UK Mental Health: Lessons from the Third World?

Re: Mental health services in crisis – tell us your stories The Guardian 21.6.11 Amelia Hill

It can’t be a very ‘happening’ news day when the Guardian’s lead story is ‘Mental health services in crisis over staff shortages’. Not that I have a problem with that, it’s just a little like proclaiming ‘Piers Morgan is a Twat’. It’s not really a story, more a statement of the obvious shoved into the media spotlight on one of those rare days when the coalition haven’t done a U-turn and Premiership footballers are shagging each other’s wives in the relative safety of Dubai or LA rather than the VIP areas of Manchester nightclubs. I’m no sub-editor but I might have shortened the headline to just ‘Mental health services in crisis’. Full stop.

But why? The prod for the story comes from the retirement of Professor Dinesh Bhugra as President of the Royal College of Psychiatrists. Dinesh is a man I barely know personally but who has a professional reputation as a doctor who has combined high-flying eminence with the sort of decent, caring persona that now seems as rare in the mental health professions as an NHS Manager who doesn’t punctuate every other sentence with ‘going forward’. His is a voice I will gladly listen to and take note of above and beyond any half-baked politik-speak from the Department of Health civil servant or, God forbid, a politician. Understandably, Bhugra’s concern centres on his own profession’s lack of ability to attract doctors to psychiatry from the sexier reaches of medicine or surgery, swanning around the wards with a stethoscope and a British National Formulary tucked into a white coat pocket.

But he also points toward what I call the ‘Bedlam Factor’. In-patient psychiatry which used to be, in the olden days of my asylum student nurse youth, divided into Acute Admission, Long Stay or Rehabilitation, Elderly Mentally Ill and Locked Intensive Care is now little more than a series of ever decreasing beds for ever increasing levels of nightmarish psychiatric distress housed within the crumbling ruins of our various Something Somewhere NHS Trusts. The comments from Guardian readers, many of whom have experienced the rawest edges of mental illness for themselves, are punctuated by stories of services falling apart at the seams led by a psychiatric ideology of medical model-ness propped up by labelling, diagnostic box-ticking, inappropriate detentions and powerful medications. 

Some of the more extreme anti-psychiatric views are a little hard to take for an experienced mental health professional who has, I hope, helped a considerable number of people over the years using the sort of skill and empathy that has made me proud to be a psychiatric nurse along with the countless numbers of superb professionals with whom I’ve worked over the years. And using the comments section of a left-leaning broadsheet website to blame our sub-standard mental health care on the current government really is a bit rich. Our current problems go back much, much further than any single administration or era can lay claim to.

As a blogger and occasional author of ‘proper’ books I often find myself a thousand words into a blog post or chapter before realising that what I’m writing is complete and utter bollocks. No amount of re-writing, editing, cutting and pasting will rescue the piece. If it’s that bad I simply delete the thousand words and start from scratch. 

The entire mental health system in the UK is more than just bollocks. It’s a bloody great set of diseased, swollen bollocks riddled with tumours and elephantiasis. Can we delete and start again? Do we have models elsewhere to cure the disease? Yes, I believe we do.

Dinesh Bhugra is certainly not alone in citing staff shortages in both medicine and the other disciplines as being at the core of our diseased system, but the story goes deeper and wider than a simple lack of bums in jobs, assuming that the staff vacancies are there in the first place which, as Guardian contributors have made clear, is far from the truth.

As both a former Ward Manager of a Secure Unit and a Community Psychiatric Nurse I long ago swapped the ward keys and the NHS lease car for a yearly self-assessment form and the words ‘Training Consultant’ on my passport. In case you’re wondering, I like to ensure that my status as a ‘trainer’ is not confused with one of those people in a vest and trainers who shouts about ‘feeling the burn’ and talks about ‘reps’.

But through various friends, family and especially training delegates I still see all too clearly how our mental health infrastructure works. Or doesn’t, as is usually the case. I still get to hear on a daily basis how fundamentally poor our mental health services are and how our prisons have become the new default asylums. I hear about people who listen to the voice of Barack Obama bellowing “CIA” in their ear, or whose sole ambition is to swallow dive from the top of a multi-story car park but whose ‘keepers’ I wouldn’t want looking after a pet Gerbil let alone those suffering the deepest moments of delusion, hallucination and utter despair. 

I hear hair-raising stories of mental health professionals who appear to need a small aircraft flying a banner marked ‘potential homicide’ before they can so much as think of the words ‘risk assessment’. Time after time we read inquiry reports following homicides and suicides, and time after time we hear the same old crap spouted by Chief Executives. “Patient care is our paramount concern”. “ We’ve taken on board the Inquiry’s recommendations.. “ etc etc, while the same situations crop up again and again, usually followed by the standard inquiry finding of professional boundaries getting in the way of good old communication, a total misreading of confidentiality and the Data Protection Act, and just sheer incompetence which all too often seems to be swept under the rug marked ‘lack of resources’, ‘staff shortages’ and even ‘the Receptionist being on sick leave’.

