The continuum is a one way street

A few years ago, the Time to Change campaign would have been exactly the kind of thing I spent my time arguing for. Now, mental health seems to be everywhere, and I feel somehow hollow and disinherited. I think blogger Purple Persuasion nailed it with her post ‘scary people need time to talk too’[1]; the gist of her argument is that, while the intent behind TtC and other anti-stigma campaigns is admirable, the claim that people with diagnoses are no different from anyone else creates a fairly narrow view of survivors which only includes those with more low-level, everyday conditions like depression and anxiety. Those with more debilitating labels like schizophrenia or personality disorder are often excluded.

The ‘we all have mental health’ type of argument is loosely based on the idea of positive mental health and a mental health continuum; this model presents mental illnesses as existing on a spectrum in which diagnoses are fluid not fixed, and mental wellbeing matters more than diagnosable symptoms. Everyone is represented on the spectrum, with the man from the Berocca advert at one end and a guy in a 136 suite at the other[2]. The ‘spectrum’ argument tries to counter mental health stigma and the ‘othering’ of patients by emphasising the fact that anyone can get ill, anyone can get depressed, and people with diagnosed depression and anxiety can sometimes do everyday stuff like go to work or go to a pub. Essentially, if there’s no threshold for diagnosable illnesses, then we’re all in the same boat. The problem is that the common ground between the diagnosed and undiagnosed is, again, inaccessible to those with more long term illnesses who maybe can’t go to work or go to the pub. The continuum  discourse is beginning to dominate the debate on mental health, and the meaning of the term ‘mental illness’ is changing as a result. Mental illness is starting to be seen as an everyday part of life for a large swathe of the population, less like cancer and more like the common cold. This isn’t the reality for chronic patients, who may spend their lives getting shuttled back and forth beyween different institutions.

The Time to Change campaign’s agenda is also fundamentally neoliberal. TtC puts a lot of stock in the everyday conversation as a means of social change, and it’s telling that so many of the types of conversation they recommend occur within the workplace[3]. Like always, the division between normal and abnormal, those who TtC say are OK and those who the campaign seems to ignore, occurs at the point where a person loses the ability to work. In this way TtC’s agenda fits in a bit too snugly with the old capitalist construction of disability[4] and especially with the DWP’s arbeit macht frei policies towards the diagnosed; those who are economically productive are incorporated, newly de-stigmatised, into the social mainstream, whilst those who cost the system more than they make for it continue to be tossed on the scrapheap. The shrinking of the term ‘mental illness’, so that it seems to increasingly mean just ‘depressed and anxious’, is part of this process. The working worried, whether diagnosed or otherwise, have become the new mentally ill. Meanwhile, the hospital population, ECT survivors, voice hearers, learning disabled and other inconvenients, aren’t welcome under TtC’s new definition. Whilst the stigma may vanish, this is only because those most stigmatised have been brushed under the carpet.

My biggest problem with the ‘we’ve all got mental health’ spectrum-type argument[5] is that it tends to be a one-way street. To give an example, an AMHP in my office today mentioned starting a mindfulness class for mental health workers. She said she thought it was sad that we spent all our time looking after other people’s mental health and it was time we started thinking about our own. This seemed at first like a nice thing to say- a breaking down of boundaries between middle class pro’s and working class patients, a show of empathy, perhaps a recognition of a common humanity. But, as I said, it only works one way. The anti-stigma campaign has freed social workers and CPNs to acknowledge their own mental health; it very much hasn’t freed patients to come up to the office and start writing their own care plans. The powerful are allowed to be powerless for a day, but the powerless are kept just as far away as ever from the corridors of power. And, again, mental health means something very different for the professionals than it does to the patient. Whilst we go to mindfulness classes and take extended holidays to treat our own mental health, our patients are treated with ECT and chlorpromazine in locked wards.  On forced treatment and psychiatric abuse, the anti-stigma campaign has been stonily silent.

Like deinstitutionalization and the recovery model before it, the continuum model seems to be just another in the long line of initially progressive ideas for psychiatric liberation that have been hijacked by the neoliberal Right as a pretext for cutting services and blaming users. Stigma is political, not just personal. It’s healthy to be skeptical of an anti-stigma campaign that’s funded by the DWP.

berocca

 

[1] https://purplepersuasion.wordpress.com/

[2] As opposed to a traditional medical model in which mental illness means the presence of diagnosable symptoms. The continuum model is discussed here http://www.wellscotland.info/about

[3] Point 2 here is work-based http://www.time-to-change.org.uk/mental-health-statistics-facts

[4] See Michael Oliver’s The Politics of Disablement; his basic argument is that, in a system where people are valued only for the worth of their labour,  those whose labour is worth the least are labelled as disabled.

[5] Like so https://www.rethink.org/media/1020706/What%20is%20mental%20health%20and%20mental%20illness.pdf

http://www.time-to-change.org.uk/mental-health-stigma

Workplace organising in healthcare- Part 2-Workers and patients

 The first part of this article aimed to address the practical problems for healthcare workers’ self organisation, and the relationship between workers, managers and policy makers. The second part of this article will go on to address the ethical implications of healthcare worker’s self organisation, and the relationships workers have with each other and with patients.

The healthcare industry is characterised by division. It is split between public sector and private sector, and health and social care. There are often clannish tensions and rivalries between different groups of professionals and workers. It is difficult to formulate industrial strategies for one sector that would be transferable to others. The different sectors of the industry frequently blur and overlap, meaning that workers in the same workplace or team often work for different employers, which makes fighting collective struggles difficult. Overcoming the divisions in the sector is likely to be essential for successful organising.

Divisions among workers

The healthcare industry has previously been organized on trade or craft union lines; with separate organising bodies for doctors, nurses, midwives etc and no representation at all for the unqualified staff at the bottom. Deeper social issues around class and gender, and material differences in pay and conditions, creates a rigid, almost feudal hierarchy among workers with senior consultants at the top, social workers and nurses in the middle and unqualified support workers and HCA’s at the bottom. The differences in terms between registered, salaried professionals and unregistered waged care and support staff give them little common ground from which to organise, and this segregates workers and blocks the potential for a multilateral, industrial union in which all workers are included.

A multilateral union may not be a desirable means of organising when there are such stark class differences between workers in the industry; collective struggle is a difficult concept to apply when some workers earn drastically more than others. Whilst all workers will have their grievances, those who have done well out of the system are unlikely to want to change or end it, so it may be that white-collar professionals prove to be unreliable allies for more militant workers lower down the pay scale.. High-paid professionals may fight their own battles but be unwilling to fight the battles of those whose work they see as less important than their own or, where doctors and social workers do show support for cleaners, porters and care assistants, their concern may be driven by altruism and charity rather than a genuine sense of solidarity and shared struggle. High-paid workers, senior staff members and bureaucrats, whilst still being waged workers, are just as likely to water down radical action as to get behind it.

This class division is felt acutely on the ward; I’ve sat through endless multi-disciplinary meetings and ward rounds where doctors act as if they are holding court. Middle-income professionals like nurses and social workers attempt to mediate, and any care workers lucky enough to be invited contribute little and speak only when spoken to. This is not only characteristic of the relationships between workers in the industry but also allegorical of the wider class divisions in British society. The privileged position of the educated professionals can’t just be put down to superior knowledge but to greater self-confidence and a sense of entitlement that predisposes them to dominate their working class colleagues. There is no reason to suspect a care worker’s union wouldn’t be dominated by the best paid staff, in the same way that a workplace meeting is.

Gender divisions are also stark among social care workers. The health and social care industry employs far more women than men. Women tend to be over-represented in the lowest paid roles and under represented among the highest-paid professionals and management. My social work degree program had roughly 90% female students but only about 40% female lecturers, showing that even where women are an overall majority), they are excluded from the more lucrative positions.  In fact, the healthcare industry is one of the most glaring examples of the inherent sexism of the capitalist labour market; the devaluing of care work, nursing and midwifery undeniably stems from the perception of these jobs as being ‘women’s jobs’, and therefore by implication unskilled and trivial. Any social movement built from the healthcare industry will be to a large extent a women’s movement, and hampered by sexism and institutional discrimination as a result.

Healthcare is an industry made up of women, built on women’s labour but ruled and governed by men.  When it comes to organising, it must be pointed out that male workers won’t necessarily be immune from structural sexism just because they claim to be radicals, so a worker’s organisation may well fall foul of the same gendered disempowerment that exists within the wider workforce, with a minority of men in key positions able to control the actions of an organisation with a majority of women as members. Historically, sexism within the union movement and the unequal distribution of labour in the workplace and home meant that the worker’s movement largely failed to represent working class women at all[1]. Any worker’s organisation in such a setting will need to give serious thought to the question of gender, to avoid falling into the same patriarchal pitfalls.

