This is the second piece specifically on mental health I have posted up. The first can be found a few posts further down. They will form part of a series, all sharing the title “mental health witness” and all filled of a strong sense of present emergency.(However, it’s worth saying that several of the fables, if not all of them, have a mental health theme or relevance, as well)
I am going to start this second piece by reflecting briefly on the word “abiding,” as it relates to mental ill-health. Mental ill-health is a part of Society and a part of human life. How best can we abide it ? How best abide with it ? How best can we help, and even benefit from, its abiding with us ?
Then, moving on, I shall argue that, having slowly built up better conditions for, and ways of supporting and helping and abiding with, people with mental health problems in this country, we have recently set about making things much worse across a range of fronts, to the point of crisis.
On abiding, I am largely just passing on the ideas of a friend of mine called Iain. He delivered them in a pub one evening several years ago, as part of his farewell speech, his summing up and parting gift. A social worker, he had worked for many years in a community mental health centre nearby. This was his leaving do and I had been invited to it. Previously, before Iain’s time, I had been manager of the same centre. His years there and mine, added together, would make a significant total, nearly half the time the policies of Care in the Community have operated in the UK. Iain’s reflections accorded very well with my own experience and conclusions, but also threw new light upon them.
I hope my words here do justice to Iain’s insights. In focussing on the word “abide,” they explore and reflect on some of its inter-related meanings.
Good mental health support or – in other words – the help that is needed by people with substantive and on-going mental health problems, is a matter of abiding, of abiding with, of staying there, close by, in poised and clear-boundaried friendship and connection, accepting, containing and reliable, over time and for as long as necessary.
By definition, if I have a mental health problem, whatever that may be and however temporary or long-term, there is presently something in my internal system, my processing of experience, myself, my feelings, my thoughts, my world, which I can’t abide, or contain, or be reconciled to, abide in. For whatever reason, I can’t encompass or captain or navigate certain aspects of myself, without help from outside. I can’t abide or maintain on my own certain aspects of my being, my experiencing, my seeing, my behaving, my coping in the world. Nor can the life I want to lead, or community I want to be part of, easily abide or bear me. I need help, but by definition the help I need is not easily come by. If I can’t accommodate myself, how can I expect others easily to accept and accommodate me, on my behalf ?
I need someone to abide me over time, as a way of helping me, over time, the better to abide myself. To love me, over time, as a way of helping me the better to love myself. Accepted for long enough, despite everything, despite the scars, I will learn to accept myself.
Put a slightly different way, I find some parts of me, or of my life, hard to manage. In fact, they feel quite unmanageable. I need someone else to manage those parts for me, not always, but sometimes, not completely perhaps, but partially, variously.
By definition and by any standard, those parts of me are hard to manage. If they were not, I would not need to seek help with them. I have to hand aspects of my Self that are hard to manage to someone else, trusting that person to be capable and equipped to manage them on my behalf, at least for a while.
It may be that that person, that helper, will spend a whole working day going from client to client, being asked to take on with skilled and open hands apparently unmanageable aspects of human self and situation. By the end of the day, the helper would feel very weighed down with all our difficulties and apparent defeats, were he or she not well-enough trained and well-enough supported and well-enough integrated as a personality, to continue to have spare capacity through this evening and tonight, and be ready for more bombardment on rising tomorrow morning.
I have already used the word “love” in this piece. “Abide” did not seem quite enough at that point. “Abide with me.” Yes. Abide with me. Abide me. Love me. And, in fact, Iain in the pub, at his leaving-do, ended his reflection with that loaded word. It all comes down to “love,” he said. But the word “love” is a difficult word to say in a pub, somehow. And it’s a difficult word for social workers to use in any place – or for occupational therapists, psychologists, doctors, nurses, or people who work in prisons. It doesn’t sound professional or detached enough. It sounds over-emotional, over-involved. Imprecise. It smacks of religiosity, self-righteous and patronising.
So Iain couldn’t say the word quite straight. He said it apologetically, self-effacingly, a bit like a very young man handing someone a rose. Aw, shucks, he says, self-mocking. Here’s a token of my unworthy esteem, of my, ahem, love, heh-heh. And as he hands her the rose, he fails to meet the eyes of his beloved. Then he drops it.
