The New Mental Health

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?

(The below post by Mark Brown is adapted from a 2012 proposal that never got off the ground.  Despite this, the question of how we might redefine back-to-work support to be something that people with mental health difficulties themselves control and shape is ever more relevant)

The issue of benefits change and return to work is the issue that has dominated debate in the mental health sphere, as the broader issue of benefits and welfare state reform has the public sphere.  In a political climate that fetishes choice, those involved in back-to-work activity have been perversely denied it by the structure of back-to-work provision and its mandatory nature under current policy.  Aside from the world of social media there has been little concentrated opportunity for people with mental health difficulties currently involved in attempting to enter or re-enter the labour market to share ideas, frustrations, aspirations and suggestions.

The Department of Work and Pensions’ Work Programme is tasked with the role of returning people to work, including many people with mental health difficulties who are being moved from benefits such as Incapacity Benefit into either the Work Related Activity Group (WRAG) of Employment Support Allowance (ESA) or into mainstream Job Seeker’s Allowance (JSA).

The Work Programme is delivered by prime contractors and their subcontractors.  There has been little research to date into the practical attitudes of people with mental health difficulties to work and, more importantly, what people with mental health difficulties would actually value and engage with from services that exist to support them into work.

There has been little recent research into areas involved in a return to work such as attitudinal factors, user experience of back-to-work services, the role of individual and collective agency and the factors which inhibit or promote back to work activity.

There is a need to answer the overarching question: “Can we do back-to-work services for people with mental health difficulties better and what can we learn from people with mental health difficulties to do so?

Much money, limited success

Present government policy is based upon returning a significant number of those currently claiming benefits to the labour market.  The replacement of Incapacity Benefit with Employment Support Allowance (ESA) represents an undertaking to reduce the number of people with disabilities claiming out-of-work benefits, a move intended to end the number of people with disabilities who remain outside of the labour market for indefinite periods.

In the past the DWP has found it difficult to provide support to people with mental health difficulties and other variable disabilities in relation to the labour market.  There has been a perception that the back-to-work services and benefits provision have not understood the needs and aspirations of people with mental health difficulties and that there is a distance between policy intention and on-the ground practice.

This perception has not been challenged by the introduction of the Work Programme and the acknowledge shortcomings of the Work Capability Assessment delivered by Atos. There is a belief on the part of many people with mental health difficulties that all DWP action to support people to return to the labour market is only based upon reducing overall benefit spending and is not based on supporting people into lasting, meaningful employment.

To date, there has been an overarching argument that work in and of itself is an unequivocal good and that a return to work signifies a recovery from mental ill-health.  Work such as the Sainsbury Centre for Mental Health’s (now Centre for Mental Health) Mental Health and Employment and Dame Carol Black’s review Working for a Healthier Tomorrow have tended to the overall statistical analysis of the outcomes of unemployment mental health and the effects of mental ill-health on employment prospects.  They have tended to conclude that being in work is better then not being in work; and that people who are in work tend to be less disabled by their mental health difficulties than those who are not.  These conclusions, however they have been hedged with caveats, have often translated into blunt mantras.

At present there are large amounts of public money being spent on behalf of people with disabilities – especially people with mental health difficulties –  to help them return to work.  The actions paid for by this money are currently meeting limited success.

No one is asking the right questions

There is currently little research conducted to attempt to capture the personal experiences of people with mental health difficulties who are outside of work.  Mental health difficulty is a diverse range of conditions and those that experience it are also diverse in their life experiences and situations.

For many people with mental health difficulties, the world of work has been a challenging, difficult place.  While in theory the aim is to help people to stay in work, in practice many benefits and forms of support have only begun once an individual leaves the world of work by being deemed incapable of work.  For some, the idea of work becomes conflated with the idea of crisis, ill health and stress, with a literal perception that it was ‘work’ that is to blame for the development or worsening of illness.

Many are wary of the forms of employment or employment readiness training offered to disabled people with non-physical disabilities, or of the types of training and activity into which they may be coerced.

It is time to listen to the experiences and aspirations that people with mental health difficulties have in re-entering the labour market and how services might be better conceived, designed and implemented to make this successful.

It is currently unclear how much the shape of current back to work provision was shaped by actual discussion with people who might use it.  Popular opinion within the world of mental health activism would have it the current regime was designed entirely to act upon people rather than engaging with them.

It is vital that we develop a clearer picture of the ways in which current back to work provision for people with mental health difficulties either supports or creates barriers to returning to work.  To do this we must make the case strongly that DWP and other service designers must understand attitudes and ideas amongst people with mental health difficulties to ways that these services may be improved.

If we take it that people with mental health difficulties should and would wish to contribute to making better back to work services (this is by no means guaranteed, nor should it be expected to be) some of the vital questions, currently under-explored, that could be asked and answered include:

• How much of successful back-to-work provision is transactional and how much is based on relationships? (Does it matter who does back-to-work support? Can and should people be able to choose?)

• Can back-to-work provision create perverse incentives that conflict with ‘recovery’ (both social and medical model?) (Does back to work provision as it stands now make some people more ill? How would this be avoided in future?)

• How does previous unsuccessful back-to-work provision impact on future engagement with back-to-work providers? (Does one bad experience make all future experiences more likely to be felt to be bad, too?)

• To what extent are there things such as ‘good’ work and ‘bad’ work for people with mental health difficulties? (Does arranging placements at random on the basis that they’ll ‘be good for people’ ever work?  Do some jobs make some people more unwell, especially if they are coerced into them?)

• Do people with mental health difficulties have strong ideas of what help, assistance and support they need to return to work and if so, how does this match up with existing conditions and provisions? (What happens if you ask people what would help them into work? Can it be provided at present; and, if not, what does that mean for an individual?)

• To what extent can individual agency and potential be unlocked to help someone move from worklessness into employment? (What if coercion and regimented back-to-work provision wasn’t the model? Does the current model work against itself by removing or minimising the role of self-determination and choice? What if people were supported to develop their own programme of support?)

• What ideas and experiences of work do people with mental health difficulties have and how representative are they?  Can the experiences of people with mental health difficulties in work be categorised and if so, do these experiences correlate with current or past success in the labour market? (Do people with different mental health difficulties have different experiences in the job market? Are there specific things that help some people more than others?)

If the above questions were to be asked and answered we would be some way towards working out what back-to-work support would look like if it was developed by people with mental health difficulties themselves.

The challenge is: who will ask these questions and who will support the actions suggested by their answers?

Mark Brown (@markoneinfour) is development director of Social Spider CIC.

Mark Brown (@markoneinfour) examines why debate about personalisation in mental health gets stuck and why micro-provision might get it going

Personalisation of services is something we take advantage of every day.  When I go to the shop I buy strawberry bootlaces.  I could have bought seven litres of vodka or a tin of shoe polish.  I personalised my experience by purchasing what I wanted.

Simple? So, how come personalisation in mental health is such a complex subject?  And why isn’t it being discussed as a great opportunity for people with mental health difficulties?

Personalisation: Much complications. Such debates

Personalisation in mental health is people ‘claiming’ and using personal health budgets and personal care budgets to purchase non-medical services, tailoring their support, care and treatment to their own personal preference.

From April 2013 personal budgets should be available to anyone with mental health difficulties on Care Plan Approach in England (I haven’t been able to find any readily accessible numbers for exactly how many people are eligible. If you know, leave a comment).  It should be possible to picture this being the subject of a ‘tell Sid’ style advertising campaign: ‘Don’t forget to claim your personal budget, putting you in control of your mental health’.

In practice, the idea is far more heavily contested than someone outside of mental health would predict.

The real challenge for personalisation – personal health and social care budgets – is ensuring that people actually have a realistic opportunity to choose from a variety of options and to find something that works for them.

For an individual to tailor their support, care and treatment requires a variety of different things from which to choose; available in ways and at prices which makes it possible for them to be chosen if the individual wishes.

