MENTAL HEALTH CRISIS IN IRELAND PART III - Irish Examiner August 2011

A broader platform to discuss mental health service concerns

OPINION: Harry Gijbels and Lydia Sapouna

Saturday, August 06, 2011

OVER the past number of years there has been an increasing articulation of concerns about the current state of mental health services in this country.

Such concerns include the inhumane physical conditions in hospital units, over-reliance on and excessive use of medication, lack of meaningful community-based alternatives to hospitalisation, involuntary treatment, abuse of professional power, lack of information and choice in relation to "treatment" options.

New approaches have emerged to address these concerns. These approaches recognise that the bio-medical strategy in mental health care today will at best provide temporary symptomatic relief (which may be valid as a first step), but may compound, exacerbate and even cause further deep distress. Current responses to distress fail to capture the complexity of human experiences by ignoring the underlying grief, heartbreak and trauma in people’s lives. These new approaches also recognise that the whole person needs to be centrally engaged in their own recovery.

Key actors in the development of this new thinking are diverse, but represent people who describe themselves in such terms as service users, survivors, patients, members of the mad community, carers, family members, practitioners, professionals, academics and the lay public, all of whom are dissatisfied with current forms of care and its underpinning bio-medical philosophy. Significant attempts have been made to bring about changes at different levels by individuals and groups. For example, at the level of legislation there is the campaign to delete section 59b of the Mental Health Act which allows for the involuntary administration of ECT on the basis of the signature of two consultant psychiatrist. At the level of service delivery there are some innovative examples of practice such as the Slí Eile housing project in Charleville providing a therapeutic community type environment for people with mental health difficulties. At the broader level of service ethos and philosophy there are examples such as the West Cork Mental Health Services, demonstrating an active commitment to community-based, recovery-oriented practice. However, such campaigns, initiatives and new approaches remain quite isolated and fragmented events, and have not yet achieved to significantly influence the bigger scheme of mental health practice at a national level.

In an attempt to provide a broader platform to discuss and debate concerns and share new initiatives and approaches, a two-day critical perspective conference was organised by the Schools of Nursing and Midwifery and Applied Social Studies, University College Cork, in November 2009. Informed by positive feedback, another two-day conference was organised in November 2010. At this conference, attended by 300 people each day, the setting up of a network of critical voices in mental health was debated.

The Critical Voices Network Ireland (CVNI) emerged out of these deliberations as a coalition of service users, carers, professionals, academics, national campaigning and advocacy groups, all looking for a mental health system not based on the traditional bio-medical model. This network provides a democratic space with no hierarchical structures, open to everybody who wishes to join its discussions. An e-list and a Facebook page have been established to share, debate and discuss issues of concern and different ways of working. It was agreed at the launch for the network to meet quarterly. Since then, meetings have taken place in Tullamore and Dublin, finding common ground and identifying priorities on relevant issues.

The network, in association with other organisations, organised the lecture tour of acclaimed American medical journalist Robert Whitaker, taking in seven engagements with wide media coverage. The network also provides ongoing support for the existing Delete59b campaign, which can now draw on a much wider and larger network of support. Health Action International Europe, in association with the CVNI are organising an open seminar on September 24 in University College Cork to promote greater public awareness and debate about the Irish and European drug regulation systems and situations where conflicts of interest can arise

The third critical perspectives conference, organised again by the Schools of Nursing and Midwifery and Applied Social Studies, University College Cork, but this time in association with the CVNI, will be held on November 16 and 17 in UCC. The focus of this year’s conference is on the over-reliance of medication as the main response to human distress. The conference will discuss and debate the use of medication as the dominant response to distress in mental health care, medication withdrawal concerns, strategies and solutions, and creative and enabling non-medicated ways of working.

The role of universities in networks such as the CVNI is an important one, as a key role of universities is to foster and nurture critical thinking. It is through the CVNI that an environment has been created where different and sometimes conflicting voices and agendas can be heard and respected. In that sense, UCC has begun to play an important and positive role in supporting, enabling and empowering people who have so often been silenced and marginalised.