Patients

Healthcare isn’t like other industries.  Although there is no production of goods, working in care can’t be said to be a ‘bullshit’ job in the same way as other service sector work often is. The standard tertiary sector model, in which services are provided to consumers, doesn’t seem to fit in an industry where the ‘service’ is of life and death importance and the ‘consumers’ rarely choose to be there in the first place. Despite the above, workers frequently take a great deal of pride in their work, and many feel understandably torn between standing up to their managers and doing right by their patients. Even for the most disillusioned of workers is likely to feel bound by a duty of care, and simply downing tools isn’t always an option when people depend on your labour for their quality of life. Essentially, what separates care work from work in other industries isn’t the relationship between workers and owners, but the relationship between workers and patients.

Part of the pressure of the job is the emotionally strenuous nature of the work; healthcare workers have disproportionately high rates of depression, stress and suicide, partly due to the horrendous things that most of us witness as an inevitable part of our jobs. Job security, recognition and a fair salary all help to insulate workers against the stressful nature of the job, but this is something granted to only a fraction of healthcare workers. Care assistants and support workers  are exposed to injury, poverty, disability and death just as often as doctors and therapists are, and this can be a difficult burden to bear for workers who already feel undervalued, and when combined with the day to day stresses of earning below the living wage.

In talking to colleagues, I found that nearly everyone I worked with was dissatisfied, stressed and close to burning out or giving up. Typically, workers in the lowest paid private sector roles would say that the only reason they did the job in the first place was because of their commitment to the patients. The relationship felt more personal than professional at times; workers (especially lone-workers) often seemed to forget that they were employed in a business, that they were under-paid, managed and exploited, seeing instead only the patient and the necessity of the care that they needed to do. This was exacerbated by the nature of care work in a for-profit sector; financial transaction and budgets are agreed by staff behind closed doors, often working for a local authority or another separate agency which the worker on the front line may know very little about. Many private sector companies are also owned by other, larger agencies who the workers may know very little about other than the name on the pay slip. The capitalist element of the industry is removed from the worker and kept out of sight. In this context, where the entirety of the job becomes about patient care and the profit-making apparatus are almost invisible, it was nearly impossible to talk about striking or industrial action.

This ‘doing it for the patients’ attitude seemed to be endemic amongst the lowest paid, private sector care workers. Almost every conversation I had ended on this note. Workers at times would show a great deal of fighting spirit if they thought that management were causing harm to patients. On one occasion myself and a group of other workers sent a co-written letter to CQC, the care regulating body, identifying potential patient abuse which we thought the managers were complicit in. In doing this in a group, we ensured our anonymity would be protected and that management wouldn’t be able to punish us for whistleblowing. In this case, the level of anger that my co-workers seemed to feel was promising. In this instance, though, we were fighting for others, not for ourselves. The same group of guilt-ridden, stressed and undervalued care workers would have been unlikely to stand up for their own rights with the same passion and self-confidence.

Healthcare workers often find themselves trapped in a double bind, under pressure not only from the demands of management but also from the much more real demands of the patients themselves, whose lives depend on the performance and attitudes of staff. This double bind creates a serious problem for workplace organising; very few care workers would be willing to undertake a wildcat strike if it meant leaving a ward unattended or a patient without vital care. As mentioned above, doing so could expose the worker to allegations of abuse by management. R ight-wing attacks on striking healthcare workers also invariably use this trope[2]. This is why large-scale actions like the junior doctor’s strike are so carefully stage-managed; it is doubtful that the BMA would have authorised a strike at all if essential care couldn’t be organised. In providing perfectly adequate cover during their strike, the BMA ensured almost no disruption to services and effectively rendered their strike pointless in the process. So whilst harming patients during a strike clearly isn’t an option,  continuing normal service will not achieve goals as to do so poses no real inconvenience to management. And if strikes are difficult to organise in healthcare, protests and boycotts are even less viable, when so few patients or service users choose to use services in the first place. The idea of an emergency services patient boycotting an A&E department is basically ridiculous.

Managers in healthcare settings and the red top papers often recognize this double bind, and will exploit it to control workers. I have very strong memories of being at work in a private sector care home during a public sector strike. The news was on the radio, and my coworker’s attitudes to the strikers was sneering and disdainful. A common theme of the conversation was that the striking workers (many of whom were NHS nurses) were deserting their duty to the patients. At one point my manager chimed in, saying something like “can you imagine if you lot went on strike? Who would look after everyone here?” here, the ‘doing it for the patients’ attitude was clearly used as a stick to beat the workers with; a kind of inverted form of the divide and rule tactic, where healthcare worker’s sympathy and basic good nature towards working class patients is used to sap their revolutionary energy and allow managers to avoid justice.

Despite the attitude of the Right to striking care workers, worker’s and patient’s concerns about the withdrawal of essential services can’t be written off as simply reactionary, anti-strike rhetoric. Worker’s concerns are part of their role and their professional identity, and any worker’s organisation will need to allow for this. As mentioned above, workers are often more than happy to stand up to the bosses if they are doing so to protect patients. The BMA’s insistence that junior doctors were striking ‘for patient safety’ is perhaps another example of this.

Worker’s organisation should seek to harness this energy. Ultimately, the profit drive in healthcare contributes not only to greater exploitation of staff but to poorer care as well. Workers and patients able to look past day-to-day grievances should be able to find a common enemy in the capitalists at the top and their Department of Health lackeys. Peter Sedgwick made this point in his book Psychopolitics, saying; “When it comes to strike action in hospitals, employees nearly always take a ‘professional’, rather than ‘trade union’, view of their responsibilities and will not leave wards understaffed, even though, arguably, some shock action which places patients in jeopardy would be preferable to continued collaboration with a system which daily harms the sick through routine neglect.” [3]Sedgwick’s point is a powerful one; where healthcare is run for profit not patients, it is collaboration, not resistance, which puts vulnerable people in danger.

Punching down and punching up

As compelling as this is, altruism is not a substitute for solidarity, and it is not entirely satisfactory to claim to be striking for the good of the patients when the patients themselves may feel otherwise.  Solidarity between patients and workers is a difficult concept when one group is so obviously disempowered in relation to the other; one is paid and the other pays to be there, one works and the other has the work done to them, one gets to go home at night and the other stays indefinitely.

Worker’s good intentions can often turn to resentment if frustrated, and there is a dark side to the familial attitudes that staff typically feel towards patients.  At times, workers caught in a double bind who are unable to challenge their managers will vent their anger on the patients instead.

For me, personally, as a worker, I’ve found this difficult to come to terms with and even more difficult to account for or explain. To give an example, in another home where I worked, night workers were made to work unpaid overtime after every shift, until every resident in the unit was out of bed, washed and dressed. Although the night shift was due to finish at 8am, we regularly wouldn’t leave until 9.30 or 10. Rather than complain to management, though, staff would criticise the patients themselves for being lazy and inconsiderate. Staff sometimes began waking residents up  at 5 am in order to finish on time. On a few occasions I saw workers lying to patients about what the time was in order to get them out of bed, using bullying tactics to get residents out of bed when they didn’t want to, or simply ignoring the patients when they protested. Whilst staff had a right to be angry, because they took it out on the residents not the management, no criticism was ever made of the management for introducing this stupid policy in the first place. By doing this, the workers were denying not only their own right to be paid for their work, but also the patient’s right to make choices and run their own lives.

This is just one small example of how workers, when under pressure from management, will turn against patients. More generally, calls by the rightwing media to ease the crisis of funding in A&E units by banning certain patients were met with a great deal of support from nursing staff[4]. Statistically, companies with poorly paid staff, high staff turnover and frequent reliance on agency workers are the most likely settings for patient abuse to occur. I’m reminded of Fran Ansley, the feminist thinker who explained domestic violence in the home by arguing that “When wives play their traditional role as takers of shit, they often absorb their husbands’ legitimate anger and frustration at their own powerlessness.” Poor treatment and abuse of patients seems to work in the same way. Workers who have no power except their power over patients will use that power to make themselves feel better. The only winners are the bosses.

Self-organised worker’s movements can be equally abusive. Peter Sedgwick gives scores of examples of what he termed ‘rightwing syndicalism’ among workers in the psychiatric sector. In the UK, healthcare workers’ unions frequently used strike action to demand the implementation of restrictive, draconian measures to control and coerce their patients, nominally in the name of worker’s ‘safety’. In Italy in the 1970s, Catholic and fascist-aligned nurse’s unions put a major obstacle in the way of the fledgling democratic psychiatry movement[5][6].

This reactionary unionism isn’t exclusive to the most exploited workers either; professional associations aren’t immune to self interest. Recently, less than a week after the junior doctor’s strike, two associations of doctors lent their support to proposals to end GP’s ‘fit note’ duties, and to put the responsibility for assessing the fitness to work of disabled ESA claimants solely in the hands of the DWP and its private sector minions in Maximus.  The BMA will discuss these motions at its next conference. This is despite objection from disabled rights groups, who have campaigned relentlessly against the DWP’swork capabilities assessments[7], and the spate of recent suicides among ESA recipients linked to welfare cuts and particularly to the work capabilities assessments[8].

