Some reflections on my way out the door…
After nine years as Chief Executive here at OTR I’m moving on and away from working directly in mental health.
In my final days here I’ve been asking myself what the heck it is I’ve actually learned in that time and so, for what it’s worth(!), here’s what I’m taking with me…
1. The ‘mental health system’ extends far beyond mental health services.
I’ve learned – for example – that parks and sports clubs are as important to human wellbeing as are hospitals and clinics. It follows that friends, youth workers, teachers, co-workers and even pets are as significant as psychiatrists and nurses to our mental health and wellbeing. But this is a bit of an inconvenient truth, because none of the aforementioned are ever spoken about as being part of ‘the mental health system’. In fact when we talk about ‘the system’ we’re really just using a shorthand for mental health services that describe themselves as such (and even then usually only those within the NHS). The budget for parks or libraries isn’t considered part of the overall mental health resource, and the sports coach or youth worker isn’t understood or valued for their therapeutic and protective quality. My experience has brought me to a place where I think it important we stop privileging services in our systems thinking, because the most compelling and effective solutions and support for human wellbeing actually lie outside their purview.
2. Every human is like all other humans, some other humans and no other human.
I’ve learned that while people can be complicated their needs are really pretty simple. Good quality relationships and a sense of purpose and belonging are fundamental to our psychological and emotional wellbeing and recovery. Time and again I have seen that distress is driven by the dysfunction, loss or absence of these in some way; a scenario made more likely and unjust by the configuration of our services and the structural inequalities that plague our social and economic life. Instead of our preoccupation with rationing what services and resources we have, we really ought to be more able to design our policy and service responses around advancing these three simple things.
3. The quality of our conversations as leaders in the mental health system isn’t good enough.
In my experience the way we talk to one another is a real barrier to to true transformation. Our conversations are almost always instrumental in nature (i.e. they are about what and how we’re doing stuff without ever asking why we’re doing it). If our focus is too often on operational matters, our language is also unhelpfully biased by a technical and de-politicising language and preoccupation with volume, tasks and indicators that gets in the way of genuine enquiry. Different organisations and individuals working together in the same system usually know nothing of each another in any meaningful sense beyond what is being ‘provided’ by the other. I’ve learned that the status quo is a choice, and I make that choice every time I engage in instrumental conversations of this kind, or stay silent, or shy away from being bolder and more (constructively) disruptive in meetings and forums.
4. (Lack of) Imaginationland.
There has been zero creativity in any process I have engaged in locally or nationally to design new mental health policy or services. Often there is barely even a process, just a table and some chairs. Without creativity we’re not engaging our imaginations, and without imagining potential and alternate realities we’re just moving the furniture around. What’s more, co-production doesn’t survive the absence of creativity and an enabling process, which is why so much of what passes for it isn’t co-production at all, but a corrupted form of consultation with professionalised ‘service users’ that unknowingly reproduces the status quo. The absence of creativity in the process of designing public policy and services is – in my experience – simply because creative structures, processes and facilitation are squeezed out by cognitive and data driven perspectives, and not because the people around the table aren’t capable of being creative. I’ve come to the conclusion these positivist perspectives – which are also embedded in point three above – are a prison we willingly (and weirdly) confine our thinking too.
5. Professional identities and their statuses are in the way of creating a more relational (i.e. human) system and services.
This is de-humanising to those in possession of these identities as well as to those accessing services looking for answers and help. Experience tells me that expectations of services and professionals are – given the picture described above – entirely unreasonable and unrealistic (though few will ever say that). Unsurprisingly given the socio-economic story our society tells itself, we today defer and outsource far too much of what ought to be our responsibilities for ourselves and to one another as citizens to mental health professionals, services and the state more generally. And then we are disappointed, angry even, when these expectations go unrealised by professionals carrying large caseloads working within complicated processes and protocols, behind professional masks that have been designed to protect and maintain their owners and own internal logic. As citizens and professionals our basic response is always to argue for more money for more professionals, but we’ve half a century of more mental health professionals occupying every corner of our lives – from the prison to the classroom to the lifestyle magazine – to tell us this won’t make a difference. By the way, this really shouldn’t be a right-wing argument for greater personal responsibility or a ‘big society’ either; for me it’s actually an argument for new forms of collectivism and community underpinned by a personal commitment to self-care. After all, mental health and even severe distress is not the same thing as mental illness (we seem to be confused about that distinction in our public debate).
6. We have to start privileging relationships over expertise.
Through my career I have enacted and experienced repeatedly the behaviour of almost all mental health services, which is to intervene in people’s lives in ways that takes individuals away from those people and places most meaningful to them. I don’t just mean hospitalisation either, I mean the basic assumption of public institutions and services more generally that people come to and assimilate into them in a highly managed way. That might be to go to a clinic and set times and days, but it equally well applies to the form many ‘care pathways’ take, or the processes a team might follow in adhering to a clinical and operational model. Whatever, the movement is always the burden of the individual who needs or wants support, not the institution or service. This is partly about rationing and service-led responses, but it’s also cultural, because we privilege ‘expertise’ over relationships. Clinicians are ascribed varying degrees of status in the mental health system based on this expertise, but the power and potential for therapeutic change almost always resides elsewhere in people’s lives. It’s funny, the research still points convincingly to relationships and not expertise as the main driver of change, but somehow this ‘evidence’ isn’t weighted the same as that produced by the randomised trials for treatments. I must have heard a thousand times people say ‘services didn’t get me’, but really, why would they in this context? If we instead privileged relationships, and took ‘expertise’ out from behind our institutional walls and into the lives and relationships around people, strengthening and building their capacity to hold and care for those in distress or with ill-health, we might just resolve some of the debilitating tensions our health and social care system is unable to resolve – how to ‘do care’ in the face of an ageing population and rising demand.
7. The absence of any meaningful prevention is a political choice.
Let’s be clear; training teachers how to spot ‘mental health issues’ and ‘what mental health services do’ isn’t prevention. Nor is mindfulness or any of the other initiatives packaged up and rolled out to help individuals cope better. Real prevention would sit in the domain of public health, in the social determinants of mental wellbeing and social policy that sought better housing, a more holistic and less pressured education system, to improve the ecology of our neighbourhoods, create meaningful work, promote family life and ensure strong integrated communities. Instead mental health (not just mental illness) is held firmly within the language of individualised medicine, and this is a political choice the mental health system (for the most part) colludes with. Youth mental health is in the middle of a public health crisis, but as such it must be unique in history insofar as our response is to try and treat our way out of it, one patient and course of therapy at a time.
These seven observations are more or less what I’ll take with me from my time at OTR.
Our freshly updated Strategic Plan is really a thoughtful response to them, or at least an attempt to react and disrupt constructively while being part of a system resistant to change.
But strategies and plans aren’t much cop without good people.
And so my final observation is quite simply that it’s important to remain optimistic because it is actually possible, despite the very real constraints and compromises, to do things another way; to move in a different direction and model an alternative reality.
Today, what’s happening here at OTR – in a small local sense – proves that this alternative has validity in the real world. And that, despite the challenges of working in this field, is something very real to hang onto.