This requires providers of services. Providers of services need to be sustainable, at least to the extent that they can provide the services they promise to the customer for the period for which the customer has paid for them.

While this looks like a challenge for the customer in that it presents both a risk (what if what I buy isn’t what I want/doesn’t fulfil its promise?) it also creates a significant challenge for the provider.

Much discussion of personalisation is conducted from the perspective of either service delivery bureaucracies and organisations currently providing services who may or may not look at the potential of personalisation as an opportunity.  What is often left out of the discussion is the examining the question from the perspective of people who may go on to provide services for people to purchase.

There is much discussion of the ways in which we might facilitate people  exercising choices, but relatively little about the actual things that might make up that choice.  While this understandable – we tend to be experts within the domains in which we usually work – it does leave a gaping hole:  Just how do we provide personalised services?

In most places, personalisation isn’t going to work by trying to meet a huge number of needs and preferences on an industrial basis.  That’s what we have now and why we might have got stuck with personalisation in mental health consisting of advocating for its existence and few opportunities to actually put it into action.

In what follows, I’m avoiding discussing personalisation from the perspective of those receiving services in any depth as it’s a complex and under-discussed area to which I want to do justice in future.  We’ll have to accept that personalisation looks like a failure if it means having services you were familiar with taken away without anything obvious to replace them.

At present, the locus of discussion about personalisation is currently in the areas where people concerned are most comfortable (whether it is a good thing or not) and relatively moribund in the areas of personalisation that take the debate towards answering the question of how it might work.

A threat to everything we hold dear

Many underestimate how much of a threat to an established way of working personalisation presents.

In all other debates about meeting needs, the excitement is about start ups.  Small, hungry businesses that have spotted a niche and who are going for trying to fill it.  In the debate about mental health personalisation there is just the same established voices.

The existing model of ‘can we have some money to some things with some people’ confers significant advantages on organisations and those who work for them in that it has, in the past at least, made this world stable  and predictable.  Activity follows evidence of need.  Evidence of need comes from analysis of conditions.  It is the dream of rational central planning, where money flows down from central repositories, guided at every turn by rational technocrats.  Your job in the organisation remained stable.  If you were not hitting your targets, this was due to a lack of resources.  In this world, pay and conditions can be altered by collective bargaining.  It is a world where you know where you are.  It’s a world where someone, somewhere else could work out how things should work and where you could petition them if they didn’t.  Seen from this perspective personalisation profoundly destabilises this world and it’s disingenuous to argue that it doesn’t.  How you feel about this destabilisation depends on how frustrated you are with things as they are.

When I look at large organisations talking about personalisation I think: ‘you can’t get there for here’.  In other words, I keep thinking there is no way that an organisation structured like that can get to providing services that small numbers of people directly want to purchase.

The main reason for this is, for those organisations, the cost of providing large amounts of discrete, different services is far greater than providing the kinds of high volume services for which they structured.  They just aren’t structured for personalisation and often are trying to replace sources of revenue that have been lost, such as block grants or contracts.  Once organisations reach a certain size they become less agile.  Staff recruitment becomes more specialised, with strictly delineated job roles. Contracts become honed and precise.  Redundancy payments become an issue.  This is stability: great from the perspective of working for this kind of organisation, but it does make it difficult for an organisation to change direction or to innovate quickly and iteratively.

To provide a service in a way that allows you to continue to provide it on an ongoing basis you need to be able to service any debts it creates while making, in theory, enough surplus to make it worth your while in actually doing it.  This means that for any provider to enter into providing personalised services, there is no guarantee that the money spent on setting up the service will be recouped quickly enough by providing that service.  The natural level of return for that service (the number of people who want to purchase it and the amount they are prepared to pay for it) may not be equal to the money it costs to provide it, or may not make enough of a profit to repay the money invested in keeping it going.

Larger organisations are asking the question ‘How can we deliver personalised services that will generate the revenue to replace the revenue we have lost so that our organisation may continue as it has done?’  The answer is: either you can do something that you call offering personalised services and get closer to that aim, but betray the idea of personalisation in the process, or you can try to develop and deliver smaller, more specific services but at a really high cost because you’re organisation isn’t the right shape and the service has a breakeven that is higher than the service can ever achieve

Micro provision – the answer that dare not speak its name

The answer to the question ‘how do we make personalisation meaningful in mental health?’ is glaring obvious: we support the development of a range of providers with business models that work.  But it’s not proving to be that simple.  In mental health we can’t imagine new entrants to the market.  Indeed, we don’t really have any idea of what the value for personalised services in mental health is.

One of the only ways that I can see to find a way toward true personalisation, where people will either be able to find a service that really works for them or to bring a service that fits them into existence, lies with micro provision.

Community Catalysts define micro providers as ‘local people providing support and services to other local people, who work on a very small scale with 5 or fewer full time equivalent workers – paid or unpaid who are independent of any larger organisation’.

Traditional models build density by setting up a broad-based service in a building and saying ‘you come to us’.  Personalisation can’t work like that.  At the beginning, micro-provision will mostly be kitchen table businesses meeting needs drawn directly from people’s wishes or the hunches of plucky start-ups.

Micro providers, being very small, have a business model that is not based on achieving economies of scale but upon limiting the cost of each transaction.  In practice this means delivering a service that is only supposed to have a limited number of clients.  In a lot of situations, the needs and desires being met by personalised services will not lend themselves to density.  The chances of there being sixteen hundred people in a town of 60,000 people, with long term severe mental health difficulties and who want to take courses in linux coding are slim.  The chances that there might initially be ten is possible.  It can be guaranteed by finding those ten initial people and setting up the micro-provision to serve them at a price that works for both parties, a process otherwise known as market research.

There is a a kind of virtuous circle in micro-provision in that it can be the opportunity for people with lived experience of mental health difficulty to start small businesses or charities to provide help and support to other people with mental health difficulties.

In many respects this is something for which small voluntary sector mental health organisations in mental health have been advocating for many years: for ‘professionals’ to get out of the way and for people with mental health difficulties to be able to choose from a range of different options, some provided by their peers.

Collectivist provision vs. market:  Fight!

I think that there are very good reasons why the debate about personalisation always shifts away from the discussion of how you might actually provide either a flexible service or a limited objective service to a small number of people.  Personalisation is a profoundly political idea, and responses to it are often either overtly or covertly political.  Personalisation is caught in the conflict between market individualism vs. Collectivism.

The mental health services that we have today are built on the bedrock of a system created when no one cared what people with mental health difficulties wanted.  The idea of choice in mental health and care is in part a recognition that what people want might differ from person to person and from year to year.  The system we still have was set up for someone else, possibly in an office, to work out what was best for us.

In April last year, I was writing about  the legacy of Margaret Thatcher for people with mental health difficulties, focusing on the idea of Care in the Community.  As with personalisation, this is a stepping stone on the path away from the dream of universal mass provision of services.  As I wrote:

“Collectivism is the idea that the state should provide for the needs of everybody as much as is possible by creating structures that meet those needs. Market individualism is where choice, lots of different providers and the ability of people to make decisions and put them into action is privileged. To those without mental health difficulties – and some with – Care in The Community looked like the dismantling of a collectivist solution to mental health difficulty, where everyone would be ‘looked after’ and its replacement with a a hodge-podge of different bits and pieces that might not manage to help everyone…

“Even taken as part of the changes that the policies of Thatcher governments instigated, hinging as they did on the idea of increasing choice while reducing the involvement of the state (in theory if not in practice), and the subsequent economic and social effects that busting the post war collectivist settlement caused; it’s still hard not to see a tiny positive in the policy.

“Of course, it’s impossible to divorce the good points of a government’s policy from the overall effects that the sum of all policies and events had during a period.”

In some respects, the public sector spending contraction from 2007 onwards has forced a change within the mental health sector, with the public sector spending less in a lot of places and getting less ‘out the door’ to the voluntary and community sector.  Cutbacks have led to a reduction in services both within the public sector and without.