The above examples provide a good outline of what worker’s organisations should not do. Any movement to defend the rights of workers in the healthcare sector which ignores or tramples on the rights of patients will be a fundamentally reactionary and discriminatory organisation, no more deserving of support than the racist union bureaucrats of the 1960s TUC[9]

The relationship between healthcare staff and their patients and service users is a complicated issue. To understand this debate fully we need to look away from acute medicine and into the fields of social care, disability and mental illness, where the question of who exactly is a ‘patient’ is a political question not just a medical one. Those considered by society as disabled are arguably the worst victims of the capitalist state that worker’s organizations claim to oppose; they are excluded from the labour market, ghettoised into institutions and left at the mercy of an increasingly fickle welfare state. A worker’s organization with a broad commitment to revolutionary change and not just to winning individual victories would need to acknowledge this.

Care workers undoubtedly hold power over patients, especially in fields like psychiatry and social care, where so many patients live in locked wards which they are not free to leave, and are coerced into accepting treatment in the interests of others not themselves. In these settings the caring role is as much a matter of controlling as curing. Many radical patient groups regard the entire healthcare system as an oppressive wing of the state, in which professionals and care workers are collaborators, to be treated with the same suspicion as the police and bailiffs[10].

Workers may find these views uncomfortable but we can’t simply write them off as inconvenient truths. Social workers in particular need to face up to the fact that, because of the state-endorsed power which we hold[11], many involuntary users of services will see us as the oppressor rather than the oppressed. If the healthcare industry is hierarchical then it is the patients, not the workers, who are at the bottom of the heap, and for a movement within the industry to be genuinely ‘bottom up’ and emancipatory, it would need to show solidarity with patients’ struggles, not to ignore them as an inconvenience.

A Patient’s Union?

There is no perfect solution to the problem of how autonomous healthcare workers should protect the rights of patients. Ignoring patient’s struggles is clearly not an option. Likewise, for worker’s organisations to altruistically champion patient’s causes by themselves is not a desirable solution. as to do this would be to enforce representation and hierarchy, to speak for patients and to deny them the right to speak for themselves. But allowing patients to join worker’s organisations is also problematic; the two factions would most likely have separate, sometimes conflicting, goals, and  unless there was a majority of patients with an equal vote in the democratic process, the workers in the organisation would easily dominate the agenda and reduce the patient’s involvement to a merely tokenistic one. Above all, it is patronising to think that patients couldn’t organise themselves, or to assume that they would want to organise alongside professionals.

Self-organized patient’s groups working independently from professionals have a history in the UK which goes back hundreds of years, especially among psychiatric patients and the users of social care services who identify as Disabled. These range from Liberal and charitable groups like Mind[12] to social justice activists like UPIAS[13] and radical organizations like the Mental Patient’s Union[14]. This tradition is alive and well in the present day;  the Hearing Voices Network are one example of a patient-led mutual support and campaigning group that thrives independently from State or professional intervention[15], and activist groups like DPAC[16] and the Black Triangle campaign[17] have both been involved in anti-cuts action in recent years. A self-organized workers union would need to proactively work alongside patient’s groups, whilst respecting their independence and without taking over or dominating them. Whether the healthcare industry would allow for this to happen is debatable, but no other relationship between worker and patient is acceptable.

 healthcare org 2

 

[1] See Selma James, ‘Women, the Unions and Work Or, What is Not to be Done’, 1972 available free at http://libcom.org/library/women-unions-work-or%E2%80%A6what-not-be-done

[2] For example http://www.telegraph.co.uk/news/nhs/12005176/Striking-junior-doctors-will-put-lives-at-risk-and-heres-why.html, and http://www.the-star.co.ke/news/2015/12/22/patient-dies-hundreds-in-danger-as-msambweni-nurses-strike_c1264472

[3] Taken from Psychopolitics by Peter Sedgwick, 1982

[4]http://www.mirror.co.uk/news/uk-news/nurses-say-drunk-patients-should-3706280

[5] See Peter Sedgwick, Psychopolitics, 1982.

[6] Democratic psychiatry was a movement which aimed to end the segregation of patients in warehouse-style asylums and instead introduce community care, with an emphasis on inclusion and patient’s rights. For a good introduction to the movement see “Reform said or done? The case of Emilia-Romagna within the Italian psychiatric context” by A Fioretti et al. 1997, or read an issue of Asylum magazinehttp://www.asylumonline.net/about-the-magazine/

[7] http://www.disabilitynewsservice.com/alarm-over-proposals-to-scrap-gps-fit-note-duties/

[8] http://www.centreforwelfarereform.org/library/type/pdfs/work-capability-assessment.html

[9] http://www.unionhistory.info/britainatwork/narrativedisplay.php?type=raceandtradeunions

[10] See Pam Jenkinson’s chapter in This is Madness: A Critical Look at Psychiatry and the Future of Mental Health Services, PCCS Books, 1999

[11] Social workers can legally detain people in psychiatric wards against their will. They are also central to the child protection system, which provides the legal framework for the state to remove children from their parents and put them into care.

[12] Again, see Pam Jenkinson in This is Madness: A Critical Look at Psychiatry and the Future of Mental Health Services, 1999

[13] http://disability-studies.leeds.ac.uk/files/library/UPIAS-UPIAS.pdf

[14] http://webcache.googleusercontent.com/search?q=cache:4BNmjBY0ePMJ:studymore.org.uk/compu.doc+&cd=3&hl=en&ct=clnk&gl=uk

 

[15] http://www.hearing-voices.org/hearing-voices-groups/charter/

[16]http://dpac.uk.net/

 

[17] http://blacktrianglecampaign.org/

 

Workplace organising in healthcare- Part 1-Structures and managers

The first part of this article addresses the practical problems for healthcare workers’ self organisation, and the relationship between workers, managers and policy makers. The second part of this article addresses the ethical implications of healthcare worker’s self organisation, and the relationships workers have with each other and with patients.

I’ve worked in care homes and home care for the last five years. I trained as a social worker, and during my training worked (unpaid) in two different adult care teams and a drug treatment centre. I’m now a qualified social worker, and currently work in a complex intervention team specialising in older adult’s mental health. This article contains are some of my observations not just from reading around the topic but from my own experiences of working in the industry, talking to other professionals and trying, generally unsuccessfully, to stand up for myself and my friends. I have to admit, I’ve found it easier to see what the problems are than to see the solutions, so this article will mainly raise questions rather than try to answer them. If anyone has any suggestions of what to do in response to the problems I’ve raised, please drop them in the comments section.

Why should healthcare workers organise?

Health and social care is a kind of political football at the moment; it is the industry that has been the most affected by the current government’s public spending cuts, and will see more drastic changes at least over the next five years. Healthcare is an enormous industry in the UK; the NHS alone is one of the world’s biggest employers[1], so worker’s organizations in the UK need to take seriously the possibility of taking action in this industry. The industry itself seems to be in a state of flux and change; funding for services is growing precarious and privatization is accelerating, while changes in policy like the Care Act 2014[2] and the Cheshire West judgement[3] and a widening media debate about welfare, social care and mental health are likely to drastically alter the ways in which healthcare in the UK is provided over the next few years. This feels like the right time for workers to begin to talk about organising in healthcare, and for workers to develop effective strategies for organization and resistance. January 2016 saw a widely publicised one-day strike over working conditions by junior doctors, facilitated by the British Medical Association. In the wake of this, it is important to discuss some the problems that militant workers in the healthcare industry might face when trying to fight for their own jobs.

A large chunk of the healthcare industry in the UK is in the public sector. It is an industry in which the big TUC unions (especially Unison) already has strong ties, and there are a range of professional associations such as the BMA, BNA and BASW that exist, nominally to protect members of the registered professions[4] in workplace disputes against their employers. In the face of so much bureaucracy, organizing in the healthcare industry can feel stifling at times. That said, unqualified workers without a professional registry, especially those in the private sector, have no access to representation whatsoever and often seem to have some of the worst working conditions of any workers in any industry, particularly in the case of home care workers[i][5], so there is a desperate need for a worker’s organisation that can challenge the bosses’ exploitation of workers in this sector.

The structure of the health and social care industry also presents obstacles to effective organizing. The size of the industry itself is staggering, and since such a huge swathe of healthcare provision in the UK is undertaken by state-owned agencies, it isn’t always clear who the bosses actually are. Striking against a local manager or a local trust is likely to be a pointless exercise when the manager in question is following orders from above. Management practices in health and social care are ultimately determined by policy and the resources that are made available to local providers by central government. Healthcare workers looking to organize need to be aware that they are battling not just against their immediate bosses but the government too, to change government policy, not just to end the exploitative actions of a few individual managers. This is a huge task.

Healthcare staff are heavily scrutinized by their employers, and this makes militant organising outside the official channels a potentially dangerous activity for workers to undertake. Obviously any worker would think twice about wildcat action if it meant losing their job, however healthcare workers are more regulated and coerced than workers in other industries and this makes unemployment or disciplinary action a seem all the more threatening. It’s not uncommon for staff applying for jobs in care to have to give references not just from their most recent employers but from every employer over a five year period. There is huge pressure on staff to stay on good terms with their bosses no matter how exploitative the boss may be, since conflict is likely to have repercussions for workers not just in their current post but in future jobs as well.