I think Iain was right to end on that word, and it is understandable that he found it hard to say. But, in my opinion, he should also have insisted, dead serious and without an ahem, that there is no better, no more professional word, than “love”. “Abide” is a good route to it. But “love” has always been our only possible destination, with no religiosity attached. It is the hyphen, the fragile line of connection between human and human, human in the light and human in the shadow, “I” in here and “Other” out there. The skills of love, effectively practised, are what a civilised community is made of and cannot do without.
Now, here are some words spoken by various people who once attended the Centre where Iain and I worked. They were addressed to me over time and I wrote them down in 1994, as part of a poem :
“I am someone here
I am heard
I am not alone.”
“Here I have substance
I matter
I mean something.”
“I feel more at home
here in this place
than I ever feel at home.”
“I have a share in the world.”
“I am not odd
I am even here.”
“I am not assailed.”
Writing this piece in the Spring of 2013, I believe those words of valuing and trust quoted in 1994 could not now be spoken by the people concerned, people at the receiving end of our Society, people who are, in effect, at Society’s mercy.
A whole combination of factors, some already long in the tooth, others more recent, have come together in these days to create an almost perfect storm which I think has put the speakers of those words in actual danger, along with the agency I have been describing, with all the skills and resources available there. Under equal threat and in equal danger are the whole over-arching contract and commitment to basic notions of social responsibility and organised welfare provision. Such commitment, itself long-fought for, had made possible this place where, for a while, vulnerable people were “not assailed,” and where they knew they might safely abide and be a valued element in Society, treated with respect, warmth and responsiveness.
I shall briefly list the factors which I think have played a part. In doing so, I know that, while the list holds true for me, others will disagree with it, or with parts of it. I also know that somehow it will not explain very much. It will not answer questions which I find actually agonising. These are : how can we have allowed this to happen ? How are we still allowing this to happen ? How can we be so deceived, so quiescent ? Who are we ?
By “we,” I mean, in one sense, particular and relevant bodies and people in positions of central authority and knowledge, who have failed in their duty of upholding standards by allowing and often even enforcing these developments, presumably in the honest but false belief that they were for the good. I mean, in another sense, entire professions at all levels of their hierarchies, who are responsible for the actual delivery of services on the ground and who have acquiesced where they should have refused. In the ultimate sense, what I mean by “we” is all of us who live in this Western Society and way of life, since all of us are responsible for the way we treat our own.
The list contains policies and banner concepts which will perhaps mean little to people not directly concerned in the helping professions. They are fairly recent but are not restricted to the present Coalition government or its disastrous and toxic “austerity” strategies.
The Business Model.
I shall use the title the “Business Model” to describe a range of inter-related processes which over the years have radically changed the way in which many mental health services are managed and delivered. These processes began under Thatcher. New Labour allowed the developments to stand and in some ways further extended them. The present Coalition Government have extended them yet further.
State run services are out-sourced and taken over by the voluntary sector. Organisations compete in order to win a given “tender”. Winning a tender brings a budget with it. An organisation which does not win enough tenders will not survive.
Tenders are reviewed from time to time. Standards and costings have been worked out, by which to measure an organisation’s success or failure in delivering the service or managing the tender. Those targets are often heavily based on expenditure and other quantitative measures, rather than on quality. An organisation found to fail by the tender’s measures will be replaced by a competitor.