Add to this government policies about ‘allowing the market into public services’ and personalisation and personal budgets look like cutbacks and privatisation to many who work in the services that personalisation might destabilise. On top of this sense of wider economic instability for many personalisation raises a spectre of greater instability.  Personalisation seems to be a mantra that will tug at the tablecloth and upset all of the dishes at the dinner table.

Collectivism is a brilliant mechanism for doing some things and not others.  Personalisation gets caught in the wake of other arguments about what States should and shouldn’t do or in worries about the sustainability of the broader voluntary sector.

The alternative to this settled way of doing things, if you’re currently employed within the reasonably safe confines of a large organisation, looks significantly more scary.

 The ‘what do I eat in the meantime’ conundrum

Any service, big or small, requires a flow of resources that are overall equal or more to the resources required to deliver the thing it delivers.

The challenge for personalisation from the perspective of delivering a service is that any service takes time and resources to build up to a level where it is possible to balance in income the resources required to continue to deliver it.

This is what I’d call the ‘what do I eat in the meantime?’ conundrum.  Put simply, people need to eat.  In starting up a business, the biggest question is where the resources can be found to pay for the time between devoting time to that business and that business beginning to generate cash returns.  If a business needs a large amount of time and resource to get going, such that it is impossible to do other things to generate living money during that time, then the people starting that business will be very hungry if they don’t have either another source of income or a very long-suffering family.  In the context of personalisation, micro-provision reduces this conundrum because it’s based on keeping costs as low as possible and growing as the demand from consumers grows, but it doesn’t remove it.

If you’re running a very small business providing half hour slots to people to help them answer their post and pay their bills on time, you may be able to do this as a part time job, but you will still require some form of investment to get this off the ground.  All of the time you are building this micro-provision of a service, to a limited number of people who really want to buy it using their personal budgets, you are accruing an opportunity cost from not doing something else to make money.

 A refreshing pragmatism

Micro-provision is the structure needed to begin the process of delivering personalisation but it receives scant attention and is, at present, a marginal topic in the debates about how personalisation might be delivered.  It is caught between the anxieties of those currently providing services on one hand, and in the broader debates political debates about who and how public services should be delivered on the other.

Micro-provision is currently ill-served in the debate and is invisible to most forms of investment.  The pump-priming of micro providers could be an inexpensive way of bringing to market services from which people could select while tailoring their care and support.  These micro-providers would bring some of the benefits of start-ups to the personalisation of mental health care and support.

The development of micro-providers will be gloriously hands-on and practical, but will mainly lie outside of the spaces and domains where many participants in current debates are comfortable.  Focusing on micro-provision (people setting up tiny businesses to meet specific needs for people) will ground the discussion of personalisation in something other than ideology and bureaucracy.

A perennial frustration in mental health is the inability to escape from the structures of thought imposed by an outdated model of what it means to have a mental health difficulty, a shape to which many of our existing services still conform.  Personalisation presents an opportunity to change these shapes by redefining what good care and support can look like by starting with the wishes of the people receiving it.

Setting up a tiny business, researching your market, spending time with the people who are buying your service from you: it is impossible to do these things successfully without coming closer to providing a service people with mental health difficulties actually want.

In some respects, the best community based mental health organisations have remained homes of small-scales specific services when the commercial logic has insisted on large service delivery contracts at scale.  People with mental health difficulties could begin to build their own services meeting the needs of people with mental health difficulties.

We should be discussing ideas, business models and micro-provision strategies.  We should be doing everything we can to make it possible for people who wish to try to find start-up small enterprise ways of meeting people’s mental health needs.  The country is full of people who can advise those who wish to take the plunge.  It’s also full of people with mental health difficulties who are worried about losing any sort of service at all.

Small scale investments for small scale projects. Some will fail, some will succeed, some will grow, others will find their level and stick.  All will provide choice where otherwise there may have been none.

The debate about personalisation in mental health has gotten stuck, maybe it’s only a new pragmatism that will bring in fresh blood.
Mark Brown is the editor of One in Four magazine (http://oneinfourmag.org) and development director of Social Spider CIC.  He is @markoneinfour on twitter.

In an environment where the public sector, including the NHS, is actively seeking innovation, Mark Brown explores some of the questions that this raises

Social innovation is often seen as an almost alchemical process, where a mixture of factors combined by an arcane process can produce both new ideas and solutions to social challenges.  While this vision of social innovation is attractive, especially to governments wishing to solve intractable social challenges at a time of restricting austerity, we do not think that this view either captures the reality of social innovation or the multiple practical factors that define its success or failure.

This post by Mark Brown originally appeared at OneinFourmag.org in June 2011.  The question of who should pay for things in mental health has not reduced in importance in the year since original publication.

It’s impossible to talk to anyone involved in mental health at the moment, whether as a user of services, a planner of services or as a deliverer of services without one topic cropping up.

Everyone is asking the question ‘Where’s the money going to come from?’

So far, so familiar.  Mental health has always been an area where money is tight.  However, there’s a new urgency since the effects of deficit reducing cuts began to be felt.

It’s instructive to think about this question in a slightly different way.  Rather than asking ‘where will the money come from?’ it’s more interesting to look at the question as being ‘just who is going to pay for services in mental health?’

Prior to the advent of the coalition government, for many people the answer to this question would have been simple.  Either the state in one form or another would be paying as part of the public services, through directly contracted services or through strategically awarded grants.  If it wasn’t the state paying, then the answer would have been grants made by charitable organisations in one form or another.

Very rarely would the answer to who was paying be people with mental health difficulties themselves.

By their nature, mental health related services are based on the idea that services are being provided to those that need them but who would not be in a position to pay for those services themselves.  When a mental health service is funded by, say, a local authority what is happening is that service is being bought on behalf of the people who use it to meet their needs.  When a service is funded by a grant funder, the same is happening.  The funder is recognising a need that will be met by the proposed funded service or project and is putting up the money for some or all of that service to be carried out.

In both cases, the service is being purchased on behalf of people with mental health difficulties.

In the NHS, this process is repeated.  Commissioners put into action strategic plans to meet the needs of people with mental health difficulties by commissioning services while managers allot funds.  In essence, they are again buying services on behalf of people with mental health difficulties.

Many would say that for medical based services, it’s the NHS who should be providing and that for everything else there should be grant based funding.  For organisations such as The National Coalition for Independent Action, voluntary sector groups and organisations chasing contracts to deliver what local authorities have decided is important has reduced their independence and ruined their relationships with the people who use their services and the communities in which they’re based.  As Rachael McGill says in NCIA’s recent report Voluntary action under threat: what privatisation means for charities and community groups:

“Some voluntary sector organisations have helped to further this agenda by entering into competitions to deliver services on their local authority’s terms. They fail to recognise that although they themselves are not the private sector, they are still conspiring with a practice which turns community provision into a market place.”

The NCIA paper claims that this is a significant step towards eventual privatization of public services:

“The coalition government has embraced this conflation of ‘charity’ and ‘business’. It wants to institutionalise the idea that the preferred way to fund traditionally charitable activity is through social enterprise methods: loans and income generation through contracts, charging or trading, rather than grants or other public subsidies.”

While this point may or may not be true in principle, it does leave the massive question of who will be paying for the provision of services.  In the appendix to Voluntary Action Under Threat, there is an attempt to suggest ways that this might be brought about beyond campaigning against cuts (changing policy):

“Can we lobby independent funders to support needs-led work, preventative and holistic work and campaigning?” the report asks.

Which delivers us back to the question: just who should be paying?

It isn’t who’s selling, it’s who’s buying

Social Enterprise is often presented as a solution to problems that community and voluntary sectors are having financially.  Set up a social enterprise and you’ll be able to do business and raise money at the same time as doing good. We recently met with someone from a major social funder who was looking for social enterprise models in mental health for investment.  We thought about this a lot and advised her that there were fewer social enterprises in mental health than you might imagine, and those that we did know of were facing significant challenges.

The reason for this, we explained, was that although many people were good at identifying what needs people have and developing effective ways of meeting them, this was not the same as coming up with a winning business model.  The reason it was not the same was not that the social enterprises in mental health were not well run, well structured or not delivering high quality services but that they were lacking one important aspect of any business model.

Money.

Whatever was being ‘sold’; was not, at this time, what people were buying.

Business usually begins by working out what people want to buy and whether it is possible to supply them it in a way that generates profit.  Social action starts from working out what people need and then finding out ways to fund meeting that need.

Social enterprises ‘spun off’ from being previously part of the public sector have the problem that even as spun off services, their main client is the kind of service of which they were once part.  Local charities previously maintained by council grant that become social enterprises have the same difficulty: if the council isn’t paying, then neither is anyone else.

In effect, cuts at a local level close off that large area of revenue generation.

‘But,’ asked the representative of the social funder, ‘isn’t there room for people with mental health difficulties to pay for services themselves?’

We thought about this point for a moment before explaining that for many, the idea that people with mental health difficulties might pay for services out of their own pockets was seen as another step on the slippery slope toward the state providing no support for voluntary and community organisations.  In fact there are those that see asking people with mental health difficulties to pay for services as profiting from the disability of others.

On a less political level, it’s also the case that people with mental health difficulties who need services just aren’t in a position to pay the market price for them.

This makes things very difficult for those organisations that are sticking to their guns and delivering what people with mental health difficulties want them to deliver.

Filling the gap

In the current wash of ideas around The Big Society, there is the notion that with the withdrawal of the state will come a deluge of civic action to fill the space that withdrawal of state funding has left.

This poses us some problems in mental health.  If the state isn’t funding what organisations do either by grants or through commissioning, and people with mental health difficulties themselves are not paying for it directly out of their own pockets, then this leaves three rough areas from where money might come.

The first is from grant making bodies.  This is a tricky area.  For many there is a doubt that mental health is far enough up the list of priorities for most grant making bodies and charitable trusts.  There are few grant making charitable trusts that have mental health as a specific area of focus.

The second is from philanthropy.  Distinct from charitable grant making, philanthropy is the individual giving of time, money or other elements.  Again, as with charitable grant making, it may be possible that individual organisations or projects find patrons who can support their work, but it is not something that it is possible to put in your business plan.  Tech company start ups might be able to find angel investors, but they’re looking for a return on their investment.  Finding rich individuals to fund mental health projects might well be harder.

The third is charitable giving.  It is nice to think that the general public would be happy to raise funds for mental health projects and organisations across the country, and in many cases they do.  This however is an enterprise that benefits from economies of scale.  Organisations need large infrastructures to effectively raise funds from the public, which in turn cost money, which in turn increases the overall need of that organisation to keep pulling in money from the public keep running.  This means that larger organisations have an advantage over small organisations not only in terms of practical fundraising ability and capacity but also in terms of brand awareness and exposure.

The problem is that, as a group of people, people with mental health difficulties are currently not quite at the top of the list of people for which the general public feels worried.  In fact, some might argue that our standing with the public has gone down as a result of media coverage and government policy at exactly the time that we need the public to consider our needs more.

Is there any hope?

There are potential chinks of light coming through the darkened skies, but they are only that at present – tiny slivers of possibility, and it isn’t one that will appeal much to people ideologically opposed to organisations other than the state delivering mental health services or to the idea that organisations must avoid thinking like businesses.

The move to personal budgets both for health and social care present a new possibility for organisations.  For the first time, the theory goes, people with mental health difficulties will be able to draw down a personal budget and then spend that personal budget on buying the services that they want.  No more will others purchase things on our behalf.  In theory we will be able to give money to the services we value and those services will, in turn, try to meet our needs in ever more inventive and satisfying ways.

The problem is personalisation is moving slowly in mental health, and it isn’t clear how organisations will survive long enough for people using their personalised budgets to plug the gap.

What is clear is that for many organisations the clock is ticking, if it hasn’t stopped already.

There just isn’t enough money coming into our sector.  We must strongly advocate for the fact that it should.  We must also be cunning, be charming, be inspiring.  In fact we must do everything we can to bring in that money, from whichever source possible.

Even volunteers need support.

We must by all means make the case for who we feel should pay in mental health, but we also have to be finding out who might pay and finding ways of helping them to do so.

This NCVO / Funding Central advice and information ‘Life After a Grant – The exit strategy’ is useful for organisations facing some of the challenges outlined in this post.

This blog post by Mark Brown originally appeared at OneinFourmag.org on June 30th 2011.  The dilemma it discusses is one that has proven increasingly prominent for The New Mental Health: How do we support the new while valuing the more established in a time where there is not funds for both?

While much of the debate about health in England has been focused on the progress (or not) of the health bill through parliament reorganising the way that health services are run in England, those of us involved in mental health know that there is more to services than the NHS.

As this excellent piece by Mary O’Hara in The Guardian this week illustrates, the current economic and political climate is posing smaller organisations significant challenges.

These are often organisations that have come into existence because they have recognised a need that the NHS was not meeting. These can be anything from therapy services to art groups to advices services. As I’ve said in a previous post, there is no single frontline in mental health. Mental health is something that touches on all areas of life.

At present there’s a feeling of hatches being battened down, of feet being stamped down quite decisively on the funding hose that used to carry the flow of money that previously kept smaller organisations in business. As I’ve said, despite glimmers of hope, there’s not as much money in mental health as there should be.

I was at an event discussing mental health and big society last week where there was a marked scepticism for the idea that large state organisations would release some of their budgets to fund and support organisations from the community and voluntary sector. The view was that when it came down to it, large providers would generally choose to look after the jobs of people already working for them, rather than lose the jobs and enable others to deliver the service.

It’s a good an honourable thing to try to protect the interests of the people that work for your organisation and a good and honourable thing to try to keep the show on the road. With the public sector going through a period of being ‘slimmed down’ by the current government, it’s understandable that public sector decision makers will be looking to prop up their own houses.

But is this what’s best for people with mental health difficulties?  And what about the community, voluntary and other organisations that fall outside of the public sector but which deliver well loved services?

It’s here that lies the dilemma of our title.

Walking in two directions at once

Working as we are at a time of much reduced available funding, many of us trying to make sure that people with mental health difficulties don’t lose out from this current situation find ourselves captured on the horns of a series of dilemmas.  In a mental health and Big Society discussion we had today as part of the process of refining our thinkpiece (out next month*), a mental health policy specialist described this feeling as ‘trying to walk in two directions at once’ and it’s a good description of the dilemma many of us face.

Some of us believe that there are possibilities for the current situation, especially the set of ideas and possibilities arrayed around Big Society, to bring about positive change in the way mental health services are delivered. This can mean we find ourselves arguing that the public sector should share some of its funds. In essence we find ourselves saying ‘make cuts to the public sector and give the money to other places.’ This is something that many of us find difficult to say.

At the same time, it’s our impulse to campaign hard to minimise cuts to services, even when we may feel like those services are not meeting our needs. In essence, we feel as if we should campaign to protect services that we support in principle but which we actually don’t like in practice.

Many of us would also like to find new and better ways of meeting the needs of people with mental health difficulties and supporting people to find solutions that suit them to the challenges that they face Sometimes these methods might be less specialist, less stable or less expensive. A good example of this is setting up a regular social drop-in where people had a chance to meet and find common ground to replace a now-closed day service provision. We sometimes feel that by finding alternatives that work and speaking proudly about them we are somehow betraying the case for the funding of services that are more specialist or more expensive.

Similarly within the broader debate about the opening up of public services, many of us want to see the smaller local organisations that we use surviving, but not at the cost of other more traditional state services that we use. We do want more choice but not if that means reduced quality. Many of us want greater access to medical treatments and interventions, but not at the cost of the community, charity and voluntary organisations that we love and rely upon.

