Wand have made great progress in England when it comes to acceptance and knowledge around mental health issues. But have our basic services also improved in tandem? We are told that clinical approaches to mental health are getting better: that the coercive control of the asylum era is over, heralding care in the community; that the blossoming of interest in well-being means psychiatric care is no longer the second-class citizen of medicine. But some facts, unfortunately, tell a more harrowing story, reflecting a problem as much with ideology as funding.
In the past few months, scandal after scandal has shone a light on the appalling state of mental health inpatient care (meaning those who have to stay at least one night). First, we had a Panorama investigation into the Edenfield Centre, a secure psychiatric hospital run by the NHS in Manchester, which alleged that vulnerable patients were ridiculed and inappropriately restrained. Then a Dispatches undercover investigation shown wards in Essex where patients appeared to have been cruelly treated, despite repeated inquiries into a series of suicides between 2004 and 2015, hauntingly represented in the ongoing agony of interviewed family members. In the past week, we’ve heard of more than 20 teenagers alleged to have been mistreated in wards managed by the private sector Huntercombe Group, followed by an independent investigation into a Middlesbrough hospital, describing the failures preceding the suicides of three young women.
The same themes occur again and again. The overuse of restraint, which can spill over into the violence of being dragged down corridors; arbitrary and, at times, punitive boundaries being set; a lack of understanding of autism, eating disorders and self-injury; suicidal patients left at high risk; a lack of compassion.
It is easy to blame “bad apples” to protect our collective fantasy of angelic NHS staff. But life is more complicated than this, as are the dynamics in health systems. Teams can and do become toxic, caught up in coercive and cruel practices into which new members become socialized. We are all vulnerable to these processes, although it scares us to think so, and never more so than in a brutally underfunded, over-pressured system.
England has fewer psychiatric beds than ever before, with numbers having fallen by a quarter since 2010, from 23,447 to 17,610. Such a drop would always be catastrophic, let alone at a time of increasing demand and with drastically underfunded community services. The well-being agenda, with its focus on milder problems, can lead to great statistics in a way that doesn’t work for severe mental illness; longer-term needs get sidelined and our patients increasingly lurch between neglect in the community and poor treatment in wards.
Good care has simple principles that we too quickly forget. As patients, we benefit from a trauma-informed environment – a paradigm shift from our obsession with labeling what is wrong to asking: “What happened to you?” – that is welcoming and not too sensory overwhelming. We need a kind word and an open ear from familiar staff who know us. We need medication, at times, to dampen pain or galvanize our mood; activity or bed rest, depending on the state we have arrived in and nourishing soul food. Lacking the ethos to provide this kind of care, staff get caught up in increasing brutal protocols aimed at extinguishing surface problems rather than deeper exploration.
Everyone loses in this equation. I am in touch with two fellow activists who are inpatients and they report staff who have been in tears at the discrepancy between what they want to do and what they can. A worse fate awaits patients who experience excessive restrictive practices that directly repeat the way society or early caregivers have treated them; a particular problem for Black men and abuse survivors.
Beyond the obvious things required – clawing back the millions spent on private provider beds; specialist units for those with autism; the end of the diagnosis that is most weaponized against patients, borderline personality disorder; and training on self-injury – we need the types of non-carceral approachthose not based on a logic of imprisonment, that grassroots organizations have long lobbied 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, having little involuntary treatment and few hospitalizations. Trieste focuses on principles that are dear to patients: dignity and respect; inclusion in the city’s daily activities; an emphasis on the social relations that define us; access to nature, and that great enemy of anguish, play. Deinstitutionalisation 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 is a community scaffolding there to uphold it.
We can make this jump in England, investing in emerging projects such as Bristol’s Link House and London’s Open Dialogue that emphasizes the importance of human relationships in responding to mental health crises. The well-intentioned efforts today to create parity between mental and physical health must not lose sight of this. We are not applying a physical procedure, like a bandage to a wound, but hoping to create relationships within which the ailing person can heal. This is what we cannot afford to ignore any longer.