual closure and the reprovision of its services. He is now an
Associate Dean of
MedNet (London Deanery), a consultation service for
doctors based at the
Tavistock
Clinic
in London.
ANTONY GARELICK: