Dear Simon Jenkins,
Last week, in the Guardian, you wrote an article about the death of Robin Williams, in which you made a number of sweeping statements about “our” lack of understanding of mental health. Specifically, “Mental illness, if illness is the right word, seems lost in some dark age…Therapists wander the scene like surgeons on a medieval battlefield, at a loss for what to do…Research is paltry. Therapies are half-hearted”.
I was angry when I read this, not only because I felt it was blatantly untrue and uninformed, but especially because you described therapies as being half-hearted. Perhaps I took your comments too personally, but I read the article on a day when I’d had several powerful and emotionally charged sessions with clients.
One had experienced a significant breakthrough with a family member. As she described what had happened, my eyes welled to the point of brimming over. The pain she had been carrying for decades had been healed in a beautiful way.
Another spoke of the deep ugliness she felt inside and out. She had lived for years convinced of this ugliness. How I longed for her to be able to see herself as she really was. But in that session I could see encouraging glimpses of change. She was beginning to consider that her belief might be a result of her experiences, rather than true in itself.
A third person spoke of her ongoing battle with anxiety. Past traumatic events had led her to flinch from every sound, cringe from every stranger and to live like a prisoner in her house. It had taken every bit of her resilience and strength simply to walk from her car to my office and back again but she had managed to do it, refusing to entertain the negative thoughts clamouring in her mind. I was full of admiration for her. Yes, there was much further to go, a veritable mountain to climb, but she had started the journey and I felt privileged to be in the position of guide and encourager, map and compass in hand.
So, it was not a good time to read a description of therapies as being half-hearted. Reflecting on my close-to-30 years of working in the NHS, I could only retort that if anything was half-hearted, it was the provision of comprehensive services for mental health. Now, I’m not going to try to point blame at a particular politician or NHS managers. I understand that there isn’t enough money to go round and that cuts have had to be made. But let me take you back to the early 1990s.
I had just qualified as a Clinical Psychologist. It had been a long process, 8 years in all, but post-qualification there were lots of jobs at all pay levels so the career path looked promising. My first job was in a brand new mental health unit, which, for the sake of anonymity, I shall call “Greenfields”, in *shire. I worked as part of a Clinical Psychology team, linking with a number of community mental health teams (CMHTs) staffed by a wide range of skilled staff: Psychiatric Nurses, Occupational Therapists, Social Workers and Support Workers. Each CMHT was headed by two full-time Psychiatrists who had been in post for many years and this gave a sense of containment and safety to staff and to patients. People with mental health problems could be supported by the CMHTs for years, in fact, for as long as was necessary.
If people needed to have inpatient treatment, Greenfields had fully staffed wards and a comprehensive Day Hospital. This meant that while on the wards, patients could go to the Day Hospital and get involved in all sorts of activities, which helped their recovery: Art, Pottery, Aromatherapy, Cookery, Creative writing, Discussion groups etc. When they had recovered sufficiently to leave the wards and go home, they could still come in to the Day Hospital and be supported while they continued to recover. Greenfields had a number of attractive courtyards and gardens where patients could sit (and smoke if desired). Beyond Greenfields, there were several Social Services Day Centres: places where people with long term difficulties could be supported and find both structure and meaningful activity. (It was recognised that some people would not “recover” but still needed a service).
Two decades later I am still working in Greenfields. What has changed? Well, there have been some positives and no doubt our managers would be able to provide impressive facts and figures to show improvements. Personally I have seen our psychology team grow in size and in understanding. You might be surprised to know that thanks to the “paltry” research to which you alluded, therapies have been honed and developed over the past two decades so we now offer a more skilled response to those who need it, compared with back in the Nineties. Therapy provision is quite generous in *shire, compared with many other parts of the UK, although waiting lists are long.
Yet beyond this, I believe that mental health services as a whole have suffered hugely. The wards at Greenfield have long since closed, so now, if you need to go to hospital, you have to travel to the other end of the county. Chances are, however, that there won’t be any beds there, so you’ll have to go to the next county. Similarly, Greenfield’s Day Hospital has been closed down. The gardens and courtyards are overgrown and empty, a roosting place for pigeons. Cleaning services have been limited to a few hours each week so the cleaners have to focus on cleaning toilets and emptying bins: everything feels grubby. The Social Services Day Centres have closed. There is one NHS Day Hospital half an hour away, but you can only go there for a maximum of two weeks. An innovative service for people with severe difficulties is fighting for survival, having been threatened with cuts.
As for care in the community, the CMHTs have been restructured and bear little resemblance to the teams of twenty years ago. The uniquely trained and skilled staff have been reduced to being “generic workers” who all do more or less the same thing. They are only able to work with patients for a limited time and most of what they do involves minimising the risk of suicide and harm to others. Thus they have become highly skilled at risk assessment and risk management but their capacity to do much beyond this is limited. In addition, shift patterns erode the sense of team cohesion. I have never seen CMHT morale as low as it is now.
Meanwhile, Psychiatry provision is stretched to the limit. Over recent years, we’ve had a string of locums and junior doctors, leading to complaints from patients that they saw a different doctor every time. We now have several permanent Psychiatrists who are skilled and incredibly hard-working – but they too are under-resourced and their hands are as tied as those of their CMHT colleagues. They can only keep a fraction of clients “open” for any length of time. Long gone are the days when you could see your Psychiatrist for years; when it was recognised that some people might not “recover” and that there was value in containment and support. Free, ongoing support is no longer on offer in the NHS. For that you must turn towards the voluntary sector.
Job satisfaction for Psychologists is also at a low point. National initiatives to increase access to therapy (IAPT) have resulted in whole armies of mental health workers being trained to provide short courses of CBT. This is a good thing for consumers, providing their problems are relatively simple/recent in origin. It’s not such a good thing for Psychologists, as we are expensive in comparison. It is now very difficult for us to find jobs at anything above the lower pay grades. When higher grade colleagues leave, they are likely to be replaced by lower-grade staff. We all work above our pay grades and most of us don’t consider promotion as a realistic possibility. Yet this is a minor complaint when you consider our colleagues in neighbouring counties. They have had to reapply for their jobs in the knowledge that some would have to be downgraded to save money. I’ve heard that in some Trusts, whole CMHTs have had to be systematically downgraded to retain their jobs. All this results in workers who feel demoralised and somewhat paranoid about what the future may hold.
The spirit of the corporate world has invaded and business language is everywhere, along with bureaucracy and defensive practice. We spend a lot of time doing mandatory training in issues such as Infection Control, which helps to reduce insurance costs for our employers. This means that every year I have to prove that I know which colour apron to wear if dealing with body fluids and how to dispose of sharps, despite the fact that I have never touched a syringe or worn an apron in my whole career.
Even though our Day Hospital has long since closed, the walls of Greenfields are still adorned with paintings and collages created by former patients, a colourful reminder that therapy can turn the pain and suffering of mental illness into something redemptive and beautiful. Many of us continue to work towards this end, and we do so whole-heartedly. I will concede that there are times when I do feel like a surgeon on a medieval battlefield, at a loss for what to do. But my confusion is not about what sort of therapy I should attempt. My confusion is about what I can do within the limited resources at my disposal.
So, Simon Jenkins, please do not criticise therapy or therapists for being half-hearted. Instead, please turn your journalistic talents towards finding a solution to the damage that has been done to our mental health services.