This moment of reorganisation and redefinition does present us with opportunities to take forward many of the things we’ve been wishing for in mental health (see this and this report from our conference in May for more) but at what cost?

With the quality of life for those of us with mental health difficulties at stake, the dilemma is not an abstract or theoretical construction.

Even if we look at this period as an opportunity to move thinking around mental health services and opportunities forwards, by using this moment pragmatically to further these aims, it’s still a period where we will have to decide to do one thing over another or to follow one path while declining to follow others.

How do we make those choices? And how do we make sure that it’s people with mental health difficulties that don’t lose out?

*Actually, the Big Society thinkpiece came out in December 2011 and was finally titled ‘Better mental health in a bigger society?’ You can read it here.

‘If hope is one of the most important things in mental health,’ asks Mark Brown, ‘how can we make sure our services don’t destroy it?’

It’s fairly widely recognised that hope is an essential component of getting your life sorted out after it has been interrupted by a period of mental ill health, but what does that actually mean? If it’s so widely accepted that hope is important for what some call ‘mental health recovery’, why do we find that many services offered to people with mental health difficulties tend to fail to inspire it? If we work on the assumption that hope is vital to getting your life sorted and isn’t just a wishy-washy idea that has no place in the nuts-and-bolts of sorting your life out while experiencing mental health difficulties, what can we do to make sure that it is at the heart of services provided to help?

What is hope?

It’s probably good to try to define what I think hope means in the context of sorting your life out. The Oxford English Dictionary defines hope as “a feeling of expectation and desire for a particular thing to happen”. In the case of mental health, that ‘particular thing’ is that things won;t be unbearable horrible forever.

I think hope, at its most basic level, is the feeling that things can be better, or that the way things are today is not how they will be forever. Whether hope is based on belief or upon empirical evidence, it’s still the idea that whatever exists today does not have to persist forever. So, really, hope is recognition that positive change is possible.

When we talk about the first stage of getting your life back on some sort of track after a period of mental ill health being hope we’re actually saying: ‘the first stage of getting your life back on track is believing that you actually can get your life back on track’.

Seems obvious? Good. It should seem obvious, because it is obvious. The opposite of hope is despair, the feeling that nothing can change for the better and that no action will make a difference to that.

How then, if it’s so obvious, do we often feel despair rather than hope after interacting with service that exist only for the stated purpose of helping us get our lives back on track? If hope is indeed the vital first step in getting your life sorted out, how can we make sure that we don’t stop people’s journey to getting sorted before it even starts?

What makes us hope?

To work out why service sometime fail to make us hope, it’s worth looking at what makes up hope and looking at what hope isn’t.

Firstly, what hope isn’t. Hope isn’t just want a lack to be filled. A sense of missing something on its own can cause a sense of loss or a sense of being ignored or even a sense of anger at lacking what others have. This can lead to resentment, despair or even self blaming, where we blame ourselves for not having what it is we lack.

Hope isn’t a belief that you have been cheated out of something that is rightfully yours. A sense that you deserve better without any reasons to indicate why this should be can result in as sense of entitlement, where what you feel you should have does not relate to what may actually be possible. This can also lead to hopelessness when the gap between what you think you should have and what you have is large and where you think that you will not have to take any action to close the gap.

Hope also isn’t deferred satisfaction. A sense that things should be better without practical routes to making them so can result in fantasy or putting off things being better ‘until the next life’ or ‘after the revolution’. Thinking like that can sometimes feel like hopeful belief but it’s actually another form of hopelessness: the idea that everything in the world must change for one particular thing to change.

Hope also isn’t just positive thinking. To experience something as awful and to say to yourself ‘no, this is great’ is not being hopeful, it is a method of acceptance. Not always a bad thing, but not the same as hope.

So, what makes up hope in the context of getting your life back on track? Very simply, hope is the conviction that things that cause you difficulty can be overcome, things that you ant to happen can happen and that outcomes that are beneficial can happen. This conviction either results from, or is reinforced by, evidence that these beneficial outcomes are possible.

Hope and services

If we do ask questions about services we often ask them in terms of ‘how can we make sure this services helps people more?’ When we’re talking about hope, I think it’s more instructive to ask ‘In what ways might this service make us worse by removing our hope that things can change?’

Regardless of what services an organisation is providing, it has the capacity to either give hope or take it away.

In many senses, people take a risk in hoping that services will be able to help them. In other words, they place their trust in services. So then, hope that you can be helped is an act of trust, and based on my attempt to define hope above, the extent to which you receive positive reinforcement of that trust defines how likely you are to remain hopeful.

Services often forget that while their job might only begin when someone arrives at their door, it actually represents the end of a journey of hope for the person who has just arrived in front of them. They have turned up precisely because they hope that a service will be able to help them.

From that point on, the service can either support and nourish the hope that someone feels, or it can take a series of witting or unwitting actions to stunt or completely snuff out that hope.

Services can dispel hope in thousands of ways. On rude member of reception staff can undo a week of therapy. A couple of unreturned telephone calls can leave someone feeling ignored. A badly worded letter can give entirely the wrong impression of what might happen.

All of these things are rarely picked up in satisfaction surveys, because satisfaction surveys only ask whether the service is serving its purpose, not how it serves its purpose.

They’re the cumulative effect of services that forget that they’re actually working for people. This kind of thing happens because there is diffused responsibility for making sure that people have the best experience that they can of a service and what it offers. They are especially prevalent in services that themselves feel lacking in hope, services that feel ignored, overworked, misunderstood, unrewarded. Services that don’t believe things can be better tend to communicate that belief to the people who trust in them to make things better. When individuals raise these issues, the despairing organisation rejects them as criticism rather than recognising them as offers to provide advice about ways in which they can stop destroying hope.

Low expectations and unreasonably high expectations can remove hope from people: Low expectations by actually arguing against someone’s hopes and forcing them to question them; unreasonably high expectations by ignore the realities of someone’s life and again forcing them to question their hopes.

When an organisation, usually by imperceptible increments, begins to slide into despair itself it actually reduces its ability to be effective by managing to destroy hope rather than creating it.

What would happen if we did an audit of hope?

If hope is so vital, how can we make sure our services are engines for creating and sustaining it?

We have to be aware that many mental health services operate under demoralising circumstances, both those inside and outside the public sector. Current instability makes it difficult for people who work for them to feel secure, which compounds the wider sense of instability that is currently a reality for many.

The key is, maybe, to form a coalition between the people who work for organisations and people who use them to find ways of doing things differently. If older ways of doing things are under threat we may be able to find new ways by working together that are better and more hopeful instead of people on both sides of the provider/user split conniving with each other to build a story of despair. Initiatives like Star Wards are a fantastic starting point in thinking about what a coalition of hope might look like. Star Wards gives simple ideas and support to people who work in inpatient mental health wards to make the experience of being there better. The ideas can be done easily, simply and with little expenditure. Most of them are about getting people to do things in less institutional, habitual ways. They say ‘why don’t you stop doing things in that depressing, demoralising and despairing way? Why not do something better instead?’ They work on the principle that the best way to drive up standards is not targets but by giving often fed-up and despairing staff the encouragement to make their worklife and working environment more fun, more alive, more vibrant and more human which in turn brings them closer to patients, because patients are equally fed up and bored.

It’s interesting to ask what would happen if we were to take the ‘Star Wards’ principle into other forms of mental health services?

I’d suggest that the logical first step is for people who use mental health services of any kind to get together and agree on what things organisations do to remove hope from those that use them and make suggestions for how they may be altered.

If we can agree where services make us feel hopeless, either as people who use them or as people who provide them, then we can begin to find ways of changing the things that remove hope into things that give hope.

Would we come up with a different model of delivering mental health help and support? Would we find that sometimes the nuts-and-bolts of delivering mental health services were done in such a way that they undid any of the good that they could potentially provide?

If we were to do an ‘Hope Audit’ on every mental health organisation, working out where services support people sorting out their lives by not removing hope that life can be sorted out, what do you think we’d find?