When applying for jobs, staff typically have to explain or justify gaps in their employment history, so any period of unemployment (such as after being sacked) will seriously hamper healthcare workers when trying to find work. This makes the prospect of losing or quitting a job deeply troubling for healthcare workers, and they may be more reluctant than other workers to antagonize management as a result. Workers are also subject to rigorous criminal records and background checks, so taking direct action even outside of the workplace may seem daunting to workers who risk not only the chance of being arrested but also losing their jobs if convicted of an offence.

Safeguarding laws give managers a whole host of measures to bypass standard disciplinary procedures and suspend or even sack staff more or less on the spot. Officially, these laws exist to protect patients from abuse by staff, but managers would potentially need only a thin pretext of patient neglect[6] in order to bring safeguarding powers to bear to discipline unruly workers. In healthcare, any action that disrupts work could be framed as neglectful of patients, and workers should be aware that management will use this against them. Staff with a professional register have to face not only being sacked if they withhold their labour, but potentially being moved from the register or ‘struck off’ as well, meaning that they could never work  in their chosen field again.

All these factors put healthcare workers’ organisations in a precarious position, especially those that try to organise unofficially without even the meagre legal protection granted to workers who undertake state-approved strikes through the TUC unions. It’s partly because of this rigid legal framework that the legalism of the bureaucratic unions has become so rigid. For myself, legalism often felt like my only viable option to win concessions from management. Management would at times overstep their line, and having a good knowledge of law and proper procedure meant that I was able to challenge decisions and, provided an independent mediator was there to ensure fair play,

I did win small victories, but legal battles will always be fought on the boss’s terms and ultimately shore up the system rather than shaking it down. A legalistic campaign, especially one focussed around an individual grievance, can be a lonely place, where your only allies are false friends from higher up the chain brought in to mediate or oversee. You are constantly fighting in the dark, never knowing who is on whose side, which manager is chums with which other manager and what is being said to your workmates about you behind your back. These are not good substitutes for collective organising.

Healthcare and the NHS

The public sector nature of the industry also raises questions about who exactly should be considered a worker. Since everyone, broadly speaking, earns a salary, and there is no profit motive and no production in a material sense it is hard to identify the bourgeois, exploitative element to organise against.

As mentioned above, the TUC  unions and the various professional associations tend to dominate the sector. But these are a poor substitute for bottom-up organising. I’m not going to go into much detail here about everything wrong with TUC, since the subject has been done to death elsewhere[7]. However, it is worth pointing out that the professional associations tend to have similarly centralised and narrow working models as the major unions, focussing on individual disputes and rather than wider social change. The exclusivity of the professional associations exacerbates the class divisions that exist between different healthcare workers. The junior doctor’s strike highlights this; the public and media attitude to the strike was much more positive than it usually is in response to large scale strike action. This is in sharp contrast to the vitriol heaped on striking nurses and support workers in 2011 and striking midwives in 2014[8], and the different treatment that the two groups received reflects the different social attitudes towards doctors as upper-middle class men and midwives as working class women.

Social Care, the Local Authority and the Private Sector

Outside of the NHS, in the murky, semi-privatised world of social care, things become even more complicated. The recent cuts have fallen disproportionately on local government budgets, and as such social care and local authority workers have arguably suffered more than healthcare workers and NHS PCTs have. Adult social care sector works on a PFI system of purchaser and provider, with the purchasing of services carried out by local authority staff and the actual provision of services carried out by private companies or third sector organisations working on public sector contracts. Council-employed assessors (usually social workers) will assess service users’ needs and allocate a budget, which will then be used to buy care for the service user from for-profit providers (i.e a nursing home or a home care agency). Despite the myth of free, comprehensive healthcare, publically owned care facilities are almost extinct in many parts of the UK. For the majority of patients, the staff who provide the bulk of their day to day care are actually employed by private companies.  However, because of the procurement system, that local government’s social care budget directly impacts the wages of frontline staff in the private provider organization; it’s an unaccountable system in which pay is capped by stealth, making campaigning for pay increases nearly impossible.

Cuts to the services themselves have had detrimental effects on the wellbeing of service users, and the knock on effect of this has fundamentally changed the nature of work for local authority employees involved in what can loosely be termed ‘welfare’, but it is especially the case in social care. Social workers themselves have perhaps seen the biggest change to their profession.  As caseloads increase in volume and severity, social work becomes increasingly driven by crisis and risk prevention, less a matter of helping and protecting people and more a matter of policing and controlling them. The radical tradition in social work is rapidly dying out or becoming a purely academic pursuit with no relevance to the working realities of social care work[9]. Left, Marxist and other radical social workers are increasingly becoming demoralized, and typically either abandon the profession completely or compromise on their beliefs.

Social workers in local authority teams are typically represented by one of the big public services unions like Unison, as well as their own professional association (BASW) and the affiliated Social Worker’s Union.  I’ve noticed from my own experiences that groups of social workers tend to be more politically driven than other professional groups like doctors and psychologists, and at times this can show itself in workplace militancy. During a recent meeting in my own team our manager tried to sneak into the conversation that changes to our contracts could potentially involve a pay cut, and was called out and jeered at by the social work team. Almost every member of the team had consulted a union or BASW rep, and most were aware of their rights in relation to the contract and weren’t prepared to be fobbed off by the manager’s jargon and the contract’s small print. Discussions in the group about the new Care Act showed a similarly healthy level of cynicism and mistrust of central government, which could potentially be harnessed into syndicalist militancy. The downfall of social workers, like other white collar socialists in the public sector, is the misplaced faith they have in their official unions to fight for them. Whilst most social workers understand all too clearly the nature of their role in relation to government cuts and privatization, the TUC unions, despite their leftist rhetoric, abandoned the public sector battlefield long ago.  Unison publically vowed to oppose the bedroom tax[10], at the same time instructing reps to advise members not to oppose it in their own workplaces[11]. Whilst workers with the will to struggle continue to divert their energy into the dead-end protests that the likes of Unison offer, genuine organising will always be stifled.

Big, centralized unions increasingly represent salaried professionals instead of waged workers[12], and have shifted policies and strategies accordingly; these groups seem to pursue an individualistic agenda, where grievances and mediation have become the priority over collective struggles. The difference between a trade union like Unison and an affluent, self-interested professional association like the BMA or BASW is increasingly hard to distinguish. The above example of the contracts dispute is telling; whilst most of the workers had consulted their rep separately, none of them seemed to have discussed the dispute with each other, and the workplace rep hadn’t tried to make contact with the rest of the workforce. The dispute was treated as a string of individual grievances rather than a collective struggle, and this probably sheds light as to why organisations like Unison have failed to keep the floundering social work profession afloat.

The story is different altogether for unqualified social care workers in the provider companies. For care assistants and support workers, the crisis is more practical than principle. NHS and local authority workers enjoy a certain degree of stability and protection in their terms and pay that private sector staff do not have. The social care sector employs a proportionately higher amount of unqualified staff than the medical sector; as well as being underpaid and over-worked, these workers are frequently demoralised by the lack of recognition that their work receives in comparison to their opposite numbers in the NHS. As mentioned above, home care workers in particular suffer from horrendous working conditions. Whilst their work is undeniably skilled and valuable, the pay they receive is often minimum wage or fractionally above, and the lack of paid travel time or paid breaks eat into their take-home wages.

For unqualified private sector workers, organising is particularly difficult. The social care sector makes wide use of temporary employment and ‘bank’ workers on zero-hour contracts.  A large portion of the workforce is made up of agency who find themselves never in one place long enough to put down roots and begin networking.  Community-based staff, like home care workers and support workers, often lone-work, meaning they can go days or weeks at a time without ever speaking to a colleague and all interactions between staff are policed by management[13]. Long hours and poor pay also lead to high staff turnovers, which is a further block to effective organizing. There is no union, registering body or professional association to represent care workers, care assistants or support workers. This is very little media attention given to the work they do, and much of their efforts take place in private homes or behind the locked doors of a care home, away from the public eye. Among many co-workers that I have spoken to, there is a general feeling that the wider world doesn’t know that they exist.

healthcare org 1

[1] http://www.bbc.co.uk/news/magazine-17429786

[2] http://www.communitycare.co.uk/2014/03/14/care-act-2014-means-outsourcing-social-work/

[3] http://www.magonlinelibrary.com/doi/abs/10.12968/bjcn.2014.19.12.612

[4] These tend to be more affluent workers with degree -level or above qualifications; doctors are the obvious example but social workers, registered nurses, psychologists, midwives and a host of others would also fall into the same category.

[5] See http://www.communitycare.co.uk/2015/12/16/wasnt-able-give-clients-needed-broke/  or http://www.communitycare.co.uk/2015/12/16/feel-frustrated-lack-value-placed-work/  for examples of worker’s testimonies

[6] A wildcat strike or similar action would undoubtedly provide this pretext; if the worker isn’t working then the patient isn’t receiving care, so by implication any act of sabotage or unofficial strike could be seen as an act of neglect. This is why the striking doctors were so keen to stress to the press that hospitals would run a ‘Christmas day service’ during the strike; if wards had had to close, the striking doctors would probably have been struck off and sacked.

