On her first day in Downing Street last July, Theresa May said that "shortfalls" in our mental health services are "one of the burning injustices in our country". Let's ignore the bigger picture for a second and acknowledge that she's right.
We know that adults in acute distress often have to travel hundreds of miles for a bed on a mental health ward. We know that vulnerable young people are being sent far away from their homes and families for treatment, that people who seek help from their GP for their mental health may have to wait a year for talking therapy. The picture becomes more frightening every week. Perhaps we can loosen our shoulders a little now, though, because if the Conservatives win the snap general election May has called, we've been promised a mental health revolution.
It goes something like this: the Conservatives say they will roll out mental health support to every school in England and Wales, training staff in mental health first aid and providing a single point of contact with local mental health services. More emphasis on mental health would be introduced to children's curriculums, covering cyber-bullying and online safety. Large companies will be required to train mental health responders alongside first aiders. The Equalities Act will be altered to prevent workplace discrimination because, currently, people are only protected from discrimination if their condition is continuous for a year. This would be amended in light of people's realities and how mental health problems are very often intermittent. The party appears to be acknowledging the great need for better preventative mental health education, as well as ensuring that employers are not discriminating against those who are open about their well-being at a moment in time.
So far, so encouraging. And there's more! Jeremy Hunt says there will be 10,000 additional NHS mental health staff by 2020 (this number has increased to 21,000 in further proposals announced in July 2017), and May is making a lot of noise about how she wants to "rip up" the 1983 Mental Health Act – the legislation by which a person can be detained to prevent them causing harm to themselves or others. She wants to replace it with new legislation designed to curb the steep rise in the number of people being detained in England and Wales – a move she says "finally confronts the discrimination and unnecessary detention that takes place too often".
Big words, big numbers and even bigger promises. On the surface, there's plenty to get excited about, but crack the golden shell of May's pre-election grandstanding and you'll find a rotten core.
The Care Quality Commission found, in its last report on the current state of mental health care, "failings that may disempower patients, prevent people from exercising legal rights and ultimately impede recovery or even amount to unlawful and unethical practice". This report has been referenced in most media coverage of May's proposed reforms, but the propagation of these cherry-picked lines from a big investigation does not reflect reality.
In fact, the report outlines failings in services, but does not call for changes in legislation – certainly not a ripping up of the rule book. It draws attention to problems arising from lack of resources, and there is no evidence that there is widespread unnecessary detention. Detaining people (sectioning) under The 1983 Mental Health Act saves lives. As one psychiatrist told VICE, sectioning saves three lives a night in Hackney alone. Many people later see being sectioned as the platform from which they began addressing their problems differently and, ultimately, living better.
The process of being detained can, of course, be extremely distressing. Journalist Hannah Jane Parkinson has written openly on living with bipolar disorder and speaks candidly about her sectioning last year. For her, the care (or lack of) that came after was "much more traumatic than the sectioning itself", although when four male police officers arrived at her therapist's office, three of whom had tasers, she felt very scared. "The officers were kind, but I do worry a bit about those tasers," she says. "If I hadn't been a white woman and was acting erratic, would they have been used?"
Over 63,000 people were detained under the Mental Health Act in 2014-15 – an increase of 43 percent compared with 2005-06. Black people are disproportionately represented in statistics, with a detention rate of 56.9 per 100 patients who spent time in hospital for mental illness. Among white patients that rate was 37.5 per 100. An over-use of mental health detention for minority groups demands our attention. But aren't we spectacularly missing the point if we just focus on the detention process? Should we not be asking what, in our society, could be contributing to such an over-representation of minority groups in these statistics? Could it possibly be that life has become disproportionately really fucking difficult for these people?
No one experiencing profound mental distress should be kept – as they so often are – in a prison cell while waiting to see someone who can help them. Shouting about re-writing the law will get people fired up, but the real problem is lack of resources. People are held for so long because there's nowhere for them to go.
Plans to "rip up" the Mental Health Act are complete bollocks, deterministic, rip-it-up-and-start-again posturing that are a sexy diversion from austerity.
Parkinson was taken by the police, who placed her in handcuffs after sectioning her in a carpark, to a major London hospital. Here, she spent 22 hours in a mental health "suite" – a room with no beds, just a few uncomfortable chairs – with guards outside the door. The only mental health bed available for her was in Mile End – far from her NHS trust borough of Camden & Islington. The hospital experience after her sectioning made her feel "very abandoned". A lack of support after the initial admission meant she was admitted to a different crisis hospital unit a week later. She says the majority of the staff in the hospitals were "very good" but that she felt "stuck in a truly Kafka-esque, labyrinthine system. I must have explained my medical history to 10-20 professionals, which is exhausting and enraging. There are so many hard-working people in NHS psychiatric care but the services are completely on their knees due to lack of funding."
There's that rotten core. I spoke to a consultant psychiatrist with over 20 years experience in an east London trust about the reality of frontline mental healthcare, who asked to be anonymous. I'll call him David. He wanted to make one thing very clear off the bat: May's pledge to "rip up" the 1983 Mental Health Act is "complete bollocks".
What we're actually hearing, he says, is deterministic, rip-it-up-and-start-again posturing that is a "sexy" diversion from the reality that "the Conservatives are currently using austerity as the stick to beat NHS into privatisation". In other words, the mental health reforms just distract from the crisis in the health service, of which mental health care is one of the biggest victims.