We have a mental health system clinging on by its fingernails supported only by a medically-led multi-disciplinary team approach now well past it’s sell-by date.  It takes a brave soul to see the elephant lurking ominously in the corner of the room, but I know a number of senior psychiatrists who will acknowledge at least privately that they their job involves little more than diagnosing,  prescribing and the yeah-ing or nay-ing of Mental Health Act decisions. 

Despite the ridiculously bloated diagnostic manuals which attempt to pathologise every aspect of human behaviour from severe mental illness to a kid who gets stroppy with his Mum (Oppositional Defiance Disorder, in case you ask) the process of diagnosis in psychiatry is not usually very taxing. Thanks to Stephen Fry and various documentaries and media articles, the bloke who works behind the bar at my local has a reasonable idea of what Bipolar Disorder is, and I think quite a few of us now know that if someone spends an hour checking their that their doors and windows are locked before finally getting out of the house, they probably have ‘that Obsessive Compulsive Thingy’.  

And as for therapy, most psychiatrists spend most of their treatment time writing prescriptions for anti-depressants (to treat Depression) or anti-psychotics (to teat Psychosis) or maybe a mood stabiliser (to treat Bipolar Disorder). But Geoff down The White Hart probably knew that as well. I’ve probably been struck off the Royal College of Psychiatrists Christmas card list at least three or four times in the last two sentences, but hopefully you get the point.

Now I’m not saying for a moment that if I were mentally ill I’d want anyone who hasn’t spent many years of hard medical school graft prescribing me medication that has the potential to leave me staring at walls for hours on end or keeling over with a lethal mix of SSRIs and something I picked up from Holland and Barrett, but most competent doctors have the ability to diagnose most non-exotic mental disorders and scribble their signature on a prescription pad. The real graft and skill of mental health care goes into a therapy programme for the patient with the windows and doors issues, or the social and family support of the person hearing the voice of Barack Obama.

Radical thoughts? Not really. A very good friend of a mine is a Professor of Psychiatry called Vikram Patel. His academic affiliation is not to the psychiatric establishment, but to the London School of Hygiene and Tropical Medicine. I was lucky enough to be in London in March for his inaugural professorial lecture along with Dinesh Bhugra and a number of other notable figures from the great and good of psychiatry. Vikram spoke with great passion about the Global Mental Health movement and the World Health Organisation’s  Mental Health Gap Action Programme (mhGAP). Eh?

Okay. It’s not often that my ego will allow even a close friend’s book to be bigger and better than my own literary efforts, but Vikram’s ‘Where there is no Psychiatrist’ is the acknowledged bible of how to do mental health in parts of the world where there is no such thing as a brass nameplate on a door and where MRCPsych might as well be ‘Hello’ in Klingon.

Vikram (who now owes me at least a pint) has researched and set up programmes all over the so-called Third World (or if you prefer, the ‘developing nations’) whereby local people are trained up to assess mental disorder and put in place therapy and support programmes for local people presenting with psychological symptoms. They come from the same cultural and ethnic  backgrounds as their ‘patients’ and are trained to understand the difference between, for example, someone who ‘hears voices’ but is otherwise perfectly happy, and someone suffering a severe psychotic illness and may require further assessment and perhaps anti-psychotic medication prescribed by a visiting doctor. They possess the local, cultural understanding of how mental disorders arise from both factors such as brain pathology AND the social and environmental factors which are so often brushed aside in our traditional Western model of mental health.

To paraphrase Rolf Harris, ‘can you see what it is yet?’ 

Countries as poor and riddled with life threatening diseases such as malaria and HIV are starting to realise that early, local interventions aimed at addressing mental health issues can dramatically reduce the risk of contracting life-threatening illnesses such as HIV. They can reduce suicide. They can reduce crime. They can reduce drug and alcohol abuse and a whole host of very expensive social ills. And they can do all this with a basic, cheap but well designed and targeted training programme with all but a smattering of expensive, highly qualified medics and multi-disciplinary staff to supervise the work on the shop floor.

We have known for many years that brief psychological interventions can be at least, if not more, effective in treating many forms of mental disorder than endless prescriptions for anti-depressants and tranquillisers. Instigated by the previous government, the Improving Access to Psychological Therapies initiative aims to get GPs to refer people with mental health problems to therapists as an alternative to the script pad.  

It means well, but if I were referred to my local IAPT service in Weymouth I would be trotting along to a dilapidated prefab building plonked in the car park of a community hospital. Yes, it’s handy for parking but looks more like a Crack den than a sanctuary for my distressing psychological issues. This is how seriously we take mental health in the UK, even within a relatively prosperous seaside town in Dorset. 

Faced with a choice, would I rather have support from a trained local with a very short waiting list and a clear plan of action supported by a visiting medic who can prescribe any medication I might need. Or would I plump for an appointment with a highly qualified professional for whom I have to wait six months for a fifteen minute appointment  before being given a prescription and a further appointment for a CPN, Occupational Therapist, Social Worker or Clinical Psychologist who will, if I’m lucky, put me on yet another lengthy waiting list?

Well I know where my mental health would rather be trusted, but please feel free to leave your comments and please don’t hesitate to put me on your Christmas card list. I have a feeling I may need the your support.

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