[7] See http://libcom.org/library/unions-introduction, for a start

[8] See http://www.telegraph.co.uk/culture/tvandradio/bbc/8927036/Jeremy-Clarkson-execute-public-sector-workers-says-BBC-Top-Gear-host.html or  http://www.express.co.uk/news/uk/516794/Midwives-vote-strike-over-pay-putting-pregnant-women-risk

[9] For an overview of what ‘radical’ social work actually is, see http://www.socialworkfuture.org/articles-resources/uk-articles/77-radical-social-work-practice-adults. I am sceptical of this article’s conclusions that ‘radical social work is retrievable in today’s context if it is able to rediscover its humanistic roots’, it’s hard to treat people as human beings whilst simultaneously locking them up in psychiatric wards or taking away their children. Unfortunately, treating people like cattle or naughty children is cheaper and quicker than treating them like human beings, and in the current climate, this is all social workers are permitted to do.

[10] https://www.unison.org.uk/news/article/2014/01/unison-calls-for-an-end-to-the-bedroom-tax/

[11] http://libcom.org/blog/unison-instructs-its-members-enforce-bedroom-tax-22062013

[12] http://www.theguardian.com/commentisfree/2015/nov/19/militant-doctors-lawyers-professionals-new-union-barons

[13] I was once employed by a company that wouldn’t allow staff to have each other’s phone numbers

The politics of a new Mental Health Act

By Joanna Moncrieff, taken from The British Journal of Psychiatry Jul 2003

Recent proposals for reforming the Mental Health Act show that the Government is keen to increase restrictions on current psychiatric patients and to extend the boundaries of psychiatric legislation. The proposals contained in the new Mental Health Bill (Department of Health, 2002) seem destined to make it easier to be subject to compulsory powers and more difficult to be rid of them.

These proposals seem to indicate that the Government is motivated to increase social control through the agency of psychiatry. I will argue that although the state relinquished its historical role in incarceration of the mad to the medical profession in 1959, it is currently trying to re-establish control over the process by enacting some of the most repressive psychiatric legislation of recent times.

  • RECENT DEVELOPMENTS

Informally, the impetus to reform dates back over a decade to increasing government and media concern about the consequences of deinstitutionalisation. The perception was that the closing of the old asylums meant that people with mental illnesses were inadequately contained and were putting the community at risk. The new Labour Government continued to express these concerns and instructed the Richardson Committee, set up to make formal recommendations for new legislation, to consider how the ‘scope of legislation might be extended beyond the hospital to cover care and treatment provided in community settings’ (Department of Health 1999a, p. 7).

Shortly after the Richardson Committee was set up the Home Office, in direct response to the case of Michael Stone, announced its concern to use psychiatric legislation to ensure the confinement of people with ‘dangerous severe personality disorders’. This term was coined for the first time in the Home Office report (Joint Home Office & Department of Health Working Group, 1999).

The subsequent White Paper was clearly designed to incorporate both agendas. It also clearly stated the Government’s objectives with the statement that ‘concerns of risk will always take precedence’ (Department of Health/Home Office, 2000).

  • IMPLICATIONS OF THE MENTAL HEALTH BILL

The Mental Health Bill published in July 2002 outlines a detailed framework for new legislation. The Appendix lists some of the main ways in which it differs from the Mental Health Act 1983. The general effect of the proposals is to increase the circumstances in which someone might be assessed and subjected to compulsory detention or treatment and to reduce avenues for discharge. It will be particularly difficult to argue for discharge from a non-resident or community order. There has been some debate about whether the new act will allow the preventive detention of people considered to be dangerous. Some have argued that the treatability of all conditions remains relevant because ‘appropriate medical treatment’ must be available (Sugarman, 2002). However, the existence of a separate clause for people who pose a risk seems clearly to imply that there is no requirement or expectation, in these cases, that ‘treatment’ will benefit the patient.

Extension of compulsory powers into community settings inevitably means that use of the Mental Health Act will increase above current levels. Community orders will entail that the act is applied to people with lower levels of dysfunction than when it was applied only to people who required admission to hospital. The abolition of guardianship is an indication of the reorientation of legislation away from a concern with how to provide care towards a more exclusive focus on ‘treatment’.

The Mental Health Bill reduces the autonomy of psychiatrists in decisions about when to apply compulsion and what form treatment might take. It is not clear to what extent tribunals will engage in the details of treatment plans, but they will have the power to force doctors to ‘treat’ patients when the doctor feels that this is inappropriate. It seems therefore that the tribunal system has been designed to increase the use of compulsory powers rather than to act in patients’ interests. The lack of an independent review body and the abolition of the Mental Health Act Commission further erode mechanisms for protection of patients’ interests.

  • REACTIONS TO THE MENTAL HEALTH BILL

The Mental Health Bill has succeeded in uniting almost every pressure group, charity and professional grouping against it (the only exception is the Zito trust, which has supported it). The Royal College of Psychiatrists has described recent proposals as ‘unethical, unsafe and unworkable’ (Shooter, 2001) and has joined forces with other groups in the Mental Health Alliance to oppose the Mental Health Bill. It is widely perceived that the Government has no interest in any genuine process of consultation and it has ignored some of the main proposals of the Richardson Committee, such as the introduction of the concept of incapacity as a conceptual framework for legislation (Department of Health, 1999b).

  • HISTORY OF PSYCHIATRIC LEGISLATION

Modern psychiatric legislation combines two distinct strands of law that emerged in the 18th century in England. The first is the power of the state to incarcerate the mad, which first appeared in the 18th-century Vagrancy Laws, which empowered local magistrates to confine those considered to be ‘furiously mad and dangerous’. The second strand is the concern of the state with protecting patients’ interests. This was first manifested in relation to the burgeoning 18th-century ‘trade in lunacy’, with the passing of the Act for the Regulation of Private Madhouses 1774 (Porter, 1990). This act first enshrined the role of a doctor in ‘certifying’ madness.

These two concerns persisted throughout the 19th century. The involvement of a magistrate remained and was extended to private asylums in the Lunacy Act 1890, as a further means of regulating this sector.

From the first decades of the 20th century the Government’s agenda changed radically. This took place in a political context in which state intervention and social welfare were becoming increasingly accepted and health policy was dominated by enthusiasm for prevention and early treatment. The Macmillan Commission, which established the framework for the Mental Treatment Act 1930, was decisive in its endorsement of the medical model of mental disorder: ‘There is no clear line of demarcation between mental and physical illness’ it declared (Royal Commission, 1926). There was enthusiasm for abolishing the role of the magistrate in commitment proceedings despite the fact that the Royal Medico-Psychological Association did not recommend this.

However, it was not until the Mental Health Act 1959 that the principles outlined by the Macmillan Commission were fully realised. By abolishing the involvement of a magistrate and the legal proceedings that accompanied such a procedure, the act handed the responsibility for detaining the mad entirely over to professionals. Again, it is interesting that the Royal Medico-Psychological Association and the British Medical Association had not recommended this in all situations (Unsworth, 1987). The state also reduced its role of regulating psychiatric activities by abolishing the inspection system that had been operating since the 19th century. However, the act did set up a tribunal system in recognition that some mechanism for the protection of patients’ interests was necessary.

The Mental Health Act 1983 reflected a renewed concern with protecting patients’ interests, reflecting the influence of the civil rights movements on the 1960s and 1970s. It narrowed the definitions of certain categories of mental disorder and placed restrictions on the administration of psychiatric treatments in the absence of consent. It also reintroduced an inspectorate, the Mental Health Act Commission.

  • DISCUSSION

This historical summary demonstrates that successive governments and government-appointed bodies have taken the lead in promoting medical notions of mental disorder. These justified expanding possibilities for psychiatric treatment and freeing up the process of involuntary commitment from legal and therefore political scrutiny. The medical and psychiatric profession were more ambivalent about the appropriateness of the wholesale medicalisation of this process.

Recent reforms are justified on the basis of facilitating psychiatric treatment, but at the same time psychiatrists are rendered less autonomous. Having professionalised the process of dealing with the mad in 1959, the Government now appears to be clawing back power to itself, in the belief that psychiatrists are not locking enough people up (Today Programme, 1998). In contrast to other initiatives to increase the input of health service users, the reforms suggest a diminished concern with protecting patients’ interests. It may be that the medicalisation of the process of psychiatric detention and care has allowed the state to devise more repressive measures than would have been tolerated in a system that was more overtly political.