- Dr Harry Gijbels, senior lecturer, School of Nursing and Midwifery, UCC, and Ms Lydia Sapouna, College Lecturer, School of Applied Social Studies, UCC

Our mindset, rooted in a biomedical approach, needs a radical overhaul

OPINION: Dr Pat Bracken

Saturday, August 06, 2011

OUR national policy on mental health, A Vision for Change, was launched five years ago.

Most media attention has been focused on the resources, financial and human, needed for its implementation. However, the reality has failed to match the vision and the mental health community has been left with a real sense of déjà vu.

The main challenge of A Vision for Change is in terms of cultural change, which will not be delivered by new resources alone. The major questions to be answered are 1) How can those of us who work in the mental health system free ourselves from an institutional mindset, centred on an ethic of control? 2) How can we get beyond the narrow biomedical paradigm that shapes our understanding of mental health problems and guides our interventions? 3) How can we move from paternalism to collaboration in professional-patient relationships?

The ‘Vision’ of A Vision for Change

The essence of the policy is not the management plan, talk of the so-called ‘super-catchment areas’ or the recommendations about bed numbers, team structures etc. These have dominated media debates about A Vision for Change since its launch. What is really at the heart of the policy is the ‘vision’ of what good mental health work is all about. Mental health care incorporating the following five principles: service-user involvement at all levels, genuine multi-disciplinary working, a strong community orientation, partnership working and the centrality of a ‘recovery’ philosophy.

Management structures, service plans, team definitions etc are all important but they really only address the delivery of care to patients and families. In mental health, we can get all our teams and structures and pathways in place but we can continue to deliver very poor, unimaginative care to our patients. For example, home treatment can be a way of delivering a more democratic, less institutional, more negotiated and holistic form of care or it can be seen as a way to achieve a more rapid delivery of medication to patients in their own homes.

The Recovery Philosophy

A Vision for Change is very clear about the need to move towards a ‘recovery’-orientated service. This is also supported by the Mental Health Commission. But in the discourse of mental health the term ‘recovery’ means more than simply the absence of symptoms. Its use in mental health emerged from within the service user movement. A series of individuals who had been told they were suffering from life-long psychiatric conditions managed to find paths that led them to a sense of personal recovery. They then wrote about their journeys in an attempt to provide inspiration for others. While some of these paths involved mental health services, most did not. Some reported that traditional mental health services had worked to impede their recovery and some reported that they had been damaged by the way psychiatry framed their problems. A large literature centred on these personal accounts of recovery from serious mental health problems has now emerged. It is this literature that has given rise to what we call a ‘recovery philosophy’.

In essence, this means a move towards positioning the non-technical aspects of mental health (meanings, values and relationships) in the centre-ground. From a traditional medical perspective, these are seen as secondary concerns, and the primary focus is on the technical aspects of mental health: diagnosis, classification, medical interventions and service plans. The recovery approach does not ignore these technical factors but it maintains that they should not be our central preoccupation. Instead, it stresses the fundamental importance of trusting relationships in mental health work. It prioritises the creation of therapeutic contexts that are shaped by positive values where patients and families are treated with dignity, kindness and respect. It challenges us to imagine creative ways of helping people make sense and find meaning in their experiences of madness, distress and alienation.

From Paternalism to Partnership

The traditional medical paradigm has served to justify a paternalistic culture in mental health and this in turn shaped the thinking behind our current Mental Health Act, which was passed in 2001. Its orientation now stands in stark contradiction to the values incorporated in A Vision for Change. The Mental Health Act privileges a medical logic and vocabulary. It grants huge power and responsibility to consultant psychiatrists. In my opinion, this cannot be justified. Psychiatric knowledge does not have great predictive power. But even if it did, the sort of philosophy espoused by A Vision for Change would challenge its legal authority.

If we are serious about the implementation of A Vision for Change we will need new resources but we will also have to invest the time and energy needed to bring about a cultural change within our services. We will have to interrogate our Mental Health Act and move beyond it. We will need to embrace critical reflection on the history of psychiatric power and the assumptions that have come to dominate our thinking about mental health. Most importantly, we will have to create the conditions in which genuine partnerships between service users, carers and professionals can start to work.

- Dr Pat Bracken is consultant psychiatrist and clinical director of the West Cork Mental Health Service