The following blog post originally appeared here on David Floyd’s blog Beanbags and Bullsh!t.  We’re reblogging it here because it speaks about one of the inherent tensions present in The New Mental Health: The difference between people solving their own problems because they have to and solving their own problems because they choose to and the small ‘P’ political implications of this.

Public spending cuts lead to cuts in public services. Not a groundbreaking revelation but there’s a danger that hype-laden initiatives such as Big Society Capital and Social Impact Bonds serve as tediously over-reported distractions from the important day-to-day issues faced by millions of people who have been using public services and now find that those services are no longer there.

Whether or not we chose to use the term Big Society, the current economic climate is causing us to think differently about (formerly) publically-funded services and our relationships to them. This report, in central London local newspaper West End Extra, looks at the reaction of service users and carers to the closure of Westminster Centre for Independent Living, a centre providing activities for deaf and disabled people in the City of Westminster.

The initial paragraphs of article tell a story that has potentially significant implications if replicated across the country:

It’s not being needlessly pedantic to point out that the word ‘forced’, although it adds bite to the opening sentence of a news story, is critically inaccurate. The disabled people and carers involved in the SOS Westminster campaign group haven’t been forced to do anything. They’re making a conscious choice to look for a new local venue to carry on delivering some of the activities that were previously available in their centre, I imagine primarily on voluntary basis.

The fact that the group is looking for a new venue doesn’t mean that they’re happy about or have accepted Westminster Council’s decision to withdraw funding from the centre but – given that it is unlikely they’ll be able to reverse the decision in the short term – they’re offering a pragmatic response to the situation that will mean service users end up with something rather than nothing.

If the group find their venue and keep some services running, this is an effective (if not simple) example of people doing things for themselves. This is potentially one of the most important elements of the Big Society/what happens when the state’s no longer there (delete according to political taste). It’s not about do-gooding altruism, it’s about community self-help. Unfortunately, for the Big Society hype brigade, this kind of activity doesn’t involve exciting new financial instruments or game-changing websites that are a bit like Facebook.

Community self-help is about working hard and believing in what you’re doing. What it isn’t is a direct replacement for state-funding services. Aside from the specific case in this report, which I only know about from reading the report, the paid staff of state-funded service in the voluntary sector usually work very hard for not very much money. While there will be a tiny number of exceptions, it will not usually be possible (or desirable) for volunteers to maintain professional services for free.

The challenge that the SOS Westminster group (if they manage to find a venue) and others in a similar position face is to do what they can do with the human resources available, while keeping enough people engaged and actively involved to make it sustainable. A big danger is that, while publicly-funded services are often accused of burning through money, unfunded community activity can burn through people.

Local government (in particular), along with other public sector agencies such as (bits of) the NHS can help create a climate where this kind of community activity has the best possible chance of success. Part of that may be providing groups with relatively small amounts of funding without piling on unnecessary bureaucracy but it’s also (as with Westminster social services in this report) helping groups to find accommodation or providing useful contacts and information.

Depending on political persuasion, people have different views about what the state should and shouldn’t be paying for but all parties ought to be able to agree that – when the state isn’t paying – it can still play a role in helping things to happen.

The following is an out-take from our pamphlet ‘Better mental health in a bigger society? (published by Mental Health providers Forum in December 2011 and available for download for free here) This unused section looks at where people with mental health difficulties in the community fit into the mental health world.  It originally appeared online at Oneinfourmag.org

The NHS provides medical services well, and most people wish them to continue to do so. The idea of medical services provided by non-medical staff is not what this paper is about.

There is great potential for people with mental health difficulties working with existing NHS structures to develop new and innovative ways of supporting others with mental health difficulties. There has traditionally been confusion within the NHS and within the wider community of people with mental health difficulties and those that support them as to how to classify projects, groups and organisations who deliver mental health related services which are not, in themselves, medical. This has led to a prickly relationship between the NHS and other community based organisations.

This in part has arisen from the idea that mental health is simply a medical issue, rather than being a medical issue with significant social aspects. Coming from an approach schooled in medical thinking, organisations and groups that have come together in ways that arise from the experiences of people with mental health difficulties and those that know them can seem chaotic, fragile and to lack a strategic focus. This is the reality of groups that come together voluntarily and which reflect the on the ground responsiveness and knowledge of life with mental health difficulties that services can sometimes lack.

Organisations and groups closer to the ground have both numerous advantages and significant disadvantages when compared to services developed within the NHS. Such groups often exist to meet needs defined by themselves, their members or users. They are often extremely good at identifying gaps in provision or support and filling those gaps. This can be defined as the self-help aspect of the Big Society where people come together to find solutions to their own problems. It is important that groups like these are nurtured and supported, and that mental health services endorse and enable such groups. It is also important that these groups should not be considered substitutes for services, or treated as extensions of services.

A significant area of difficulty lies in the funding, resourcing and supporting of groups and organisations led by people with mental health difficulties. These groups may be in a position to be contracted to deliver services, but need additional support and expertise to do so effectively – seeing them solely as additional means of service delivery can neuter their potential to deliver real innovation and change. Often the process of securing service delivery contacts lies beyond the reach of groups that have come together to meet specific community needs. Reconfiguring these groups or organisations as service deliverers often removes their potential to remain flexible and to innovate.

The objective for all NHS services must be to create the optimum situation for these organisations to grow and develop, as it will be these groups that increasingly will be the conduit between the NHS and the community, and will enable the NHS to meet goals within mental health that otherwise would be difficult to achieve. Organisations, projects and individuals need to be supported from within the NHS to make a difference both within its services and without. This will involve both bringing such self generated projects, groups and organisations into the NHS as partners while also ‘opening up’ the NHS to be able to utilise and respond to these self determined groups as they arise.

The question all NHS staff need to be asking is ‘If someone did have a great idea, would they be able to get to me to tell me, would I be in a position to recognise it and could I help it to happen?’

The question that people with mental health difficulties need to be asking is ‘If the NHS was to support me to find ways of meeting my own needs, what would that support look like and what would I expect?’

Welcome to The New Mental Health blog.

What is The New Mental Health? It’s the emerging movement of mental health organisations and mental health thinking that is moving beyond the traditional division between person who receives services and person who delivers them

We’re beginning work on a publication that will bring real examples of The New Mental Health at work and discuss what they mean and what they tell us about making good mental health stuff happen.  This blog will form part of that process.

We’ve crowd sourced some of the money to do this work via Sponsume and from other supporters. It’s not quite enough but we’re going ahead anyway because we think The New Mental Health is vital to mental health in the UK.  If you can support us, we’d appreciate it greatly. We can accept financial support via paypal. Email us to tell us whether you’d like to be listed on the supporters page.

If you want to talk to us about The New Mental Health or think that you’re already making it happen, get in touch via the contact us page.

By way of introduction, here is Mark Brown’s speech to the Asia Pacific Conference on Mental Health 2012 on July 14th in Perth Western Australia.  In it he defines the characteristics of The New Mental Health and where they come from while examining some of the tensions that The New Mental Health creates.

The Emerging Generation: Moving Beyond Service User – Mark Brown

When people talk about “mental health service users” I always want to ask “which services do you mean?”

I’m a person with mental health difficulties who is not currently accessing any services, not for wont of trying. In fact, I actually deliver services like One in Four, the mental health magazine. Does that mean I’m not a mental health service user anymore?

Due to the cumulative advances in treatment, support and the reduction of stigma, the current emerging generation of people with mental health difficulties, like myself, are more likely than previous generations to have a job, have kids, have interests, to have the things that we’d recognise as ‘having a life’ or at least able to have a shot at them. Having a mental health difficulty does not now mean that we are, as a matter of course, exiled to a strange and dark netherworld completely apart from the everyday world.

Commonly, people complain of feeling a lack of ability to influence the treatment they receive, a lack of choice in service they receive for support and an overall feeling of getting to where they want to despite the support that they receive rather than because of it. In effect services often say ‘You can define your own recovery and you can hope and aspire to a better life than the one you currently have, but only if that looks like what we can provide.”