When we talk about mental health services, we are talking about the NHS – the system that so many of us have no choice but to rely upon if we become mentally unwell; the system that is now on its bloodied knees. The Tories keep telling us they're going to patch things up, but the way the NHS is functioning under this government means May's call to arms is a farcical joke to anyone working within it.
While writing this piece, I asked a clinical psychologist contact if he'd like to comment on the proposed mental health reforms. He said that he'd been given strict advice from management just that morning to not comment on the general election in the press at all. Ask any mental health professional currently working in the NHS about "management" and expect their face to drain of colour.
"There is a creeping managerialisation of everything," says David. "The services are quantified by measurement of money. Cash releasing efficiency schemes [CRES] are a standard dictat across the country. Efficiency savings of five percent to be made year on year." I'd never heard this before. It sounds chilling. Like a private landlord can increase rent? "Exactly."
Trusts can lose money just like that because their governing body says so. Labour's shadow mental health minister Barbara Keeley said this week that the Conservatives have actually consistently raided mental health budgets over the last seven years. It begs the question: where is that money going?
"Management," says David. "Measurement organisations, quality outcome frameworks – structures that don't go into the cuts. But look, we just closed down our service outreach team. We are 'streamlining services' and laying off doctors. Our administrator, who ensures the lights stay on in our buildings, is being made to interview for her own job." What about the 10,000 additional mental health staff being promised? "These figures are wonderful, but are they all going to be clinical psychologists? Where are they going to come from? What approach will they be delivering?" Let's remind ourselves of Jeremy Hunt's pledge for 5,000 extra GPs and how well that's going.
For psychiatrists, psychologists and other mental health professionals trying to help people through distress, working in the NHS increasingly means an exhausting maze of paperwork, box-ticking and justifying your keep. All while people's lives hang in the balance. David and his colleagues have to categorise patients by "diagnostic cluster" – "are they mad, neurotic or bad? Are they a bit mad? Are they not mad but have drug problems?" – all of which he says have nothing to do with suffering. "It's about how much money we can justify pumping into them, for paperwork that's sent to back offices."
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I am retraining as a psychologist and have recently been working in an NHS trust. I've seen first-hand how the job means trying to deliver compassionate treatment while constantly having to measure "success" and provide data to vindicate the service. Patients have to fill out reams of self-reporting questionnaires so scores can be measured before and after treatment. "Outcome measures" and "KPI" (key performance indicators) are terms spoken all day long. Considering how oversubscribed mental health services are, this bureaucratisation of well-being equates to mountains of admin that often has to be done out-of-hours. But I have witnessed astounding kindness and humanity in clinic rooms, despite the chaos lurking outside the door.
An interest in other people's well-being and the belief that everyone should be able to access psychological services for free eclipses clinicians' frustrations with the system. They stay because they care too much not to. Yet, "wild frustration" should really be listed under NHS service job descriptions.
David is now obliged to measure success in his clinic by something called a HoNOS score – the final product of a battery of psychometric scales. He explains a case that neatly underpins the dilemmas therein. "'Barry' is addicted to crack. He was raised in children's homes and suffered profound sexual abuse. At 30, he gets a diagnosis of schizoaffective disorder. He was very psychotic and believed he was the Archangel Gabriel incarnate. After treatment, although Barry's delusional beliefs had been changed, his depression shot up to suicidal scores. However, because of how we're measuring things, that's considered a success!
"The problem is that no one has ever given a damn about this guy. Substance misuse, trauma, unemployment, inconsistent education and depression is, on the whole, higher in lower socioeconomic groups, where you find lots of chronically unwell people like Barry. People who are ignored."
"Theresa May is right about mental health services being in crisis, but a comprehensive mental health policy doesn't just mean providing better services for those in distress. It means making life less unbearable for people so they have less chance of becoming distressed in the first place."
Successful prevention of mental illness is invisible. It requires a reappraisal of society and how people best function within it. David is adamant that increasing isolationism in our culture is the backdrop to worsening mental health. "Our nervous systems are connecting machines," he says. "Emotions are about connecting to other people. You don't get rich and poor people drinking at the same pubs any more. The disparity in salaries has risen from 20-1 in the 1960s to above 200-1. That's like in Henry VIII's reign. This is the backdrop. It's bullshit."
It's hard to promote soft relationships. We'd do better to promote social conduits like the Sure Start scheme, introduced by Gordon Brown in 1998, under which mental health service waiting lists came down. The problem is that these things are seen as indulgences of the poor, so money is snatched away. Funds are being drained from every bit of our societal framework that can help people stay upright and connected. Empirical evidence tells us over and over that the growth in mental health problems is caused or exacerbated by poverty. That is why services are overrun. Add cuts to voluntary and statutory services working in preventative care to the picture, along with staff shortages in all relevant public services (policing, social care) and you have a perfect storm for "burning injustice".
For every complex problem, the Tories appear to have an answer that is clear and simple. Theresa May is right about mental health services being in crisis, but a comprehensive mental health policy doesn't just mean providing better services for those in distress. It means making life less unbearable for people so they have less chance of becoming distressed in the first place. We should challenge this "reform" rhetoric at every corner, because it's under May's government that people's minds are breaking.