The recent debate about mental health sparked by the Inspector of Mental Health Services' report for 2004 is to be welcomed. Dr Teresa Carey painted an alarming picture of a service that was badly managed and seriously underfunded. Although there is a clear consensus that drastic measures are needed, different agendas are starting to appear, with different sets of priorities. These are based on fundamentally different ideas about what progress in the field of mental health is all about, writes Dr Pat Bracken
On one side lies the voice of traditionalists within psychiatry. The dominant framework here is a medical one, in which mental health issues are seen essentially as technical problems that call out for solutions in terms of science, technology and professionals. Questions about meanings, ethics, relationships and social position are not ignored, but they are of secondary importance. Progress is about white-coated doctors announcing "breakthroughs" in genetics and headlines about new wonder drugs. This version of innovation drives much of academic psychiatry across the world. In the past 20 years it has been fine-tuned to correspond closely to the corporate interests of the pharmaceutical industry.
Traditionalists within psychiatry maintain that current clinical practice is basically sound, but that there is a need for more of what is on offer at present. The agenda for the future involves more hospital beds, more outpatient clinics, more professionals, more research in biological aspects of mental disorder and some increased funding for psychological therapies. From this angle, progress in mental health has been, and will be, expertise driven.
On the other side of the debate lies the user movement that has emerged in the past 20 years. People who have used mental health services have started to come together to share experiences and demand change. This movement is international and increasingly organised and influential. It speaks with many different voices.
Some service users are happy to use the vocabulary of psychiatry and to look to medical science for answers. However, a growing number of users argue for a very different agenda.
They want to make technology secondary to a discourse focused on the needs they identify themselves.
In a book on Community Mental Health Care, published by the Royal College of Psychiatrists in 1993, Christine Dean provided a useful summary of these needs: "The type of needs expressed by service users at stakeholder conferences are for 24-hour, seven-day-a-week availability of help; meaningful occupation or employment; friendship; to be recognised and treated as an individual; not to be stigmatised; to have local accessible services; a satisfactory standard of living in terms of a home, food, information; availability of respite; safety/security (at times); and transport."
Using this framework, progress in mental health means a move towards the fulfilment of these needs. It does not demand more science, technology or research evidence. It seeks many of the things that the rest of society for the most part takes for granted, such as a social role, acceptance and inclusion: in a word, citizenship.
In fact, in the opinion of many service-users, it is their loss of social position that is their single greatest burden. Real progress here is about overcoming social exclusion. This is not an expertise-led agenda, but a struggle for democracy, inclusion and rights.
While traditionalists within psychiatry continue to promote a predominantly medical programme, many professionals from other disciplines are arguing for change. Indeed, many psychiatrists are also beginning to question this agenda and its priorities.
I am a founding member of the Critical Psychiatry Network (http://www.critpsynet.freeuk.com/). This has campaigned against the British government's plans to extend compulsory treatment into the community and, more recently, has worked to expose the influence of the pharmaceutical industry on the profession. The network recently hosted a successful day-long seminar at the recent agm of the Royal College of Psychiatrists in Edinburgh.
In Ireland, the chairman of the Mental Health Commission, Dr John Owens, and the Inspector of Mental Health Services herself are clear they want to see a genuinely community-based, user-centred service developing in Ireland in the coming decade. Other psychiatrists, such as Dr Michael Corry, have also been outspoken critics of the status quo.
How can a genuinely user-centred approach be established? How can we work to overcome social exclusion and stigma? I believe that three elements are needed if we are to have genuine progress.
1: We need to develop services that move us beyond the limitations of the traditional medical model of care. We need to shift the centre of gravity out of the hospital and clinic, closer to the home environment of the user and his/her family.
We require services that are able to respond to crises and breakdowns with flexibility. The sort of intervention we offer users needs to encompass more holistic forms of care; ways of responding to distress that do not privilege medical interventions above everything else.
2: There is also a need to listen to the voices of service users themselves. People who have negotiated their way through states of madness, alienation and distress have something important to say to us all, but most importantly to those who are still struggling. An important literature from individuals and groups centred on the idea of recovery has emerged in recent years. The recovery approach is based on the observation that many people who suffer episodes of mental illness recover without the assistance of traditional forms of psychiatric intervention, such as drug treatments and psychotherapy.
Many users maintain that psychiatric interventions have actually served to undermine their efforts to re-establish a normal pattern to their lives. There is now a body of knowledge about the therapeutic helpfulness of things such as work, leisure, spirituality, meditation, creativity, community and friendship. These are not secondary "adjuncts" to "real" treatment involving drugs or therapy. The recovery agenda seeks to foreground them. Individuals who have used services themselves are in a particularly good position to become skilled in this work and to support others who are struggling to find a path forward.
3: Overcoming the burden of social exclusion will require work to develop more supportive communities. This is not simply a job for professionals or for service users and carers. It involves some major questions for us all as citizens, such as: Are there ways in which our places of work can become more friendly to people with mental health problems? How can we work to overcome the negative stereotyping of service users in the media? How can we move to a situation where the positive contribution that people with mental health problems bring to society can be highlighted and appreciated? How are we to tackle the question of suicide?
I believe that through the establishment of community mental health forums and community development initiatives there is room for real movement on the issue of social exclusion. We know in Ireland, perhaps better than anywhere else, that cultures can and do change.
We can change the social position of service users and with this make it easier and more culturally acceptable to seek help from different quarters in times of crisis.
This is a time to be optimistic about mental health. The Government's expert group will hopefully report before the end of the year and the signs are they that that will produce a progressive and forward-thinking document.
Life can be better for service users. This will require substantial investment, but also new thinking.
Dr Pat Bracken is a consultant psychiatrist and clinical director of mental health services in west Cork