The needs and wishes of people with mental health difficulties are changing more quickly than a rigid focus on service delivery can accommodate. We are both trying to raise the aspirations of people with mental health difficulties to develop ownership of their recovery, putting them in the ‘driving seat’ of services and support defining their own goals and outcomes while at the same time having difficulty in responding to those aspirations and demands within existing inflexible methods of service delivery.

I think that we’re seeing a step beyond that, something that I call ‘The New Mental Health’, people stepping beyond being ‘service users’ which I hope to define for you today. It’s about people with mental health difficulties using their own skills, ideas and experiences to make and run their own organisations, projects and services, sometimes finding better ways of doing things that traditional services have done, sometimes doing things that are completely different.

Before I define what ‘The New Mental Health’ is in greater depth, I’d like to take the opportunity to define the situation as it generally stands now. Whether by accident or design, Mental health difficulty is still seen as primarily a medical issue rather than as a disability. To put it another way, it is seen as an abstract experience of ill health rather than something that people live with over a period of time. Eventually, the medical model suggests, mental health difficulty will be eradicated like rickets or TB. Mental health difficulty is seen as something that can be solved, and as such, does not represent something that is weaved through all of the elements of the life of the individual that experiences it. The recovery model has tried to challenge this, but has its own particular challenges.

There is still an over-riding bias toward seeing people with mental health difficulties as a group that others do good for without seeing us a discrete group in society who may have opinions and ideas of our own.
I think one of the shifts that I’m noticing is people with mental health difficulties moving beyond seeing their identity as being defined by their interactions with services. We’re moving beyond seeing ourselves as ‘service users’ and shifting to the wholly more logical position of seeing ourselves as people in our own right with complex needs, wishes, aspirations and ideas.

A LITLE ABOUT OUR HISTORICAL MOMENT

I think that there’s a new generation of mental health projects, campaigners and organisations that are developing new ways of thinking about mental health, all springing from a refusal to accept that getting the services you’re given is good enough.
I think that there is a new mental health, one that isn’t defined by the term service user. More than ever people with mental health difficulties are finding themselves in situations that would probably not have happened to previous generations. We’re running into questions that don’t have established answers.

Through editing One in Four, the magazine written by people with mental health difficulties that I created, I often see fiercely independent and resourceful people running headlong into the fact that things aren’t changing as fast as we want or need them to, hitting every glitch in the way services work and uncovering every inconsistency in public attitudes or the conduct of organisations or individuals.. This is because our lives and aspirations don’t fit the old ways of seeing mental health difficulty. In fact, for some, the experience of interacting with services that are inflexible and over which we can exercise little control in fact contributes to the overall sense of disempowerment we experience as part of recovery from a period of mental ill health.

People aren’t running into an unfocused idea like ‘stigma’ but actual hard situations where what they are trying to do is countered by ideas about who or what they are as a person who experiences mental health difficulty and what it means.

This is the area that the New Mental Health operates in. Not about services but people.
As long as relevant and timely medical treatment is available (which is a whole different disscussion in itself) people with mental health difficulties are out there. We’re mingling with the rest of you. We aren’t just service users. Sometimes we’re your employees, your peers, your colleagues. Sometimes we’re even your boss.

What unites us is that we’re running into challenges that aren’t about how to get ‘better’ from our mental health difficulties and pick up where we left off but challenges that ask ‘how can I have mental health difficulties and still just get on with life?’

We’ve shifted the focus of our attention from medical services as the sole provider of help, support, advice and treatment and are asking ‘if we do want help to make our way in the world, who is going to give it?’

And, for The New Mental Health, the answer is often ‘ourselves or people like us’.

THE NEW MENTAL HEALTH

So, what is The New Mental Health and why does it take us ‘beyond service user’? The New Mental Health is not so much a movement, but a broad range of projects, organisations and services that are moving in similar directions.

Broadly, the defining characteristics of the new mental health are:

• The New Mental Health is pragmatic not ideological
• The New Mental Health blurs the old boundaries between people who provide services and people who receive them
• The New Mental Health come from outside of (in the UK), the NHS or large providers
• The New Mental Health is not usually about campaigning
• The New Mental Health works with non-medical aspects of people’s experience
• The New Mental Health constantly struggles for existence
• The New Mental Health is not still fighting old wars
• The New Mental Health is directly responsive to needs
• The New Mental Health generates real opportunities for people

One of the over arching qualities of the New Mental Health is that it is pragmatic and focuses on getting things to happen by which ever method is best. It isn’t hung up on a particular form of organisation. It doesn’t turn it’s nose up at the idea that social enterprise might be the best method of making things happen. It isn’t scared of getting in there an making its case. What it isn’t so interested in is hewing close to old sectarian divisions – the service users or survivors versus ‘the system’. It spots gaps and it tries to fill them.

Traditionally services in mental health are provided by professionals without experience of mental health difficulty for those that have. The new mental health is often developed and delivered by people with direct experience of mental health difficulties. There isn’t anything that blurs boundaries more than that. In the case of my own company, I have a mental health difficulty. My co-director doesn’t. In the case of One in Four the mental health magazine we publish, all of the writers have direct experience of mental health difficulty. I’m not a service user supported by my ‘normal’ colleague.

When the people running a service have direct experience of the thing that their service addresses it becomes more difficult to see the issue that the service addresses in isolation. Practices like co-production and peer working bring the ‘service users’ to the same table as the service providers. This changes things. Working with organisations run by people with mental health difficulties means that suddenly, if that’s something you aren’t comfortable with, the barbarians are no longer at the gates, they’ve breached the citadel.

Very often the New Mental Health comes from outside of large providers. There are a number of reasons for this. The first is that coming from a background of lived experience, organisations run by people with mental health difficulties recognise gaps and opportunities that large providers don’t. That’s because they start from a very direct knowledge of what problems people face and a personal understanding of where people’s aspirations differ from the menu of opportunities that is on offer from established sources.

When we started One in Four, I drew on my own experience of mental health difficulty and specifically my own experience of how uninspiring and bitty information about mental health was. We started from the point of asking ‘what do people with mental health difficulties want to know?’ rather asking ‘what does our organisation have an obligation to tell them?’.

The second reason that the new mental health comes from outside of large providers is that often the new mental health is in some way disruptive of established ideas or ways of working.

Star Wards in the UK is a phenomenal success. It’s a loose programme that individual mental health wards can sign up to which helps staff to see ways that their ward might be changed to be less awful, less depressing, more lively and an all round better place for both staff and patients to be. It sounds like the kind of initiative that health providers start all the time to improve standards but it isn’t. The person who started it, Marion Janner, is both a public sector professional of some standing and a person with mental health difficulties who is entirely open about the time that she herself spends in hospital. Star Wards grew from her own thoughts about how crap it was to be in hospital and extends suggestions to mental health professionals who want to change the experience from the bottom up. Its very value is that it comes from outside of large providers and remains separate from them.

The third reason is that large providers don’t employ as many people with experience of mental health difficulties as they should and when they do they tend to employ them in roles that are very much defined by the way that the service in question thinks about people with mental health difficulties. It is a very different thing to be employed specifically as peer worker by a large provider to being a peer worker in an organisation that is run and managed by peer workers. Within larger organisations it is possible for people with mental health difficulties to drive through innovation, but it doesn’t happen as often as it should.

I know of one person who tried to get their managers interested in the idea of delivering mental health awareness sessions to public sector workers without much traction. In the end they booked the largest space their organisation had while their managers weren’t looking and went ahead with inviting as many decision makers as possible to experience the kind of session that was being proposed. That was the birth of one of the most exciting round of mental health awareness sessions I’ve witnessed. They wouldn’t have happened if their founder hadn’t just gone ahead and done them.