  • APPENDIX
  • Features of the Mental Health Bill, 2002
  1. Broad criteria for compulsory powers include the presence of any mental disorder (no exclusions), and compulsion is necessary for ‘health, safety or protection of others’ or if there is thought to be ‘substantial risk’ and ‘it is necessary that treatment be provided’ (Department of Health, 2002, p. 4). Medical treatment must be available in all cases, but this includes ‘care’.
  2. Non-resident orders for compulsory assessment and treatment in the community.
  3. Tribunals will make decisions about compulsory assessment and treatment in all cases lasting longer than 1 month. Tribunal will approve a care plan presented by the ‘clinical supervisor’and will be able to retain the right to discharge a patient to itself. Tribunal may apply a treatment order when the clinical supervisor wants to continue assessment.
  4. Tribunals will only review cases on the basis of points of law.
  5. Anyone can request a Mental Health Act assessment and trusts have a duty to respond to all ‘reasonable requests’.
  6. The Mental Health Act Commission is abolished.
  7. Guardianship is abolished.
  8. The right to prevent admission and request discharge of the nearest relative is abolished.
  • Received January 3, 2003.
  • Accepted April 9, 2003.
  • © 2003 Royal College of Psychiatrists
  • References

Department of Health (1999a)Reform of the Mental Health Act 1983. Proposals for Consultation (Cm 4480). London: Stationery Office.

Department of Health (1999b)Report of the Expert Committee: Review of the Mental Health Act 1983. London: Stationery Office.

Department of Health (2002)Draft Mental Health Bill. London: Stationery Office.

Department of Health/Home Office (2000)Reforming the Mental Health Act. The New Legal Framework. London: Stationery Office.

Joint Home Office & Department of Health Working Group (1999)Managing Dangerous People with Personality Disorder. London: Stationery Office.

Porter, R. (1990)Mind Forg’d Manacles: A History of Madness in England from the Restoration to the Regency. London: Penguin Books.

Royal Commission (1926)Report of the Royal Commission on Lunacy and Mental Disorders (Cmd. 2700). London: Stationery Office.

  1. Shooter, M. (2002) White Paper on the Reform of the Mental Health Act 1983. Letter from the Chair of the College’s Public Policy Committee. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/college/parliament/responses/mhbReg.htm

Sugarman, P. (2002) Detaining dangerous people with mental disorders. BMJ, 325, 659.

OpenUrlFREE Full Text

Today Programme, Radio 4 (1998) See psychiatrists hit back at the Home Secretary. BMJ, 317, 1270.,1270.

OpenUrlFREE Full Text

Unsworth, C. (1987)The Politics of Mental Health Legislation. Oxford: Clarendon Press.

 

Anti State, Anti Capitalism, Anti Psychiatry

“In its function, the power to punish is not essentially different from the power to cure.”-Michel Foucault

Anti-psychiatry is the belief that the psychiatric system is, at its core, a system of social control masquerading behind made-up science. Protest against the mental health system is not a new phenomenon and in fact goes back hundreds of years to the 17th century, when inmates at Bethlem hospital began petitioning the House of Lords for more humane treatment. In the 19th Century, groups like the Alleged Lunatics Friends Society campaigned against the assaults and abuse that were meted out routinely to inmates in the warehouse-style Victorian asylums. These groups were often self-organized, patient-led groups, but their ideology was essentially a liberal one- they campaigned for civil rights and the rule of law in the mental hospital, greater accountability of psychiatric power and reform of the psychiatric institutions. This tradition continued throughout the 20th century up to the present day. The National Association for Mental Health (now MIND) is one of several examples of user-led reformist groups.

Anti-psychiatry was distinctive from this tradition because of its radicalism. Rather than seeking to modernize psychiatry, check its power or prevent abuse, the work of R.D Laing, Thomas Szasz and others challenged the legitimacy of the whole psychiatric hierarchy. They argued not for a change in psychiatry but for an end to it. Anti-psychiatry was as political as it was medical; the movement flared up in the 1960s, a time of relative popularity for the revolutionary Left among the UK intelligentsia, and anti-psychiatry (with the neo-con Szasz as a notable exception) was very much a part of this progressive intellectual surge. Leftwing anti-psychiatry saw the psychiatric system as a coercive wing of the capitalist State, waging psychological warfare against the working class. Key thinkers fused Marxist materialism, philosophical libertarianism and revolutionary sentiment into a theory that called for the end of medical-capitalist hegemony and freedom for the proletariat from mental slavery.

Anti-psychiatry never made good on its promises. Despite making waves in intellectual circles, the theoretical movement never permeated to where it was most needed; in the asylums themselves. In 1965, Laing, Cooper and others formed a group called the Philadelphia Association and established an ‘anti-hospital’ or ‘community’ at Kingsley Hall in London. They lived and worked from within this separatist bubble, treating a handful of affluent patients and building their reputations through their written work whilst swapping struggle and revolution for anti-psychiatry lifestyle-ism. Without anchoring itself in real-world struggles, the movement drifted philosophically towards apolitical spiritualism, dying out at the end of the 70s with the rest of the hippie counterculture.

“The behaviour that gets labelled ‘schizophenic’ is a special strategy that a person invents in order to live in an unliveable situation.” –R.D Laing

Anti-psychiatry was never a homogenous movement. Apart from the Philadelphia Association, there was never an anti-psychiatry union or club, and as such there is no manifesto or definitive text that could serve as an introduction or overview of anti-psychiatry ideas. Many of the movement’s key thinkers rejected the term ‘anti-psychiatry’ altogether or rarely have their influence on the movement credited,  and frequently disagreed with each other’s definitions of what anti-psychiatry actually is. Without clear practical applications, the reams and reams of text can seem nebulous, metaphysical and wilfully obscure. Trying to understand Szasz and Foucault’s works in particular can often feel like grasping at smoke.

To summarize every key text comprehensively would take a whole book in itself. For a quick overview, though, there are four basic arguments that make up what is usually called anti-psychiatry;

  • That mental illnesses don’t literally exist, that the science behind psychiatry is not a real science[1], and that psychiatry is actually a branch of the legal system rather than a discipline of medicine. This the argument put forward by Thomas Szasz in The Myth of Mental Illness.
  • That mental illnesses are created by our environments, our society and our relationships with others, not by problems in our brains or bodies; this can be true on the level of abusive personal relationships (see R.D Laing in Sanity, Madness and the Family) or oppressive political and economic relationships (David Cooper most famously argued that capitalist exploitation caused mental breakdown in the working class; see his essay in The Dialectics of Liberation)
  • That mental illnesses should be understood as ‘iatrogenic illnesses’- that is, that the psychiatric system actually creates most of the illnesses that it pretends to treat (see Ivan Illich’s book Medical Nemesis),
  • That mental illnesses provide a pretext for the state or society to control people, and psychiatric power is a useful way of enforcing compliance to laws or norms. See Erving Goffman’s Asylums, David Cooper’s Psychiatry and Anti-Psychiatry or Murray Edelman’s Political Language, for more on this.

As mentioned above, anti-psychiatry is usually seen as ‘over’; outdated, irrelevant and a product of its time. This is partly true; Szasz’s apolitical anti-psychiatry quickly sold out it’s humanist potential to free market liberalism, and Laing’s reputation went up in smoke as he ditched credible psychopolitics in favour of LSD and spiritualism. The feminism implicit in Laing’s early work was undermined by his and his exclusively male colleagues relationship with their predominantly female patients, particularly David Cooper’s nasty habit of prescribing ‘therapeutic sex’ to patients too ill to consent. Activists will struggle to find role-models among the original anti-psychiatrists, and there are few professionals now that would use the label for their own work.

Laing

“Modern medicine is a negation of health. It makes more people sick than it heals.”-Ivan Illich

Despite claiming radicalism, Anti-psychiatry failed largely because it didn’t go far enough; whatever the name suggests, Anti-psychiatry was still, at its core, psychiatry. Its biggest stars (Laing, Cooper and Szasz) were all psychiatrists themselves, with little interest in working with existing service user groups or the emerging psychiatric survivor movement. Laing and co. perfected a kind of psychiatric Leninism. Their revolution was a top-down one, in which freeing patients didn’t involve actually listening to them.

The survivor movement had also been developing over the course of the century, and in Laing’s time there was a growing precedent for Marxist and Libertarian patient groups actively resisting state oppression in the asylums. These collectives were independent from the state and professionals, often based in squatted buildings, and typically organized democratically, from the bottom up, by the patients themselves. In lieu of formal therapeutic training, members of the collectives used their own experience to offer support to each other in a kind of therapeutic direct action.

As well as offering mutual support, survivor organizations were fighting forces in their own right. 1972 saw the birth of the Mental Patient’s Union in the UK; a self-organized patient movement with uncompromisingly communist politics. Whilst Kingsley Hall had become a countercultural myth, and Laing a household name, the MPU was stonewalled and ignored by the British media, and it’s legacy has been largely forgotten. In West Germany, the SPK (Socialist Patient Collective) therapeutic commune  was facing brutal repression for its alleged involvement with political dissidence. Two doctors, Wolfgang and Ursula Huber, were jailed for their support of the movement. On both fronts, the anti-psychiatrists in the Philadelpia Association were silent. Laing and Cooper continued to practice at Kingsley Hall, taking patients and ‘treating’ them without ever stopping to question the validity of their own power. Anti-psychiatry, like conventional psychiatry, was something given by doctors and passively received by patients. Structurally speaking, and despite its ambitious rhetoric, it changed nothing.

