In all our sanctuaries we sit at risk

Mental Health Witness – how to consult with people who have turned to you for help


Here is a version of a message just written to a mental health manager who recently sent me a draft-“user involvement strategy” being put together for the service where she works. I am soon to retire from a part-time post as free-lance consultant to a group of mental health service users. My task has been to facilitate the process by which their experience of local services is fed through to and influences the people who manage those services.

“As you know, you have caught me on my way to the exit, so to speak, and my response will no doubt be affected, not just by my proximity to the vast outside, but also by a sense of having left much undone and un-achieved. There are important battles still to be fought, in my view, which I have failed to win ;  major points that need to be seen and understood, of which I have failed to convince people.

I will not go on at length here, because I have gone on at length elsewhere ; and I will continue to go on, as I depart, and after I have departed. For, somehow, this topic goes to the heart of what the mental health services are about and of the realities they are dealing with. Thus, I talk quite a lot about user consultation on the site of a charity I run called Hyphen-21. I shall be going back to the relevant sections there over the next few months, but have no reason to change much. I need only add and update. The link is

I am also quite often writing about mental health on this blog these days.  The present piece will the second post directly about consultation.

Now to your strategy. I will make three main comments on it.

You are to be congratulated on having one at all. I think the process of engaging on it is in itself a constructive one. I think as a statement of intent and of principle your draft document is commendable, although I would make one suggestion.

This suggestion is that you should look over it again with the following line of thought in mind, in order to see whether that thought would change either tone or phraseology in any way. I will start the line of thought with a true story. I came off my bike some while ago, straight over the handle bars and onto my head, mercifully helmeted. As I lay on the tarmac, flat on my back, I was not thinking of choice, which hospital I might prefer, which cuisine, which décor ; I was not thinking of “user empowerment” and how much involvement I would be given in my care, how many questionnaires I would have the chance to fill in. I was helpless and needy. I just wanted the nearest hospital and I wanted a safe pair of hands for the support of my head, hands skilled, confident and careful.

Your document is full of your concern to listen. But is it also full enough of your belief in your own skills and ability to hold me when I am in a state which needs your holding ? I think there is a danger in some of the language that gets used in this area, that it can actually mislead and even intimidate. If I break my head, I don’t want to feel that in doing so I have just taken on responsibility for running the NHS. Or that the people who will be holding my broken head will be so nervous of failing to listen to my directions, that their hands will tremble…

In proposing that line of thought, I am honestly not criticising your paper. I am just suggesting it as an extra filtration stage, in case it is useful. I think clear boundaries and very clear statements are important.

The next comment is more an observation. It is that your strategy has a slightly different backdrop or context than many other mental health services, I believe. The difference is that you are working from a small network of community mental health centres. Many of these centres’ clients have attended there for several years. The centres work to sustain these people in the community, who would not otherwise cope without frequent relapse into hospital.  So centre members know each other well, and meet staff members and each other very often. This makes for greater confidence of inter-action, greater freedom in the expressing of views, a stronger sense of belonging, of being in community. In a sense, “consultation“ is endemic in the way you work and have always worked. So power to your elbow, in this brave new world of ever deeper cuts, ever glossier and more delusional slogans, and ever more precarious professional standing.

The last comment is that your strategy must eventually address the issue of methodology. Ultimately it is how it is done, how the principles are implemented, that requires the greatest thought, and – in my view – most warrants a binding code of professional good practice. For I think there is much bad and damaging practice methodology in consultation, for all sorts of reasons. Paradoxically, the whole target and brownie points culture whose aim is to maintain and measure good standards, is probably the main culprit. Rushed managers look to the tick in the box rather than to the person in front of them, to the quantity of people in the room, rather than to the quality of communication in the space between people in that room. 

We need to address the fact that user consultation can actually do damage to the people concerned unless conducted with skill and care. It cannot just be a set of good intentions, or for that matter mere blind obedience to a set of directives from above. It must involve suitable methodologies, using creative practitioner skills, methodologies which support and exemplify the respectful listening and responsiveness and sensitivity for which consultation was conceived in the first place. In other words, the means of consultation are core to the end of consultation. Without excellence of means, the end will be meaningless (just as having a “user” in every professional committee is, in my opinion, largely meaningless, and even perhaps irresponsible).”