Mental health is waking up to the era of demand

And we’re finding it terrifying

A photograph of a forest, yesterday

The following is the text of an introductory comment to the session ‘Mental Health and The Public’ presented by Mark Brown at the Kings Fund Annual Conference in London on 28th November 2018

The conversation about mental health has moved over the time I’ve been doing things in and around mental health. It can appear that we are always at the best of times and worst of times in mental health, constant veering between head-in-hands despair and backslapping optimism when any small progress is made. I think what is actually happening is we are waking up to the enormity of mental health and that awakening is uncomfortable and scary and disconcerting.

We find it difficult to focus on futures in mental health and when we talk about mental illness. The discussion of mental health and mental illness is messy, it slops over the sides of the containers we try to store it in, it becomes so about everything and then somehow becomes about nothing again. We try to keep it small and manageable but it soon becomes huge and all encompassing. Everything that affects people has an effect upon mental health and the decisions we make collectively affect what we do and who it affects. Too often we treat social conditions and funding decisions as if they were inarguable natural laws, not things that could be changed. If we do not believe huge change is possible and all change is incremental we need just look at brexit. A future changed over night.

We thought that the science of vaccination would end diseases that blighted societies for centuries. But now we are seeing it is not about science alone. People and politics and economics and beliefs about what is right and true dictate where vaccination happens.

Louise Appleby, tweeting about the recently published prevalence statistics for young people and mental health summed up much of the present broader mental health moment with more eloquence and economy than I might:

“So problem is not that mental illness in children (as opposed to older teens) has become more common but that demand for services has grown hugely, presumably because it’s more readily recognised & reported — that’s good, isn’t it? And it’s fair to say: (1) we’ve relied for decades on children with mental illness not asking for help (2) that’s no longer sustainable (3) raising awareness & tackling stigma can work but (4) logical consequence is massive investment or a system overwhelmed.”

We are not as far from the water towers of racist’s favourite Enoch Powell’s famous speech as we might like. We have never had a national mental health service; we’ve always had something gummed onto the edges of physical health, like an errata pasted into already published book. The structures we still have, both physical and conceptually come from things built before we even really had the idea that those experiencing mental health difficulties are really people, where the demarcation line between normal people and the unwell was as well policed and barricaded as a border wall.

The trajectory of the national conversation about mental health has moved from not speaking about those who experience mental distress and mental illness at all, to speaking of ‘those over there’, to speaking of ‘those beside us’ to eventually speaking of ‘us’.

More than a decade of anti-stigma campaigning and awareness work has created a country at least more conversant with the idea that people experience different states of mental wellbeing, if not any more comfortable with what might need to change to really support those people. People have always known that mental health difficulty exists in others, what has changed is that people are more receptive to the idea that such difficulty might exist within themselves, too. The battle isn’t now to get people to admit the existence of mental health difficulty, the battle is help people understand what it means for them and society that it exists.

It is now popularly accepted that those experiencing mental ill health deserve sympathy. We have yet to to transform that sympathy into a reliable repertoire of actions which we might take at the interpersonal, community and national level. People know what to say, but they do not know what to do. And even when they do know what to do or what to suggest, too often they are placed in an intolerable position of knowing the services, supports and recourse to justice that exist in theory do not exist or fulfil their promise in practice.

I think those moving into the terrifying, excruciating and awful experience of recognising that something isn’t going right for them still do not find the warm arms of care and support they were led to believe should be present. Still, as in previous years, the experiences of more severe mental distress can feel like tumbling through the canopy of a dark forest, each branch you grab at too rotted or too green or as brittle as cake icing as the ground approaches. Eventually, there are no branches left, just great indifferent trunks with nothing to stop the fall. We still fail too many people, too often and the work of putting right that failure becomes an ever increasing part of the work itself. We must somehow find the political will to stop the fall so those who survive it are not lost and forgotten in the forest forever.

The risk or the challenge is that mental health, illness and distress becomes a proxy for whatever moral or political judgement or bugbear that commentators and politicians wish to turn it into. Mental illness and mental health difficulty still too often is viewed as a kind of barometer or measure of what is not working in a society, not a clear statement of demand for things to be changed in the here and now.

And I think that’s what we’re entering: the age of demand. Mental health and mental illness and mental distress cannot be made invisible again, nor can the people who experience inequality and injustice as a result of structures they did not make and which they cannot overcome alone. It feels like we are on the precipice of the having to prove that talk isn’t cheap and having to work out what it truly means to accept mental illness and distress as important. We are smarting at our own fear in the face of the question ‘What must we give up so that others may live better and more comfortable lives that are not destroyed by mental ill-health?’ What are so conditioned to think about mental health in terms of services, we always ask as a society ‘what must we do?’ without also asking ‘what must we not do?’

How would it feel if we took to heart the idea that the way people with mental health difficulties are treated is ‘a burning injustice’? What would a dedicated nation mental health service look like? How would it feel to use one? How does ‘doing our best’ and ‘good enough’ become the beginning of the story not its end? I recently saw footballer Clark Carlisle and his wife Carrie talk about their own struggles with mental health. One of his main questions was ‘where is the urgency?’ What if we decided to give research and development and exploration and future making the resources it needs? What if we actually paid the full bill for the demand of unmet need rather than refusing to accept the writ at the door? What are we prepared to stop doing as a society so that might be able to be more, to live more? What if we spent more time asking ‘what if?’

Establishing the social determinants of mental health might belong to the sciences but doing something about them belongs to people and politics.

I think far from being in a moment of crisis around mental health: we are in a painful, long and disorienting moment of waking up.


Mark Brown edited One in Four, mental health mag 2007–14. Does mental health/tech stuff for cash (or not). Writes for money. Loves speaking. Get in touch

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