‘Disease and illness can only affect the body. “Mental illness” is a metaphor. Minds can be “sick” only in the sense that jokes are “sick” or economies are “sick.”’-Thomas Szasz

The failings of the movement can’t entirely be blamed on the inertia of its leaders, though. The mid twentieth century saw a gradual process of deinstitutionalisation in mental health services across the UK, US and Europe. Successive governments committed themselves to health and welfare reform, and the vast asylums of the pre-war era were gradually phased out in favour of psychiatric wards and community care. Partly, this was driven by a liberal interest in desegregating patients and integrating them as citizens into society at large.

By the 1980s, though, when Peter Sedgwick released his seminal Psychopolitics, a critique of (and obituary for) the entire anti-psychiatry movement, it was clear that deinstitutionalisation had not led to psychiatric liberation. Why the patient liberation movement died out is not easy to explain. Naturally, some of the patient collectives disbanded and others were co-opted. Furthermore, governments who still paid lip service to the idea of ending segregation had made it undeniably clear that rights and freedoms  were no longer on the agenda. The relative freedom promised by the shift in state healthcare policy in the 1960s and 1970s was compromised at the dawn of the 1980s, when the post-war drive for citizenship and democracy within the psychiatric system crashed headfirst into anti-welfare onservatism.

If the motive at the start of the asylum closures was a liberal one, the motive at the end was decidedly profit-driven. In the state of California, the first community mental health facilities were opened under the Reagan governorship, and in the UK, the first Minister of Health to implement deinstitutionalisation was Enoch Powell. The new community care facilities were left cash-strapped and dangerously under-staffed, and the current mental health system, where the housing of patients is routinely palmed off onto emergency housing, homeless shelters, police cells and for-profit landlords, was born. In the present day, user-led groups like MIND have found themselves tasked with meeting statutory requirements, patching up the holes in the welfare state and trying to confront the relentless demands for frontline care left behind in the wake of vanished public spending. This leaves little time for political organizing.

We demand the right of patients to join and fully participate in a trade union of their choice. We demand the right of Mental Patient’s Union representatives to inspect all areas of a hospital or equivalent institution. We deny that there is any such thing as an ‘incurable’ mental illness.” –Mental Patient’s Union

The 60s are long gone, and to academics, Laing’s work has grown boring. Why should anyone care now? What does anti-psychiatry have to offer, to the workfare and PFI generation?

Psychiatry is big at the moment. Adverts promoting ‘better mental health’ seem to be everywhere, from billboards and buses to Facebook feeds. These so-called ‘anti-stigma’ campaigns, like ‘mental health awareness week’ and ‘#mandictionary’,  are often state-funded, presented without context, and frustratingly apolitical. Psychiatric reform has also resurfaced in the agenda of the parliamentary Left; In his first week as Labour leader Jeremy Corbyn created the office of the Shadow Minister for Mental Health and appointed Luciana Berger MP to the role. This was largely a response to pressure from the anti-cuts movement which propelled his ascendancy. Several anti-cuts organizations have identified that cuts to welfare would trigger mental health problems among the working class, whilst cuts to the social care sector would leave it unable to cope with the new influx. The recent suicides among disabled people after work capability assessments is just one statistic of many that seems to prove their point.

Significantly, though, the anti-cuts movement has seen self-organized patient/service user groups come to the forefront. Disabled People Against Cuts are the among the most militant of these. Members of DPAC famously chained their wheelchairs to the railings in front of the 2015 Tory party conference, and a group of DPAC activists were responsible for triggering a UN Human Rights investigation into the DWP’s murderous welfare policies.

Clearly, there is dissatisfaction with the status quo. However, whilst the anti-cuts movement makes all the right noises, it is essentially a short-sighted, legalistic and reformist campaign. The clear links between class, poverty, mental illness and suicide were well-documented long before the beginning of the last government’s austerity experiment. Psychiatric oppression is inherent in all capitalism, not just in the Thatcherism currently being hawked from above. It will not be ended simply by replacing one government, one top-down system, with another.

The anti-cuts movement will inevitably sell out or fail, and when this happens there will be disaffected patients and healthcare workers left behind looking for a new cause to rally behind. For meaningful change to occur, it is important that a radical, abolitionist movement is ready to rise up in the place of failed legalism.

The Tory government has already begun to install therapists in jobcentres and jobcentre staff in GP surgeries. The collaboration between psychiatry, capitalism and the state has never been more blatant. To resist effectively, a new movement would have to see the bigger picture behind the cuts to services and the rise in mental illness, to recognise the now undeniable links between the invention of mental illness and the control of the working class by the capitalist state. Patient-led groups like Hearing Voices Network have already started to look beyond narrow questions of policy and funding; In a recent statement in response to the release of the DSM-V diagnostic manual, HVN openly challenged the scientific validity of the entire psychiatric system and called for greater patient control over mental health policy and the de-medicalising of patient care. For groups like HVN and DPAC, direct action seems like the obvious next step from protests and petitions. A self-organized patient’s union with a clear anti-state, anti-capitalist agenda could be the organizational tool from which direct action is launched. Anti-psychiatry, for all its flaws, provides the theoretical basis for such an organization.

Written by Apsych. Please distribute freely.

[1] This is not to say that mental suffering doesn’t exist or that patients are in any way ‘making up’ their illnesses, since things like hallucinations, eating disorders and feelings of suicide are undeniably real to those undergoing them. Rather, the argument is that the experiences suffered by mental patients are not measurable, predictable or scientifically observable, and do not have a clear biological, chemical or physiological cause, therefore mental ‘illnesses’ aren’t actually illnesses. Simply put, you can see a broken leg on an x-ray but you can’t see a depression or a schizophrenia. Mental illnesses can’t be understood in purely scientific terms.

Dr Bruce Scott: Why officials must realise that mental ill health is a political problem

Dr Bruce Scott: Why officials must realise that mental ill health is a political problem

taken from http://www.commonspace.scot

Dr Bruce Scott offers a Marxist perspective on mental ill health

JEREMY CORBYN’S Labour Party leadership victory, his subsequent rousing celebration with the singing of The Red Flag, and the most interesting appointment of Luciana Berger as the first shadow mental health minister, raises hopes that mental distress will at last be addressed from left of centre.

The side effects of neoliberalism’s Lord Layardian happiness agenda may yet be exposed for what it is; neuro-cognitive imperialism intent on a cultural hegemony of suffering and experience, obscuring the political from the personal.

R.D. Laing, the radical Scottish psychiatrist, coined the ‘acid Marxist’ by some film buff in previews of an upcoming film about Laing’s life, and his radical South African colleague Dr David Cooper, a veritable committed Marxist in theory and practice, must both be spinning with delight in their graves concerning recent leftist leaning events that have taken place in the UK which indicate a growing discontent with neoliberalism.

The biological model of ‘mental health’ is highly questionable and dubious from scientific and philosophical perspectives.

As well as the election of Corbyn as the Labour leader and his appointment of a shadow mental health minister, the recent onslaught of 56 SNP MPs on Westminster, a near miss in the 2014 Scottish independence referendum, a second independence referendum no doubt on the cards, and the emergence of Rise – a radical left socialist alliance notably with the Scottish Socialist Party and Scottish left Project – all point toward a growing discontent with toxic neoliberal capitalism and Tory austerity.

Notably for Laing and Cooper, these would be happy events, but even more so because of the fact that this year marks the 50th anniversary of their joint creation of the Philadelphia Association, a vehicle to launch a critique and counter attack on oppressive, inhuman, institutional psychiatric and psychological practices.

One would think a few drams should be the order of the day.

However, a moment of caution must be observed. Both Cooper and Laing would be very wary of the false panaceas of Cognitive Behavioural Therapy (CBT) and the UK Government’s Improved Access to Psychological Therapies (IAPT), as well as the role of psychopharmacology, especially the role of private pharmaceutical corporations and how they currently influence culture, politics, industry, and research.

Moreover, they would be aghast at the proposals by Iain Duncan Smith and the Department of Work and Pensions (DWP) to locate cognitive behavioural therapy and similar therapies in 350 Jobcentre Plus offices around the UK.

The obvious premise of such a move by the DWP is that unemployment is a reflection of individual psychological deficit or ‘mental illness’. What such a move means is that the state blames the individual for worklessness while ignoring the obvious political and economic reasons for unemployment.

Little discussed is the important matter that the discourse of ‘mental health’ or ‘mental illness’ is not all it is cracked up to be. In other words, the biological model of ‘mental health’ is highly questionable and dubious from scientific and philosophical perspectives.

We cannot continue to conceptualise mental distress as a symptom to be eradicated like a medical disease and ignore the political and economic facts that neoliberalism and capital are the real major reasons for misery.

The evidence of organic substrates attributed to the cause of ‘mental illness’ is nowhere near on the horizon to be found and has been dead in the water for decades.

The recent paradigm shift by the Division of Clinical Psychology (DCP), away from a disease model of ‘mental health’ is a testament to that, albeit, it was old news, decades old; Laing, Cooper, and many others discussed this in the 1960s.