One of the qualities of the new mental health that challenges traditional ideas about service user groups is that the new mental health is more about doing than it is about campaigning. Campaigning is asking one group (maybe a particular service, maybe the general public, maybe the government) to do something on behalf of people with mental health difficulties. In many ways, the new mental health only exists because of the excellent campaigning that our peers have done before us. It was those people that changed laws and modified services so that we could get at least some of what we need. There is always room for campaigning, but the new mental health is about doing. It’s about recognising a gap and deciding to try to fill it for yourself and your community. It’s a shift from saying ‘someone needs to do something about this’ to saying ‘we’re going to do something about this’.

As I’ve already said, traditional providers of services have come from a medical understanding of mental health difficulty and are trying to evolve a more rounded view of the role they play in people’s recovery. The New Mental Health tends to look at the bits of people’s lives that lie beyond the consulting room, the ward and the clinic. It doesn’t tend to see its activities as making symptoms better but making lives better.
Cooltan Arts, the London mental health arts organisation, doesn’t see itself as providing arts activities because they are therapeutic. It provides high quality arts activities by and for people with mental health difficulties because often people with mental health difficulties find those valuable experiences difficult to access. It isn’t about providing a diversion for people to fill in their time as a ‘service user’ but about doing high quality arts.

Another defining characteristic of the New Mental Health is that organisations and projects are often struggling for their very existence precisely because they’re new and are coming at mental health from unexpected and untried angles. It’s precisely the fact that they are moving beyond definitions of service user that makes them difficult to place in the existing hierarchy of organisations. This can make it difficult for them to find funding because they do not fit traditional ideas of what organisations should be like but also that they do not fit traditional ideas of what people with mental health difficulties are looking for from services or projects. These organisations can be ahead of the curve of innovation. This means that their understanding of the needs, aspirations and wishes of people with mental health difficulties can be in advance of the existing fixtures in the landscape. These organisations can also find it difficult to work with organisations with less forward thinking views, a point I’ll come back to.

One hallmark of the New Mental Health that brings it into conflict with existing service user organisations is that it is not as interested in redressing the injustices of the past but in focussing on activities for the future. To develop a mental health difficulty now is not the experience that it was thirty, forty years ago. It is still distressing, disruptive and bewildering, but many people do not experience the worst excesses and unpleasantness that unreconstructed services were capable of inflicting. The people involved in this developing wave of mental health thinking have not had the experience of a pre-recovery model world or have decided that making things better for people in the future is more important. This, coupled with a focus on doing, rather than campaigning can sometimes make the new mental health sits ill with more established user movements.

When the New Mental Health thinks about changing things it tends to be pragmatic and start from looking at what can be changed in the here and now. Where it works, through neccessity, it tends to start small and to meet the needs it finds directly. This is partly because it tends to grow from identifying a particular problem that a particular group of people have rather than attempting to find an answer that will work for everybody. It’s also partly because this new wave of innovation doesn’t find it as easy to secure the funds it requires.
The New Mental Health also generates opportunities for people with mental health difficulties by creating things that we have a stake in and which we can influence and feel part of… Would you rather be an involved service user or someone working for a mental health organisation. Which is more likely to look good on your CV and generate opportunities in the real world?

SO, HOW CAN WE MAKE THIS NEW MENTAL HEALTH HAPPEN?

First and foremost we must recognise that innovation and ideas might come from outside of traditional ‘professional’ routes.

At the moment, bigger organisations have all of the money, all of the staff and all of the resources. In the past they may have helped out organisations led by people with mental health difficulties, but kind of as an optional extra. In times of tightening budgets, however, it’s often a different story as services retreat behind keeping their frontline in place.
In short, the New Mental Health needs people prepared to believe in it, support from people inside services and communities outside them, some cash and resources to make things happen and recognition that it represents something different.
Beyond that, one of the challenges that the current generation of people with mental health difficulties face is that having come to doing stuff as ‘service users’ or ‘people with mental health difficulties’ we find it very difficult to escape from that pigeon hole.
Just because someone uses or has used a service does not mean that they can never be involved in delivering a service themselves.

I have coined a verb: to beneficiary or to be beneficiaried. This describes the chilling moment in a meeting or professional situation when someone changes their attitude towards you after you disclose that you experience mental health difficulties yourself; shifting you from professional peer, colleague or partner in delivering a service to beneficiary of that service. You can feel it, the withdrawal of fellow feeling and a retreat into professional well meaning, the defensive barriers rising…

We also have to recognise that being involved in service user involvement in traditional services as a service user isn’t something that always delivers great benefits to anyone other than the service itself. Service user involvement is often represented as a way for people with mental health difficulties to take a step on from just being a service user and make use of their experiences to make services better for people in similar situations.

The next dimension, the step beyond service user, is to find ways of that asset of experience can be something an individual can profit from in their life, rather than just in a service.

If we are committed to recovery then we have to ask: ‘how can we help people to cash in their assets in the real world beyond the doors of our service?’ To do that, larger organisations have to recognise that the chaotic, vibrant ever shifting world outside of the doors of their service isn’t an unfortunate hindrance to delivering services, it’s where people actually live. Organisations and groups that work in that world, that come from that world, are your natural partners. They’re ways that people can move on.

How have organisations supported the New Mental Health? In the UK the government’s Office of Disability Issues funds a programme to support disabled people’s user-led organisations (or DPULOs) to deliver sustainable services and opportunities led by people with disabilities including mental health. I know of one NHS mental health trust that invested in the set up of five social enterprises led by people with mental health difficulties, taking a seat on their board until they were confident that the companies could stand on their own two feet. If your organisation doesn’t have money to commission or fund organisations outside of itself as partners in doing mental health, it can make available some of its assets to help out. Large organisations have lots of assets, not least knowledge and experience. Could you loan a member of your staff to a local mental health organisation run by people with mental health difficulties? Could you do it without trying to take control?

One of the important bits of the recovery model is defining your own outcomes and finding a role and meaning in your life. There is an obvious argument to be made that an organisation that has seen you primarily as a patient may not be the best organisation to support you to not see yourself as one.

To really help people move beyond being service users we need to make sure that there is enough variety, choice and self-determination that they don’t turn into just service users.

I’d argue that the new mental health, that is, the idea of people with mental health difficulties taking control directly of making services and running services is the natural next step from the recovery model. The new mental health, building on the recovery model, realises that, actually, when you think about it, maybe what people need to get on with their lives is something that might not actually come from traditional services at all.

It’s an unpalatable fact that sometimes for something new to arrive, what is old has to end or be replaced.  There’s a lot that’s good about current mental health services but also a lot that isn’t what it should be.  In times of tightened budgets, for new and exciting things to come into being, or successful things to expand, some of what is here will have to go.

The New Mental Health presents the challenge: what if you tried to give up some of your control of the mental health landscape? What if you stepped aside from trying to provide all aspects of mental health services? What if you invested what you had in services that might ultimately mean your service is no longer needed? What if you made people with mental health difficulties partners rather than service users? Can you put your money where your mouth is and help people to develop new things for their mental health that you don’t control?

Now, when you think that through, that’s a pretty disruptive idea if you’re only really getting your head around ‘service user involvement’. Sometimes you might have to accept that the thing that stops people moving beyond being a service user is the services they use.

Is the New Mental Health happening everywhere? Not yet. It happens in small isolated pockets where conditions are right and individuals and organisations break through the old understanding of mental health and decide that just being a service user isn’t good enough.

That’s the thing about the New Mental Health, it’s already here but it’s not everywhere at once. It needs recognising, nurturing, supporting and promoting. We’re a generation finding our feet but we don’t have all the answers or, often, much of the money.

When I think about the New Mental Health I often think of science fiction author and inventor of the word cyberspace William Gibson. When people asked him how his predictions about the future were so accurate he explained that he hadn’t actually been predicting anything. He told people that he just noticed elements of the world around him that other people hadn’t spotted.

I’d like to finish on that note; to quote William Gibson “The Future is already here, it’s just not evenly distributed yet.”