Why mental healthcare is a mess
It is the authorities' own ever-widening definition of what it means to be mentally ill that is straining resources.
Two reports on the standard and efficiency of mental health services in England were published last month. Both concluded that there are many failings in the system, but they failed to see that it’s the widening definition of mental illness and the increase in therapeutic measures that put strain on mental healthcare.
The first report concerned the care of Michael Stone who was convicted of the murder of Lin and Megan Russell in 1996. Stone, diagnosed with a severe personality disorder, had a long history of drug addiction and violent behaviour. Five days before attacking Lin and Megan he had told his psychiatric nurse that he wanted to kill someone. The Stone case provided impetus for the proposed reforms of the Mental Health Act 1983, in particular the proposal to allow people like Stone to be detained indefinitely before they commit any crimes (1).
The second report by the Healthcare Commission reviewed 174 mental health teams in England, rating only nine per cent as excellent, 45 per cent as good, 43 per cent as fair and three per cent as weak. The management of medication for people diagnosed with schizophrenia came in for much criticism, with 84 per cent of mental health teams rated as only fair or weak in this respect, and 89 per cent failing to record side effects of the medication or indeed how the patient’s mental state had responded to the drugs. The report argued that there is a greater need for ‘talking therapies’ such as counselling, cognitive behaviour therapy or psychoanalysis (2).
According to Marjorie Wallace of the mental health charity Sane, the report is further evidence of the failings of community care policy. Anna Walker of the Healthcare Commission acknowledges the benefits of, and patients’ preference for, community over hospital care, but argues that what is required is more funding, flexible ‘out of hours’ crisis services and more therapeutic interventions. Nigel Edwards, of the NHS Confederation, bemoans mental health services’ ‘Cinderella’ status, given that ‘one in four of us will experience a mental health problem every year’. In response, Louis Appleby, the national clinical director for mental health services, claims that in recent years there has been an increase of 1,700 clinical psychologists and 1,000 primary care therapists working in mental health. He claims that these therapies are victims of their own success, their very effectiveness creating an ever-increasing demand (3).
These reports, and the responses to them, do not only highlight many mental health failings; they also demonstrate the need for a more critical perspective on contemporary mental healthcare.
The killing of Lin and Megan Russell was a terrible tragedy and Michael Stone is undoubtedly a seriously disturbed and dangerous individual. It is perfectly understandable for Shaun Russell to claim that ‘if everyone had done their job right maybe Stone wouldn’t have murdered my wife and daughter’. However, the key word here is ‘maybe’. While the report listed a sequence of failings – for example, the prison service lost Stone’s papers and one GP administered an incorrect dosage of medication – it concluded that ‘the inquiry has found no evidence that they [Stone’s crimes] would have been prevented’ even if the identified errors had not been made. Furthermore, it was satisfied that ‘the agencies and professionals involved here all did what they perceived at the time to be for the best. We doubt that much more could have been attempted anywhere else in the country.’ (4)
While many viewed Stone as a highly dangerous individual, it is not an easy leap to see him as a potential killer. If this was the case, you would have expected the police to have interviewed him earlier than they did, which was 12 months after the killings following a psychiatrist’s telephone call after an episode of BBC’s Crimewatch. In other words, predicting that even someone like Stone is a killer is far from straightforward – a reality lost on those who propose allowing for indefinite detention in cases where professionals believe someone may commit a crime at some time in the future.
The second report from the Health Care Commission shows the detrimental impact some government policy has had on mental health services. It is certainly the case that services for the most seriously mentally distressed are often inadequate and poorly resourced, and the views of those in need of help are often disregarded. The numbers of psychiatric in-patient beds have indeed been cut back, with many people who require hospital admission unable to be admitted. However, it is arguable whether the need is for more mental health provision or for more specific targeting of existing services.
Nigel Edwards’s hackneyed phrase that ‘one in four of us will suffer from a mental health problem’ is misleading. It conflates the more serious instances of severe and enduring mental distress with the more mild fluctuations in mental state that many of us experience. According to some definitions, you don’t even have to be unwell yourself in order to have a mental health problem – if a relative or friend is suffering, and this is affecting you, then you too are a sufferer.
Campaigners are wrong to claim that mental health services are being slashed; on the contrary, there has been an exponential rise in community mental health provision. The problem is that it is being targeted too broadly. For example, half of general practice surgeries now employ a counsellor, even though there is a lack of clear evidence for the effectiveness of such a strategy (5). And there is a plethora of telephone helplines to deal with people’s emotional problems – Saneline, Crisisline, The Samaritans, Careline, Mindline, to name but a few.
Louis Appleby may be correct in claiming that there is increasing demand on mental health provision, but he is wrong on the reasons why. It is not so much the proven efficacy of many of the therapeutic techniques on offer today that is creating the demand for them, but rather their promotion by professionals and government as the correct course of action for us as we negotiate the problems of everyday life. Government policy is increasingly concerned with the minutiae of our lives, including our internal lives as it focuses on our emotional wellbeing in a quest to make us happy. This quest results in the portrayal of all of us as patients, or potential patients (6).
In such circumstances, it is not surprising that we increasingly seek assurance and help from therapeutic professionals when we encounter emotional difficulties. The irony is that for the vast majority of the population professional therapeutic intervention is not necessary, but by promoting the therapeutic imperative, the government makes it more difficult for those who could benefit from such assistance to access it.
Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England.
(1) I have discussed the mental health reforms on spiked as they have progressed, pointing out, among other things, the implications of pre-emptive detention and compulsory community treatment orders. See A mad approach to mental illness, Mental until proven innocent and Mental health bill: a U-turn for the worse, all by Ken McLaughlin
(2) ‘Mental health services “failing”’, BBC News online, 28 September 2006
(3) All cited in ‘Mental health services “failing”’, BBC News online, 28 September 2006
(4) See ‘How the big Michael Stone story was missed’, by Ivor Gaber, Guardian, 2 October 2006
(5) J. Eatock, (2000) ‘Counselling in Primary Care: Past, present and future’, British Journal of Guidance and Counselling, vol. 28, pp.161-173.
(6) See Why the politics of happiness makes me mad, by Frank Furedi
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