Guest post on Lenin's Tomb.
The following is a storified version of events that led up to the way mental health care is organised in the UK today. It should be familiar to all mental health professionals, and shows, I hope, just how evil - and I do not use the word lightly - care provision truly has become.
Institutional care brings to mind horrific scenes. Whether it's the iatrogenic madness of Crispina at the end of The Magdalene Sisters, gossip about the Rosenhan experiment, Broadmoor, or a fondness for Foucault, mental health institutions bring to most people's minds padded walls, straitjackets, isolation, forced injections and unheard screams.
The truth, in some institutions, was certainly not very different from this, and many were the rich families who felt it too cruel to let relatives rot there as if imprisoned. Their alternative though, was the provision of private nurses working in the home, and as this was expensive it was the privilege of a select few. Institutions were expensive, too, for the state - more so even than prisons. And so the dream of mental health care outside internment grew as the number of institutions grew, in some circles because of love, in others because of profit.
Enter Roy Griffiths. Griffiths made his bones in Monsanto (director, 1964-68) and then Sainsbury’s (1968-91), and naturally, this gave him uniquely brilliant insight into mental healthcare. Thatcher had commissioned Griffiths in 1983 to write a diagnosis of the problems of the NHS. What he decided the NHS really needed was more managerialism and internal markets (ask anybody that works in the NHS today what the biggest problem and waste of money is, and they'll all tell you, too many managers and markets), and this seemed to set him up as the best possible person to respond to the media crisis brewing around the terrible quality of institutional care in the UK.
Griffiths produced his report, Community Care: Agenda for Action, in 1988. It was a call to complete deinstitutionalisation, and as with the Browne Report last year, the Conservative government loved it, and implemented its recommendations as fast as they could. But Griffiths didn't just advocate deinstitutionalisation alone, because providing care in homes would cost even more than institutional care. Instead, he wrote that the state needed to move away from being a 'provider' of care, to being instead merely an 'enabler' of care. This move is crucial and in it lies the evil. For the state to deinstitutionalise its patients would surely have meant that institutional staff would become health visitors, but that's not what Griffiths wanted. What Griffiths argued for -and what was adopted in the 1989 White Paper Caring for People - was the abolition of health services for patients, and the managing of the resultant situation with social work. And when the White Paper became the Community Care Act 1990, so 'Care in the Community' was born.
You might be thinking that this sounds a lot like the Government refusing to care for people with mental health difficulties, and that’s because that’s exactly what it is. You may be wondering, what of the patients with complex and specific needs who need round-the-clock care? Well, the Big Society would take care of it. Charities like Mind, who do 'befriending' services, and the weekly chats with social workers were supposed to take care of it, and when they weren't there, well, the Community would step up.
But ordinary people aren't trained to cope with and treat mental health problems. What's more, they have their own lives to lead, and can't deal with such an enormous and permanent responsibility as full-time care. Add to this the fact that people with mental health difficulties are assaulted and raped far more often than the average, and a very ugly picture begins to emerge.
It's OK, though, from the Government's point of view. The ugly realities of social work do occasionally make the headlines, in cases of systematic abuse, but in the other 90% of cases it is just not written about that people (and it is usually women) have to give up their jobs, their independence, their relationships, even their children or control over their own bodies, because nobody else will be the caregiver. The 1995 Carers Act went some way to relieving pressure (and enabling married women, for the first time, to receive an income for their work), but in many homes care was just impossible, and people were forced onto the streets*.
But there were even bigger problems than this: suicides, and assaults by people with mental health problems. Of course people with mental health difficulties are very rarely the attackers, far more commonly the victims, but when they are, it is the stuff of tabloid sensation. Suicide is far less glamorous, but if the Government's new deinstitutionalisation policies triggered a mass wave of suicides, it would nonetheless be distinctly embarrassing. So police were further trained on their sectioning powers, and they became the people you're put through to if you call the emergency services about a potential suicide.
There's other evidence of this suicide-containment strategy at the GP level. GPs are given extraordinarily little mental health training, not to mention limited surgery time, and so they really only have four possible strategies. Firstly, they make people fill in a self-assessment form, which we'll come back to later. Then, if the person really doesn't sound happy, they'll be prescribed SSRIs. Thirdly, if they embarrass themself by crying or some equally heinous act, they'll be given the phone numbers of Care in the Community services, which range from free online CBT courses or private group therapies to social workers and befriending services. Fourthly, if they're really weird, or the doctor is feeling particularly phobic that day, they can have you referred to a therapy course, which almost invariably is CBT. My descriptions are offensive, but I chose them because this is how people are made to feel in surgeries.
Now I could of course write about how calculatedly ignorant this provision is and how obviously deliberate it is - after all, if we want people out of institutions, we should empower them to be flourishing there - or I could write about how CBT is not therapy, but instead a way of forcing economic outcomes from people - but I'd rather focus on that self-assessment form. You can see a version of it here.
The purpose of this form is to return a simple numerical value to guide the GP's actions. Of course a single number cannot say anything at all about somebody's mental health, but that isn't the point of the form at all. If it is too high, and the person admits to considering suicide - and GPs are required to ask if they are - the GP is supposed to call the police, but if the patient is lucky and they have half a heart, social services instead. Obviously the poor patient, confronted by their social worker, let alone a couple of ignorant, bullying cops, immediately withdraws into themself and denies any such thoughts.
The patient is desperately seeking help, human warmth and reasons to live, and what they have been confronted with is in the best case someone with the power to take away their children, and in the worst case a group of loudmouthed, laddish bullies who will talk about them in the third person as 'this nutter', with the power to intern them against their will, potentially indefinitely. With the only concern an avoidance of suicide, it could not have been less caring.
Lots of GPs, of course, are wonderful people who do their level best to learn about mental health, and subvert the system in all sorts of ways, just as lots of nurses and doctors in those old institutions did their best, too. Certainly most social workers do everything they can with the impossibly limited resources they have. But as I hope I have shown, it is not because of unpleasant individuals that mental health care in the UK has become an evil thing. It is the way the system has been designed.
*One of the things that can give people the designation of ‘intentionally homeless’ is the accusation that their behaviour is ‘antisocial’. Crisis estimate that those on the streets are 50-100 times more likely to suffer from a psychotic disorder than the average.