As a model for commercial operations this has its own logic. As a model for mental health service delivery, I submit that it is inappropriate and destructive in very many ways. It undermines continuity and long-term development, as well as inter-organisational co-operation. It biases managers towards subservience to top-down measures and the chalking up of cheap brownie points, in order to win tenders, rather than a true and independent commitment to creative and imaginative work and genuine high standards. It creates a bias away from good practice for everyone’s sake towards eye-catching promotions for an organisation’s sake. Inherent in the system is a huge temptation and built-in incentive to cook books, take short-cuts and work by catchy slogan and flashy shop window display. But whenever people are caught succumbing to such temptation, the rule-makers of this bent game are the first to blame the functionaries concerned, even though it is the game itself that ensures and almost enforces their behaviour (a recent example is the “gagging clauses” which some NHS Trusts seem to have imposed, and which Jeremy Hunt swiftly condemned). The whole business is based on the belief that people need duress and competition, in order to function to a standard. I say with utter certainty and conviction that people have other drives than greed, fear, competitiveness and the need for kudos, and one of those drives is service. Good social care for people with mental health problems needs structures that build on the human drive to provide good service and to take pride in good creative work, not the drives of jungle, market place and grocer’s shop, dogma and zealotry, the feeding of Caesar.
Social Inclusion
This heading and starting point for new ways of thinking and acting on social policy is associated with New Labour. I had high hopes for it, but it has yielded ideas and approaches that have been hugely disappointing, paving the way for, and making intellectually acceptable, the withdrawal of necessary specialist mental health support services in the community for people who need them, services developed from knowledge and experience over years. The thinking here is that a more inclusive wider community should make those services unnecessary, since they are damagingly separatist and create over-dependency. The reality is that, for many people, the services are essential for them to have any community at all. The services’ withdrawal means merely a return to isolation and greater precariousness – social exclusion, in other words, absolutely the opposite of the result intended.
The Recovery Model
Here is another supposed “good” which, in ways I find hard to understand, has swept through the systems like a new religious faith. Professionals cease working from their own creativity and experience, and turn instead to this gospel’s chapters and verses. Agencies and organisations now flag up their loyalty to the model, as if proclaiming themselves justified by faith, sure of heavenly bliss (and budgets). “Recovery” becomes a mark of success, rewarded by funding, and thereby for some needy individuals, and perhaps for many, creates instantly and most mischievously, a new trap and category called “failure.” Insidiously, interest, resources, energies and quality of living, begin to be withdrawn from those people whose disabilities do not respond to the chapters and the verses, the rousing tracts and the classes….
I find nothing new in the “Recovery Model” except its gross simplification of complex realities, its evangelical tone and promotion, and its tendency, in the present climate, to be another justification for withdrawing help from people whose need is greatest. It is making life yet more unforgiving for those of us who fail to break through Society’s “recovery” ceiling.
I am writing about this model in more detail in a separate piece.
Personal Budgets, etc. – Making Money the Medium.
I have kept this section separate from the “Business Model” above, even though they are obviously connected.
“Personal Budgets” have been a long time coming to mental health services, but the concept’s early prophets and messengers always made clear to their audiences that it would bring radical change to the way services were delivered, such that they would never be the same again. Those changes are beginning to bite now. Devolution of care budgets are being taken all the way through and out of the care system to the level of the service consumer, the “customer,” and will no longer be in the control of service provider, the “shop assistant”. The principles at work here are quite hard to decipher and I am going to say that I believe they are a mish-mash, some conscious, some not. “Choice” and “Empowerment” are conscious ones. The service consumer should not have to be at the mercy of institutional service providers a/ to decide what they need, and b/ to provide for them en masse. Consumers should be able to decide what they need for themselves and to buy those services individually, from wherever they might be delivered. Like customers in a street market, choosing between vendors.
But I believe there are other, less conscious drives at work here. One is a distrust and even resentment of professionalism and its integrity and skills, even a suspicion that trained professionals are unnecessary in the first place. Another is a devotion to the god of the market and a third is plain denial.
We have no right, actually, in our desire to be “inclusive,” to talk or act in denial of the fact that people with mental health problems do really experience mental health problems, of one kind and another. The problems can be long-standing and seriously disabling. They can often leave you confused and pre-occupied, such that you don’t actually know in detail what you need and you don’t always want the responsibility and fiddle of managing a budget yourself. Once, I lay on my back on the road, having just gone over my bike’s handle-bars onto my head. At that moment I wasn’t particularly interested in my Right to Choose between one hospital and another, or in being empowered to decide how my help should be packaged or budgeted. I just wanted help, now, help I could safely assume would be well managed, well trained and careful of me. I wanted someone to lift me up, with care and expertise, since I was incapable just then of getting up myself. Just so.
