image: Flickr/Thomas Lieser (https://www.flickr.com/photos/onkel_wart/)
People with mental health problems are receiving ‘substandard care’, MPs complained this week in a report from the All-Party Parliamentary Group on Mental Health.
Two months ago the media briefly frissoned another dark story from our NHS: seven recent suicides and one homicide amongst acutely mentally ill patients who had been told no psychiatric beds were available for them.
But how have these problems arisen - and what can we do about them?
As a young psychiatrist forty years ago I heard hopeful talk about how more scientific diagnosis and specialist, focused treatment would make longer-term and residential care unnecessary. As with surgery, improved speed, accuracy, and efficiency would benefit mental healthcare (and deliver economic savings). The closure of large mental hospitals became a celebrated symbol of this.
My view, though youthful, was jaded: we were over-reaching our medically-modelled treatments to complex human distress.
Most of these early doubts have proved dishearteningly accurate. As a now veteran inner-city GP I have seen the dismemberment, then disappearance, of our better forms of long-term containment and care. It is not just that the asylums have closed. It is that the wider ethos of ‘asylum’ – compassionate containment – has become increasingly rare.
I find it almost impossible now to find for my patients the kind of protective spaces and relationships that are essential for many kinds of healing and growth – the kinds of investment I could more easily make as a young practitioner.
How has this happened? How – amidst our plethora of Royal Colleges, think-tanks, specialist trainings and massive resources (yes!) – have we departed so far from our better sense and sensibility?
We have failed to heed the subtle differences yet synergy between treatment and care, and have thus lost our capacity to craft our best therapy.
Care comes from ethos, while treatment comes from technology. Care is about wholes and relationships, treatment is about parts and mechanisms. Care springs from – then returns to – the intersubjective, treatment remains closely tethered to the objective.
Treatment may fix, but it is care that heals.
In recent times we have lost the skills of blending these delicate amalgams. Paradoxically, this is due to the many and dramatic successes of our technological treatments. We have adopted such potent activities as the dominant and determining paradigm.
Increasingly we have replaced care by treatment; personal understandings by formulaic care-pathways. Pastoral healthcare - all those therapeutic engagements that cannot be resolved rapidly by standardised, technology-based interventions - now suffers.
As the technologically complex sharpens and burgeons; the humanly complex is short-circuited and neglected.
Such displacement of care by treatment is seductive. Treatment seems to bypass human vagaries and uncertainties and, instead, anchors us to what can be reliably manufactured, measured and managed. But like many seductions this is hazardously specious. It obscures what we may lose – our unindustrialisable humanity – our realms of relationship, imagination, meaning and spirit, our ability to circulate with others, to heal and grow – or to endure with equanimity.
The economic costs of our loss of compassionate human containment are hard to measure but probably vast. Much distress is pleomorphic: it takes on other forms and is then dealt with by other agencies: A&E departments, other medical specialists, police, Social Services, probation, courts, lawyers, prisons (a desperate asylum)…
Such human and economic cost extends far beyond psychiatry. The submission of care to treatment has etiolated the entire spectrum of pastoral healthcare, including mental health, general practice, chronic disease and rehabilitation. In a culture dominated by goals, targets, financially linked points, managed procedures and care pathways there is less and less head-space and heart-space to nourish human imagination, connection and meaning.
To start, we become demoralized and alienated.
Morale and sense of connection are crucial to human welfare. Several decades of research has shown how important these are in the genesis and outcome of innumerable health and welfare problems - both for patients, and staff.
Evidence mounts of NHS healthcarers’ increasing demoralisation and burnout. We see it officially in statistics of sickness, early retirement, career abandonment, emigration, drug and alcohol abuse and litigation. We hear it informally in a steady flow of descriptions of professional loss, alienation and stress. Our healthcare ‘family’ has turned into a hostile network of siloed and fractious factories.
Personally infused acts of care become executively managed procedures; the quiet warmth of vocation becomes the staccato clamour of career. Such accounts have common undertones: bleak loneliness, dispirited ennui and impotent anger.
By contrast, good quality care nourishes the giver as well as the recipient, for care – unlike treatment – is rooted in human resonance. This is what we have jettisoned.
‘Seven suicides and one homicide’ was a deserving headline, yet merely the iceberg’s tip. Far beneath the surface, extending massively, lies the dying body of an ancient healthcare ethos.
How can we resuscitate a dying culture?
What are the best conditions to foster experiences of meaning and connection in our work?
As with any living culture we must first depend on a nurturing substrate. Yet our NHS substrate is now formulated in a way that becomes heedless of this vitalising principle. It is a realm is now governed by institutions and language of lifeless objects. Purchasers and providers, competitive markets, commissioning, commodification, and competition between boundaried, autarkic trusts.
In such a milieu our contacts and experiences become disinvested in human interest and relationship. We are now confronted with a very difficult dilemma. To make a path back to a humanly nourishing and sustaining culture will require much demolition of many of these recent developments.
The stakes are high: contention will be fierce.
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