Reprinted with permission from Openmind © Mind (National Association for Mental Health)
Safety and psychiatry
Pat Bracken and Phil Thomas
Like most other people in the country, we thought we were waking up to a new world on May 2nd 1997. We hoped the new government would bring a fresh approach to the health service, and to mental health policy in particular. We hoped, at last, for a long term strategy. We were frustrated and demoralised after years of Tory vacillation, in which policy continually shifted in response to the latest crisis. Most importantly, we hoped that under Labour, the importance of social, economic and cultural issues in relation to mental health would be recognised and substantially inform policy development.
Our hopes were raised by the speech of the junior health minister, Paul Boateng, at MIND's annual conference last November. In this he stressed the importance of mental health problems and indicated that the Labour government "planned to take on board the ways that poverty, unemployment, bad housing, racism and educational failure contribute to the causes of ill health". He also indicated a concern to listen to the views of users. This was followed by the White Paper on health in December, which contained a number of interesting proposals, including the concept of Health Action Zones. This has potential and could result in more resources being directed at deprived inner city areas. Our hopes were knocked when we read a newspaper interview with Frank Dobson on the 17th January. Apart from being annoyed that we had to buy the Telegraph to read the story, the headline Care in the Community is Scrapped, left us confused and disappointed. Mr. Dobson was reported as saying that ministers were drawing up proposals to build new institutions in which people could be treated against their will. Furthermore, it was reported that the government had plans for a 'Mental Incapacity Bill' which would make provision for compulsory treatment in the community.
However we remain hopeful. It is clear that this government wants to move forward, but they appear stuck on the notions of 'public confidence' and the 'credibility of community care'.We urge ministers to study the arguments and evidence carefully and not be swayed, by Populist concerns, into adopting an agenda dictated by tabloid headlines.
Our reading of the relevant literature, and our clinical experience in inner-city Bradford, have convinced us that:
a) there has been no increase in the 'threat' posed to the public by people with mental illness in recent years.
b) our society is obsessed with 'risk', and this has led to the public becoming more fearful about a number of issues (Furredi, 1987). In turn, this has led the media to focus increasingly on topics concerned with dangerousness and risk. At the same time, stable communities have been weakened by unemployment and increased social mobility.
c) this increased fear has meant a real increase in the violence, threats and discrimination suffered by the mentally ill. There is increasing intolerance, stigmatisation and rejection.
In our opinion, building more 'secure' facilities will not help. If the public is fearful of the mentally ill, then this fear needs tackling. Forcing people to stay in institutions, against their
wishes, will not achieve this. In fact, it may make matters worse. Making psychiatry more coercive will only result in users becoming less trustful of professional staff. As a result, they will avoid staff in times of crisis. They will actively avoid engagement with services and view overtures from staff with suspicion and fear.
On the other hand, a move towards a coercive style of community psychiatry will mean many professionals becoming preoccupied with 'risk assessment' and 'risk management'. There is evidence that this is happening already. Various instruments have been developed in a vain attempt to 'measure risk', as if risk was a variable like temperature or pulse rate which was continuous and available for measurement. This is dangerous nonsense. Ticking boxes on checklists is no substitute for really getting to know someone. Indeed, in our experience, reliance on risk assessment protocols can be an impedance to building a trusting relationship, and trust is the key to any real understanding of increasing risk. In addition, when professional staff develop relationships of concern with service users they are more motivated to act and organise help when things are deteriorating. One of the clear messages from recent enquiries is that the most dangerous situations arise when service users become alienated from professionals, and no individual professional or agency feels responsible and leaves it to others to act.
The current discourse about risk is premised upon a strong individualist orientation. From this perspective, risk is something to be identified in individuals and their histories. Contextual factors such as the social environment and the attitudes of professionals and other authority figures are systematically excluded from the debate. In our opinion such contextual factors are most important. We believe that the safest situation, for all concerned : users, their families, the general public and professionals is to be achieved through well resourced services, which practice in a user-sensitive manner, and to which people will turn in times of need. These need to be easily accessible and have a practical value to the user. We also need social policies which will tackle 'dangerous' social environments from which people can emerge both alienated and angry.
Safety is an important issue. However there is a danger that 'assertive outreach' could easily become 'coercive outreach' if the present government only listens to one side of the current debate. This will not decrease the fearfulness of the public and will return many users to a life of misery. It will also mean a closing down of some of the most important aspects of the debate on safety. This would be a disaster for all involved.
Furedi, F. (1997) Culture of Fear. Risk-Taking and the Morality of Low Expectation. London: Cassell.