The Worcestershire Mental Health Partnership NHS Trust provided a rare and very welcome opportunity for members to hear about the work of some of its senior clinicians in a meeting on October 21. Two consultant clinical psychologists had prepared interesting presentations that they delivered in an engaging way, but the content of the presentations had disturbing implications for the way patients will be treated in future.
About forty people turned up to hear the presentations on the subject, “What is Good Mental Health?” Rather than addressing that question with any seriousness, however, the presenters spent most of their time talking about well-being and happiness.
Defining mental health
Sally Denham-Vaughan, from the Trust’s Primary Care Business Unit, took as her starting point the World Health Organization’s definition of mental health, which changes slightly depending where you look, but is along the lines of:
Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.
Unfortunately she had not noticed that this definition makes no sense. It implies that there are individuals whose mental state prevents them from realizing their own potential, coping with the normal stresses of life, working productively and fruitfully, or making a contribution to their communities, but they have no mental disorder!
If that were really true, psychiatrists would quickly have filled the gap with new diagnoses that specify the details of such individuals’ disabilities. It has not happened. The internationally agreed mental disorders do appear to cover the spectrum of disabling mental states pretty thoroughly.
Even more unfortunately, she had not noticed the conflict between treating people who have no disorder and the NHS Constitution, in which the second of the NHS’s seven key principles requires that:
2. Access to NHS services is based on clinical need…
Untroubled by such constraints of logic, she went on to declare that “Optimising well-being is the job of the Primary Care Business Unit”. A diagram of a brain soon appeared. Cognitive Behavioural Therapy (CBT), one of the most successful treatments for depressive illness, amongst other things, was dismissed as merely “replacing negatives with positives — it’s a hard-work therapy”. Obsessive-compulsive disorder, potentially a devastating disability, was equated with rumination.
Effortlessly breaking free from most of the accumulated wisdom of psychiatry, psychology and psychotherapy, she implied that mental health is really about well-being, well-being is really about happiness, and happiness is really about having positive thoughts, so that all you need to do to avoid mental illness is to have lots of positive thoughts (but not too many, because that would be manic). For example, think of something you are grateful for six times a day and you’ll be just fine.
Jo Smith, who works with young people in the early intervention in psychosis unit, tried to continue in the same vein. “Well-being helps to prevent mental health problems,” she told us at one point (and I wrote down her exact words). But pent-up audience reaction began to cause more and more interruptions.
Meeting human needs
At the heart of this second presentation was the hierarchy of human needs proposed in 1943 by Abraham Maslow in his paper, A Theory of Human Motivation. Health is just one of the many needs that Maslow catalogued. Jo Smith’s proposal was that well-being results from all those needs being met, implying that meeting all human needs, not just health, is the job of the NHS.
This was too much for one audience member, who interrupted to ask incredulously, “Is that your job?” Jo floundered, explaining that, “We try to move people away from an illness model.” Then Sally tried to help Jo out by saying, “No, it isn’t our job,” contradicting her own presentation of just minutes before.
Other objections from the audience followed, and the presenters’ responses followed the same avoidant pattern. Each time they would lean over backwards to agree with the questioner, never defending the point of view that they had just put forward in the presentations.
For example, the point of the presentations was clearly to suggest that well-being in its broadest sense is properly the work of the Trust. Someone in the audience challenged this by saying that it is more properly the work of families. Yes, yes, the presenter immediately agreed — it is the work of families. Then someone else said it is more properly the work of schools. Yes, yes, the presenter immediately agreed — it is the work of schools.
Recovery was another topic introduced in the second presentation. However, it was not clear that the word “recovery” in this context meant what most ordinary people think it means. There was a sense that “recovery” could include permanent disability requiring permanent NHS support.
Again, when someone in the audience challenged this, the presenter immediately backed down and told a story about a patient who really had recovered, who had gone off to live a normal independent life as a civil servant. Weirdly, the story was told as a kind of parable about swimming across a river, with Jo turning back half-way across leaving the patient to swim the rest of the way alone. I found this analogy difficult to take seriously.
Mental well-being checklist
Attendees got a handout, the National Mental Health Development Unit’s Mental well-being checklist. I do not understand what the NMHDU is, or its role in mental health strategy, and these things were not explained by the presenters.
The checklist seems to go far beyond mental health, and to be a list of all the nice things in life. Perhaps the idea is that if everyone’s life can be made perfectly nice, no one will ever become mentally ill. It includes such things as “Workplace job control”, “Shared public spaces” and “Access to quality housing”.
One of the more revealing items in the checklist is this one:
Maintaining independence e.g. support
to live at home, care for self and family
That word “support” in there suggests that the kid of independence envisaged is not so independent after all. And that, I feel, is the subtext of the whole document, that all the nice things in life require the expert intervention of a government agency like the NMHDU.
I thought the handout was a political document, out of place at an NHS Trust meeting.
Conflict and confusion
The overall impression from both presenters was of some kind of hidden conflict being played out, some kind of cognitive dissonance, but it was not clear exactly where the conflict lay.
Perhaps, for example, they had been forced by management to present ideas that they do not really believe in. That would explain why they backed down when challenged, relieved at not having to keep up the pretence.
Perhaps they really do believe in these ideas but fear they are too radical to be accepted by the general public. In that case, they might have backed down because they did not feel they could win an outright argument.
Or perhaps their belief in positive thinking is complete, as if they are members of a religious cult, so that they cannot tolerate the negative thoughts raised by an honest exchange of views. Religion was mentioned in the first presentation, and Sally seemed enthusiastic about the idea that the Trust could promote religious belief and spirituality.
Whatever the truth of the matter, these were strange and baffling presentations. They ended with a kind of Sunday school magic trick involving a sweetie jar and some golf balls, pebbles and sand. “If our life is just sand, there is no room for golf balls,” was the moral.
The disturbing part of all this was that the Improving Access to Psychological Therapies (IAPT) programme was mentioned more than once. IAPT was intended to provide proper psychotherapy for people with real mental illness, and to achieve real recovery of the old-fashioned kind (the symptoms of illness actually go away). It would be a terrible tragedy if Worcestershire’s IAPT funding is diverted into a campaign to encourage nice happy thoughts.