On the Brink (eBook)

INTRODUCTION

This book is about my experience working with people whose mental suffering has taken them right to the edge of human experience – many of them facing it with great courage.

It is also a reflection on our relationship as a society with mental illness,* about the precarious state of our mental healthcare services, about the fragility of progress and how easy it is for things to go into reverse.

Most importantly, it is about the potential for change, about how things can be turned around if we can only engage wisely and nurture the creative opportunities that are there even at the darkest and most chaotic of times.

I started my career as a psychiatrist nearly forty years ago at the Towers, one of two Victorian asylums in Leicester. It was a profoundly flawed institution where I encountered patients who had been locked away and forgotten for years – institutionalised, infantilised, their individuality eroded. And yet I began that first job full of optimism. We all knew that change was under way: plans to close the Towers were already in place, and the generation before us had taken huge steps towards humane care, reforming the Mental Health Act and breaking down the barriers between the asylums and the community. We believed in progress. It was an era filled with hope.

Just six months later, I moved on to a brand new mental health unit attached to the General Hospital. It was a hugely significant change, one that reflected the reforms taking place throughout the country, indeed throughout most of the richer countries in the world. The building itself seemed to embody a new and hopeful chapter in the history of psychiatry. At the time it felt as if I was part of a great leap forward, playing a small part on the right side of history, my future career glittering in my imagination with grateful patients, exciting discoveries, and a palpable sense of progress.

And indeed some things did improve. We now understand a lot more about the human mind and have a growing evidence base informing us how best to help people who are struggling. There has also been a sea change in attitudes to mental health more generally. People are more open about their feelings, and mental health problems are no longer the taboo they were a generation or two ago. Celebrities – even royalty – talk publicly about their battles with mental illness. Mental well-being and mindfulness have become part of everyday language and therapy is increasingly seen – in some sections of society, at least – as a normal, healthy thing to do. Public health campaigns reassure us that there is no shame in sharing feelings of despair and thoughts of suicide and remind us that mental health problems will affect as many as one in four of us at some point in our lives.

But despite all of this, mental health services have not thrived in recent years. Morale is desperately low on the front line. People with serious mental illness are likely to die on average fifteen to twenty-five years earlier than those without SMI, largely from preventable diseases such as heart disease and diabetes.1 Report after report has confirmed what every mental health worker knows: that the service is in a terrible state and that the shocking chasm between what is needed and what we are actually resourced to provide is getting larger, leaving an increasing number of vulnerable people and their families in dark and desperate states of mind. The theme tunes seem horribly familiar as the potential for depriving, brutalising and dehumanising mental health patients re-emerges in different settings. To my great sadness, we seem to be moving backwards: the progress made during my early career steadily eroding.

Now we have services where desperate patients wait for months to see a psychiatrist or therapist; where the bed shortage is such that we end up sending severely ill adolescents hundreds of miles away from their families; where traumatised refugees are housed in detention centres that are more like prisons than care facilities. Why, at a time when we seem so much more comfortable talking openly about mental health and have so much more knowledge than previous generations, do we put up with sparse, inadequate and sometimes even abusive services? There seems to be some sort of paradox here: a shadow as dark and gothic as those lunatic asylums of old.

Funding is, of course, a huge issue. Health ministers talk recurrently about ‘transforming’ services and promise more money, but action doesn’t seem to follow the rhetoric. Despite all the positive talk, the gap between what we spend on mental health care and the level of need in our society has been growing steadily since the 1950s. The proportion of healthcare money spent on mental health has also declined. Since 2013, the NHS constitution in England has included a commitment ‘to improve, prevent, diagnose and treat both physical and mental health problems with equal regard’. But despite strategies and legislation,* we continue to miss this by a long shot.

Much of the first edition of this book was written during the Covid-19 pandemic. Like most people I often felt frightened. The world seemed a dangerous place. As a psychiatrist, I know that a crisis can go both ways and always contains the seeds of opportunity. But early glimpses of values and priorities shifting and the hope of ‘building back better’ were not sustained after the pandemic. Far from binding us together, our country – the whole world, in fact – emerged more unequal and divided than ever; and individuals more fearful, more vulnerable, more unstable.

Covid-19 exacerbated an already perilous situation. It is now clear to most people that the NHS itself is on the brink, in desperate need of proper attention, long-term planning and economic investment. Is there a special case for mental health services? Clearly some of the problems are being felt in other specialties across the NHS, but there are issues of scale and important differences not acknowledged or understood properly that I hope to clarify in this book.

Just how much mental health services had lost their way was brought home to me in the first few weeks of the pandemic. The edict from NHS England was to discharge as many inpatients as possible. Clearly the risk of infection was real, but the mental health charity MIND has published research suggesting that in some cases this was done with no review of ongoing mental health needs and worrying outcomes for the patients.2 Our local mental health trust, among others, discharged the majority of its outpatients at the beginning of March 2020, giving them instead a central crisis line number to ring in an emergency. Cutting off ongoing support at a very frightening time to those already identified as mentally vulnerable seemed utterly brutal to me. It showed no understanding that encouraging people to use support to pre-empt crises is a fundamental premise of mental health work, and that abruptly terminating an ongoing therapeutic relationship is likely to be disturbing and dangerous.

There has been a lot of talk in recent years about ‘parity of esteem’, treating mental health on a par with physical health, but these decisions seem to show just how low down the ranking order mental health services themselves see their patients. Compounding everything else, the pandemic presented the country with a mental health crisis. But extraordinarily, rather than stepping up, it seems that mental health services (with honourable exceptions) were stepped down.

Such a stark example of a whole organisation turning away from the mentally vulnerable patients it was responsible for, at the worst possible time, focused my thoughts on the uncertain progress of psychiatry over the last forty years.

How has it happened that we value our patients and our attempts to help them so little? How has it happened that our services are increasingly designed to deny people care instead of helping them to access it? We seem to have drifted into a culture, in many ways as harsh and neglectful as I encountered in the institutions of old.

Perhaps the truth is that severe mental illness is just as frightening, just as stigmatising, just as much a taboo as it always has been. Our relationship as a society with mental disorder is not straightforward. How we think about the mentally ill, how we relate to them, how we manage the feelings they evoke, whether we see them as deserving of serious investment, even where we house them – none of these questions seems to get easier, however much progress we make in other areas. We do not want to face the reality of the suffering of those with more serious mental health problems, nor to fund their care adequately – or perhaps we simply don’t know how. It is easier to tranquillise, restrain, separate, lock them up or ignore them than it is to engage properly with their needs and their pain.

The reality is that being up close with mental disturbance is difficult and discomforting. There will always be a degree of ambivalence. Connecting with others in severe mental distress can jolt us into facing our own vulnerability and hook into fears of dependency and losing our own sanity – fears that are often deeply buried. And the fact is that mental well-being is not something any of us can take for granted. Adverse life events can push most of us over a threshold where vicious circles – a complex mix of social, psychological and biological factors, all interacting and amplifying each other – start to take hold.

In the twenty-first century, mental health problems are not about the ‘other’, but about you and me, our families and friends. Most of us know...