WWe have made great progress in England when it comes to acceptance and knowledge about mental health issues. But have our basic services also improved along with it? 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 flourishing interest in wellness means that psychiatric care is no longer medicine’s second-class citizen. But some facts, unfortunately, tell a more harrowing story, reflecting a problem of both ideology and funding.
In recent months, scandal after scandal has brought to light the dire state of inpatient mental health care (that is, those who have to stay at least one night). First, we had a Panorama investigation into the edenfield center, a secure NHS-run psychiatric hospital in Manchester, which alleged vulnerable patients were ridiculed and inappropriately held. then a Dispatch undercover investigation showed wards in Essex where patients appeared to have been cruelly treated, despite repeated investigations in a series of suicides between 2004 and 2015, eerily depicted in the continuing agony of the interviewed family members. In the last week, we have heard about more than 20 teenagers allegedly having been ill-treated in wards run by the private Huntercombe Group, followed by a independent investigation in a Middlesbrough hospital, describing the failures that preceded the suicides of three young women.
The same themes are repeated over and over again. Excessive use of restraint, which can lead to the violence of being dragged through the halls; arbitrary and sometimes punitive limits are set; 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 the “bad apples” for protecting our collective fantasy of angelic National Health Service 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 in which new members socialize. We are all vulnerable to these processes, even if it scares us to think about it, and never more than in a brutally underfunded and overpressured system.
England has fewer psychiatric beds than ever before, with numbers having fell by a quarter since 2010, from 23,447 to 17,610. Such a drop would always be catastrophic, let alone at a time of rising demand and drastically underfunded community services. The wellness agenda, with its focus on milder problems, can lead to big statistics in a way that doesn’t work for serious mental illness; longer-term needs are sidelined, and our patients are increasingly reeling between neglect in the community and mistreatment on the ward.
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 asking, “What happened to you?” – that is cozy and not too sensory overwhelming. We need a kind word and an open ear from familiar staff who know us. We need medication, sometimes, to dull the pain or boost our mood; activity or bed rest, depending on the state we have reached and nourishing food for the soul. Lacking the values to provide this kind of care, staff are trapped in brutal protocols aimed at extinguishing surface problems rather than deeper exploration.
Everyone loses in this equation. I am in contact with two fellow activists who are inpatients and they report that staff have been crying over 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 Y abuse survivors.
Beyond the Obvious Things Required: Recover the millions spent on beds from private providers; specialized units for people with autism; the end of the diagnosis that is more armed against patients, borderline personality disorder; and self-harm training: we need the kinds of non-carceral approachthose that are not based on a logic of incarceration, which grassroots organizations have long defended.
Ask any consultant where they’d 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 focuses on the principles that are dear to patients: dignity and respect; inclusion in the daily activities of the city; an emphasis on the social relationships that define us; access to nature, and that great enemy of anguish, the game. deinstitutionalization works in Trieste; before there were 1,200 beds for a population of 240,000 citizens, now there are only six general hospital beds and 30 community night center beds. But it works only because there is community scaffolding there to hold it up.
We can make this leap in England, investing in emerging projects like the one in Bristol link house and the one in London open dialogue that emphasize the importance of human relationships 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 are not applying a physical procedure, like a bandage to a wound, but hoping to create relationships within which the sick person can heal. This is what we cannot afford to ignore any longer.