As we now move into the era of Personal Budgets, it looks very possible, indeed likely, that they will mean the end of organised and on-going provision of mental health services in the community, working and accountable to high standards of care. Rather than take services forward, Personal Budgets seem likely to eradicate everything put in place since Care in the Community began. For people with severe and enduring mental health problems, it will be back to isolation in the bedsit and the street. Here again, dogma and denial will have undone what years of careful and sometimes painful development have built up.
In this same section on Money as Medium, I shall cover very briefly the topics of : the interviews being conducted by an organisation called ATOS ; the Coalition’s Benefit Reforms ; the decision by at least one Local Authority I know to make mental health service users pay, henceforward, for their support in mental health community centres, etc.
I shall say, first, that of course a very large proportion of people on long term benefits in this country suffer from long term mental health problems.
“Mental health problems are the largest single source of disability in the UK, accounting for 23% of the total ‘burden of disease’ (Dept. of Health 2011b)” This quote is taken from a King’s Fund Report called “Long-term Conditions and Mental Health. The Cost of Co-morbidities” Naylor et al, February 2012.
“The numbers who can’t work because of mental health problems (1.1 million) are not much off the total number claiming Unemployment Benefits (1.5 million)” writes Neil O’Brien in The Telegraph, May 10th 2013. Neil O’Brien is Director of “Policy Exchange”, an independent think tank working for better public service.
Against that background, it is not surprising that – as I understand it – the proportion of people on long term benefits in this country suffering from long term mental health problems is around 2/5ths. While I am sure that George Osborne, our present Chancellor of the Exchequer, would not dream of implying that people with long-term mental health problems are “skivers” – and didn’t mean them at all when he made his venomous, misleading and carefully calculated little “Strivers and Skivers” sally, I cannot guarantee that large numbers of people with long term mental health problems did not hear his words as a direct attack upon them. Here was this sleek, well-heeled political leader saying that people with mental health problems are just lazy and either need to pull their socks up or, by God, George and his millionaire friends would pull them up for them. Does Osborne realise the effect those words of his might have had on some very vulnerable people ? Maybe he does, and maybe he doesn’t. Either answer should by rights be cause for dispossessing him instantly of his position, before he does further social harm. Here is an element in our Society infinitely more anti-social than any “skiver” one might meet.
Onto Atos. This is a large international organisation which, having won the government’s tender, has been interviewing people on long term benefits since 2010 to ensure that all have been appropriately assessed as unemployable. (In much the same way, the international organisation G4 won the tender to cover security at the London Olympics, before being found woefully unequal to the task and being replaced by the army).
Inevitably, people with severe and enduring mental health problems have been caught up in ATOS’s procedures, and been called to interview by ATOS functionaries. First, I want to make the point that, before ATOS came along, mental health assessments of the people concerned had already been made by trained and specialist professionals, who had decided they were disabled by their conditions and therefore qualified for long term benefits. Presumably, the functionaries employed by ATOS were considered more competent than these professionals – or was their attraction their greater compliance ? Was ATOS required by its contract to meet certain targets for State Benefit reduction, however inept and irresponsible its individual decisions, whatever the effects on the people concerned ?
Shocking and shameful findings are quoted in the contemporary Wikipedia entry for Atos Healthcare, as follows :
A government study published in 2012 found that half of the people identified as “fit for work” by Atos Healthcare’s Work Capability Assessment on behalf of the Department of Work and Pensions in the UK, remained unemployed and without income.[35][36]
In 2012, 43 complaints against Atos doctors and nurses were being investigated by the General Medical Council or Nursing and Midwifery Council.[27] Criticism has been directed at Atos over the ability of its staff to deal with complex mental health problems and conditions whose symptoms vary with time.[37] In August 2012, Atos Healthcare claimed they had appointed 60 Mental Function Champions to provide additional training.[27]
Atos assessors have found patients with brain damage,[38] terminal cancer or severe multiple sclerosis to be fit for work.[39] According to government statistics, 1300 people died shortly after being declared fit for work by Atos.[40]
It has been reported on good authority elsewhere that 40% of ATOS’s decisions that people they interviewed are employable after all, are overturned on appeal. It has been found, as well, that those individuals who go in for their interview with an advocate beside them, tend to do better in having their disability confirmed (rendering an appeal unnecessary), than those who don’t. Which suggests that the 40% figure, already appalling as an indicator of incompetent decision-making, is probably conservative.
