Mark Brown has been trying to work out the political landscape of ideas in mental health. So far, it’s not been easy
It’s been a concern of mine for a while that in mental health we don’t really understand the context in which we are trying to innovate or in which we are trying to make new things happen. It’s often struck me that the ideologies (guiding ideas about how the world should work) that people do or don’t share have as much of an effect on the possibility of their idea, project or policy working as their own skill, drive or the ‘rightness’ of the thing they are intending.
In mental health I often see a lot of assertions about how the world ‘should’ work which are met with equally emphatic responses about how the world ‘does’ work. Often this obscures how something could be made to work. Often in mental health our head tells us one thing but our gut tells us another. I’ve always been surprised by the amount of people who have told me that they’ve never been able to reconcile their political beliefs with what they do or have experienced in mental health.
I think the area of ideology in mental health is fairly under explored. Where does a survivor user differ from a service user? How does the vision of personalised services for someone completely opposed to private sector involvement in NHS provision differ from the vision of someone who feels there should be more user-led charities providing services? For a while, I’ve been trying to work out where various schools of thought and ideas in mental health fit into a broader political context and how they relate to each other.
The axis below is my first attempt at trying to develop a framework for trying to understand the political positioning of different mental health ideas. They don’t yet map onto broader political ideas as it’s a work in progress and probably one beyond my skills and knowledge.
On the vertical axis; solutions that are collectivist are ones that are based upon the idea that best solutions to things are ones where we all put in and we all receive things in return. Collectivism can be egalitarian (a member group where everyone has an equal say or stake) or hierarchical (our government, the NHS). Collectivist solutions are affected by the need to balance the needs of everyone who is included in their collective group. At the opposite pole are market individual solutions, which at their extreme are people buying what they want from whom they want for whatever reason they want. Pure market individual solutions don’t involve any consideration of anyone beyond their purchaser.
The horizontal axis captures the position between medical model at one pole (the belief that mental health difficulties are purely individual medical conditions which can be treated purely by medical means) and survivor / non medical (this needs to be phrased better, but tries to capture at its extreme the idea that mental health difficulties are socially constructed and do not, as such, exist) at the other. Initially I placed the social model of recovery in opposition to the medical model, but I don’t think this is correct as this pole needs to cover ideas that acknowledge the existence of mental health difficulty but differ as to the most appropriate way of alleviating it and ideas that do not acknowledge mental health difficulty as an illness category at all.
In the first quadrant (Collectivist / survivor non medical) you’d find ideas that were about, for example, using the power of the state to reduce the things that impact on general wellbeing or which are known to be common factors for people who have mental health difficulties regardless of whether they recognise themselves as having a formal diagnosis. Also in this quadrant are things which are not medical but which people feel should be paid for via collective means such as taxation. Much non-medical voluntary sector activity around mental health might be found in this quadrant, as might ideas and practices derived from mental health social work. This quadrant retains the idea that there is a responsibility inherent in society to make sure people are OK.
In the second quadrant (Collectivist / medical) you would find ideas similar to our current system of mental health provision: a universal system of medical support funded through taxation; with decision making made along hierarchical lines. You might also place large provider charities in this area depending on the charity and depending on their structure. At its extreme collectivist / medical can be top down, get what you’re given regardless of whether the decision making is egalitarian or hierarchical. Even if everyone has a vote, that’s no guarantee you’ll get the outcome you want. This quadrant also retains the idea that there is a responsibility inherent in society
The third quadrant (Survivor non medical / market individual) is at its extreme people paying for whatever they want, whenever and however they want it. At its purest this is people directly paying for things that they want, at price they want to pay and at price a supplier can provide them: the market for consumers. This quadrant does not have the same notion of collective responsibility as the collectivist ones; if you make a choice, it’s your responsibility to deal with the consequences. In its purest form the consumer does not need to consider the effect that their decisions will have on other people.
The fourth quadrant (medical model / market individual) is where we would find currently optional medical treatments for mental health, self-funding of treatment and other interventions based upon individual choice and/or purchasing interacting with medical professional knowledge. Medicine tailored to the individual might also sit here as would the various industries currently serving the NHS with drugs, equipment, buildings etc.
While these quadrants may seem simplistic, in reality it is often more difficult than it looks to place particular ideas, positions, services, methods of working or policies into this grid. Playing with it as a tool to help thinking, I’ve found that it’s often a best fit rather than snug one for most mental health ideas, but that the process of trying to place them makes it possible to examine them in vaguely new ways.
What is most interesting to me is that the placement of particular ideas shows up the tensions within them. For example, the idea of service user led non-medical interventions is one that, at present, only public money could consider supporting. This would place it in the collectivist/non medical quadrant. For many, for them to succeed and remain true to the wishes of ‘service users’ requires freedom from the hierarchy-based imposition of external targets presented by many types of public funding. This would suggests placing it in the non-medical, market individual quadrant where people could be willing consumers of whatever they chose to consume. This, however is politically anathema to many setting up such services and also doesn’t guarantee the income to guarantee the continuation of such services. The idea of the mental health consumer as someone with buying power is again heavily contested as a percentage of people with mental health difficulties tend to end up skint due to being out of work for long periods and those that do not are encouraged to see themselves as no longer in need of support or opportunities specific to people with mental health difficulties. This is not to say that there aren’t ways out of this tension – there are – but the act of trying to place these ideas into a political framework shows the strong tensions within them.
At present there is much talk of the need to find new ways of delivering and developing mental health for all in the UK at a point where Scotland and, to a lesser extent Wales, are travelling in a very different political trajectory in regards to their health and social care services.
While it’s nice to think that we can remake the world in our image and trump economic, social or political conditions it’s hard to see that we could do that to make our mental health project happen. Even if we could; we’d need to work out exactly what the implication of making that change would be and where it fitted into wider ideas about how things should work. Mental health is not a world on its own. If we can identify roughly what form our ideas take we can begin to learn from similar ideas with their own history and lineage in other areas of human activity.
Maybe we aren’t all on the same side in mental health?