Further and still worse, The Independent has reported that if people attend an appeal with a Citizen’s Advice Bureau (CAB) officer or lawyer, the ratio of ATOS decisions overturned goes up to 70 %. (Since that Independent report, legal aid for most benefit appeals has been stopped. Furthermore, CAB funding has now been radically reduced).
I won’t give much more detail on this, here. We should be grateful to the The Independent and The Guardian for holding some light to ATOS operations, as it works its way through the most needy and vulnerable people in our Society, with – it still seems – the electorate’s support and consent. And I need also to congratulate Re-think Mental Illness for commissioning, last year, a study on the Atos Fitness to Work tests. On October 4th 2012, The Independent reported on the study’s findings as follows :
“..Six per cent of doctors have experienced a patient who has attempted – or committed – suicide as a result of “undergoing, or fear of undergoing” the Government’s fitness to work test.
A survey of over of 1,000 GPs across the UK by ICM also found that one in five had at least one disabled patient who had thought about suicide because of the test, which is aimed at assessing whether people claiming incapacity benefit are fit to work.
The survey, highlighted by Exaro, the investigative website, also found 14 per cent had patients who had self-harmed as a result of the test.
The charity, “Rethink Mental Illness”, which commissioned the poll, said it showed that the work-capability assessments were pushing some of the most unwell and vulnerable people in society “to the edge”.
I will add three observations of my own ; first, the ATOS interviews, already threatening and made yet more so by the reports of the organisation’s manifest incompetence, will confirm to the mental health community that Society is now out to get them by whatever means. That dread will not easily be articulated and cannot be measured, but let us keep in mind those Rethink findings. There is always and anyway a high rate of suicide in the mental health community. I have no doubt whatsoever that the conditions of dread and bewilderment presently being inflicted by these interviews, will be greatly increasing that rate, even as I write. Literally, the Atos “Fitness to Work” tests are killing people.
Second, a literal observation. My friend and colleague Caite Doyle, Community Psychiatric Nurse, went to support one of her clients called for an ATOS interview. The interview is a rote and generic one, more applicable to people with physical disabilities than mental, a crude and clumsy, depersonalising tool. Describing it to me, Caite put up her arms in imitation of what her client was asked to do, in order to show whether or not he was capable of employment, this man with serious mental health problems.
Third, a picture of my own, entirely fanciful, an image. But is it an image of mere fancy, or of the essential truth ? People a bit subdued after a very long and hard day’s work, are converging as usual on the supermarket, eager to buy in supplies. Suddenly, they see someone gaunt and fragile being dragged round the back of the building by a bunch of roughs and rude-boys, rather well-dressed and sleek. The shoppers quickly turn back to compiling their shopping lists. They know what’s going to happen next, out of sight and round the back, and they don’t want to think about it. “I bet that person deserves all that’s coming,” say one or two to themselves, uneasily.
Next, the spate of changes in Welfare Benefits, Housing Benefits, etc. etc. presently going through. These too are directly affecting very large numbers of people with severe and enduring mental health problems. But how many of the electorate know this ? How much of the “free” press, how many politicians, will be correctly informing them ?
I shall not engage here in detailed analysis of how much the income of people on State Benefits, already minimal, will be reduced by the Disability Living Allowance changes, or how many people will be adversely affected by the Housing Benefit changes.
I shall restrict myself, instead, to suggesting, again, that dread of these changes, the consternation they cause, coupled with the distorted emphases and witch-hunt atmosphere created by the right-wing press on this issue, ably supported by Osborne and his friends, will have as much impact on people with mental health problems as the actual reductions will have, however dire.
Now for the local example, spread rancid on top of the cake. I think it was last year that a local authority I know decided that it would be “fair” to start charging people with long term mental health problems for their use of community day care and similar support services. So a Council Policy document came out, called “Fairer Contributions.” To make sure that this development followed due procedure, there was a “consultation exercise” before implementation. That implementation is now going ahead, even as the ATOS interviews continue to take place and the Benefit Changes initiated by the Coalition Government begin to bite.
According to the new policy, individuals who have been going to community centres for years free of charge, as part of Welfare State provision for those in need, are now receiving bills. The bills began coming through in dribs and drabs, with an apparent randomness and much inconsistency as far as individual starting dates for payment were concerned. But after several months, they have caught up with the great majority of people who attend these services, often their only link with any community. The bills are sent out from a Council department which uses the term “Debt Collection” at the head of its invoices, a phrase which must sound strange and frightening to people who have never before acted, or thought of themselves, as debtors. The department appears to have only part-time workers, who are therefore hard to reach on the phone and slow to reply to correspondence or appeals. The workers have not generally had dealings before with people with mental health problems, and lack knowledge and training in how to work sensitively with people struggling to understand what is this sudden debt they have accrued.
To comply with the new policy, the mental health centres concerned have had to categorise and cost each element of their services and are now telling their clients in detail, how much an individual session with a worker will cost them, how much it will cost to attend a “drop-in” session in the sitting room, etc. Those clients are leaving in droves. First a conversion to this new Recovery religion is required ; then the service, their main support for years, suddenly explodes into chargeable fragments. What other religion charges its parishioners for belonging ?
Yet these are services which for years have helped people maintain their mental health in the community, who would otherwise struggle, with re-admission to hospital all too frequent, and self-harming a common and powerful temptation. I believe the outlook is grim now for those services and for the people they once supported, now cast adrift.
I shall briefly re-cap :
Initially here, I described a few ideas that struck me as a good way of conveying in general terms what needs to be available in the community for people with extensive mental health needs. Then I quoted what some people with mental health problems have said about a service where they felt upheld, included, encouraged and safe, where – as one put it – “I am not assailed.” I went on to list recent policies and developments which in my opinion are misconceived and have been ill-implemented, many of them following the dogma that anything based on market principles and “Choice” must be good. On the contrary, I believe that, together, the developments constitute a perfect storm now assailing some of the most vulnerable people in our Society, in the process undoing years of good work, love and learning, and shaming us all.
Finally, another poem. I wrote it in May 1994. It describes a typical meal which once took place in the mental health centre where Iain and I both worked. Already, the kind and quality of that meal, and of its preparing and partaking, are things of the past. From what forsaken places are we gathered here today.
The Meal
Something of power about the meal
something electric forging the dull elements
into a new and hushed
and human vibrancy –
a making.
The food here is fresh, new-made,
each choice of menu a matter of passion
personal risk and urgent debate
resolved in meetings weeks in advance.
The tables are round
of plain deal
but five years on
still surprisingly smart.
They like the tables.
They remember earlier times :
“We used to eat on trays
all around the two rooms
and we had to queue
quietly
in a long line.
No-one questioned it.
Who were we to complain ?”
The two cooks get a tenner
and a free meal.
There is a stringent job description
so the money’s hard earned.
They sit apart
once the meal is served
eating with their morning’s worker.
The morning’s sweat
drying on three foreheads
seals their fellowship.
And they come, the people,
from all their far edges
from all their fastnesses
to sit here at the plain deal
eight per table
forming the circle.
They come with their famishment
no food can satisfy
with their lostness
no finding here can heal.
The limitation of the event
with its essentialness ;
the simplicity of the being together
in these plain circles
with the distance each has travelled
to get here ;
simply the eating
makes a new sense here
a true valuing.
No-one would dare
say a grace here
but grace is present
in all the racket of the business
of eating, the clatter, the voices’
rise and fall ;
in every movement
of fork to lips, of eye to eye ;
in every word that is spoken ;
in every moment the circles
remain unbroken.
From what forsaken places
are we gathered here
today.
Rogan Wolf