No doubt there are political motives in the DCP’s shift. Further, the neuro-cognitive imperialistic discourse of mental disorders is grossly misleading and excludes other discourses of how to conceptualise mental distress.

There are thousands of years of philosophy and numerous other alternative psychotherapeutic and psychoanalytic practices which deal with ‘mental distress’ in rather different ways, which do work, but are hardly amenable to the ‘rigorous’ nature of ‘evidence-based medicine’.

Plus recent evidence shockingly exposes the lack of effectiveness of CBT and other ‘therapies’ of adaptation (e.g., back to normal, back to work); in essence they are castles in the sand.

We cannot continue to conceptualise mental distress as a symptom to be eradicated like a medical disease and ignore the political and economic facts that neoliberalism and capital are the real major reasons for misery.

If we ignore these reasons we go down the road of pathologizing political discontent and protest; this is not beyond the bounds of possibility as we already have Oppositional Defiant Disorder as outlined in the Diagnostic and Statistical Manual for Mental disorders.

I just hope Luciana Berger, the new shadow mental health minister, and the next intake at Holyrood 2016 imbibe the spirit of Laing and Cooper, and grasp the idea that mental distress is a political matter, not a personal failure.

I hope Luciana Berger, the new shadow mental health minister, and the next intake at Holyrood 2016 imbibe the spirit of Laing and Cooper, and grasp the idea that mental distress is a political matter, not a personal failure.

If they don’t, it will be a terribly wasted opportunity.

To end, a quote from Mark Fisher in his book, Capitalist Realism. I am sure Laing, the acid Marxist, and Cooper, the Marxist, would both agree on this.

“We must convert widespread mental health problems from medicalised conditions into effective antagonisms. Affective disorders are forms of captured discontent; this disaffection can and must be channelled outwards, directed towards its real cause, Capital.”

Time does not always heal: state violence and psychic damage

Alfie Meadows following surgery. Credit: Justice for Alfie Meadows, Facebook.Alfie Meadows following surgery. Credit: Justice for Alfie Meadows, Facebook.

The individual is only a symptom of the broader social whole. For decades now, (anti-)psychiatrists, activists and political thinkers have said that mental health cannot be dissociated from the pathologies of the culture in which individuals are deemed to be unwell.

Any supposed polarisation between ‘the mental’ and ‘the social’ is torn apart in situations where political activity puts you in direct confrontation with the state.

When the state’s actions are directly responsible for injury, stress and mental illness, it is imperative that we do not dissociate one from the other. We cannot continue to blame individuals for profound structural wrongs.

I want to talk about the personal impact of a serious, prolonged encounter with the criminal justice system, and the collective impact this continues to have on friends and family. Above all, I want to stress that the way in which the state uses time is a method of punishing, even before it seeks to actually penalise you, what I have elsewhere called ‘the weaponisation of time’.

This stretching out of time is a central feature of what punishment is, from the slowness of bringing someone to trial, to the trial process itself, to prison, the purest manifestation of time used as a weapon, against the very nature of what it means to be human.

The implications for mental health, with the anonymous, seemingly indifferent state with its multiple faces – the police, the prosecutors, the guards – against isolated individuals, named, stripped of any context, are extreme: and it is always the most vulnerable who end up in the worst places, with around 70 per cent of prisoners suffering from two or more mental health disorders.

In December 2010, my partner Alfie Meadows was nearly killed by the police when an officer at an anti-tuition fees demo hit him over the head with a truncheon.

After recovering from the brain surgery that saved his life, he was charged with a serious public order offence. This was despite, or indeed, because of the fact that there was video footage of (and documentation relating to) the attack on him.

Police bloggers nevertheless continued to spread disinformation that Alfie had been hurt by another protester, repeatedly claiming that he had been hit by a concrete block. The frustration and anger about not being able to speak out about the truth of the situation online only made the situation more upsetting.

Alfie spent the next two-and-a-half years in and out of lawyers’ offices and courtrooms, before finally being acquitted a year ago.

Even before charges were brought, several months after he was seriously hurt, I was so viscerally, brutally angry I stopped being able to feel temperature. Months of poor sleep, poor eating and profound rage eventually mutated into something altogether much stranger as I entered into a strange twilight world, lit up by glimpses of things I knew weren’t there but were temporarily convinced were utterly, completely real.

Oscillating between panic and guilt because the person who was still recovering from surgery was now having to look after me, it took weeks to get back to some kind of flatter, less jagged space.

By the time the charge of ‘violent disorder’ was announced, when the Crown Prosecution Service had decided Alfie was fit enough to go to court, I was able to handle it calmly and coolly – after all, this is what they do isn’t it?

If they don’t kill you they try to blame you for their violence, for playing the role of victim, even.

As the trials rolled on – the first ending in a hung jury, the second falling apart after multiple delays and lawyer illnesses – support from friends, whether distant or near, a Facebook message or someone holding your hand in court – became ever more important. By the time of the final day, four weeks into the third trial, it was indispensable.

We were all suffering. Seeing the state up close, seeing senior police officers lie and discuss how they would have turned machine guns on protesters, how they had called for rubber bullets, how the students had ‘asked for it’ – was extremely distressing. Where we couldn’t laugh about it we would drink and sink deeper into the horror of it all, repeating silly phrases from court, mocking their ridiculousness.

When jury members cried at the footage of protesters being smashed with shields, hit with batons, charged with horses and crushed on Westminster Bridge we cried too, even though we had seen all the footage many times before.

By the time of the verdict, we were almost too close to it to feel any relief, even as the political significance of it became increasingly apparent. Alfie and I got sick for weeks afterwards, feverish and full of nightmares. Attempting to chair a conference in a windowless room, I panicked and ran out, being unable to stay anywhere that resembled a courtroom.

Only after the verdict was announced did I realise we had already started to see the world as a prison, locked-down, narrowed to a single dot. As this frame gradually lifted away I was left with an immense feeling of gratitude for all the support – from every card someone had sent Alfie in hospital, to every meal that someone had thoughtfully prepared.

Time started to unfurl less towards a single, bleak point than towards multiple possibilities, back to life, back to colour.

To avoid prison is to be immensely privileged. To avoid prison is to recognise all the factors – most of which have nothing to do with the ‘crime’ alleged to have been committed – that come into play: questions of race, of gender, of educational and class background, of age, of appearance, of the way in which you come across in court, your ‘likeability’ and demeanour.

In serious cases, it is to throw yourself on the mercy of the jury, to hope and rely on their inherent humanity and understanding. It is to hang an image of the future on the compassion of strangers.

It is a process that sees you repeatedly imagining the moment when they return their verdict and the bluntness of the one or two words that determine your life from that moment on. Never forget, as they will never let you forget, that ‘not guilty’ is not the same as innocent. You are never that.

If we managed to survive this ordeal, it was because of the support of people around us. The long-term costs to our collective mental health are still unclear to me: fear of the police is having a debilitating effect on some of those who spent most time at court, or who are very close to Alfie.

Protests are always accompanied by a feeling of violent hatred towards the police and fear of the harm they can do. But there were such positive aspects too. Having a politically astute legal team made a massive difference, and Alfie’s own strength of will in the face of his injury and a potentially lengthy prison sentence was incredible: this gentle, lovely, shy person being punished over and over again, just on the off-chance the state could make some pathetic political capital.

I still feel, I think, too close to the past few years to properly understand what happened, and what it has cost. At this point I only know that you can’t underestimate what support means in times of crisis, and that we need a more honest and open discussion of the types of psychic damage that the state inflicts upon those who try to question it.

When time takes on the form of the enemy, all your thoughts are potential wounds. It is worth remembering that time does not always heal.

Life and death under austerity

Life and death under austerity

(Article taken from Mosaic Science- http://mosaicscience.com/story/life-and-death-austerity)

In times of economic trouble, governments can choose to cut public services to save money. But at what cost? Mary O’Hara meets those on the sharp end of austerity in the UK to find out what it means for mental health.

6 October 2015

When Mark Wood was found dead in his home in August 2013 it could have been just another tragic, but private, event for one family. But it wasn’t. His death came a few months after his disability benefits had been cut because he had been declared “fit for work” by the assessors appointed by the government to implement its “back-to-work” strategy. When his body was discovered he weighed just 5 st 8 lbs.

His sister Cathie said that 44-year-old Mark had struggled to live on just £40 a week after his disability and housing benefits were cut. She says that his ongoing mental health problems, including anxiety, obsessive traits and an eating disorder, were seriously aggravated by the extra stress. A letter to the Jobcentre written by Mark’s GP at the time his benefits were being cut was presented at the inquest into his death. In it, his doctor cautioned that Mark was “absolutely unfit for any work whatsoever”. At the inquest, the GP told the coroner that, in his view, the loss of benefits was an “accelerating factor” in Mark’s decline and eventual death.

The circumstances surrounding Mark’s death hit the UK headlines after his family launched a campaign calling on the government to rethink its cuts and other austerity-driven policy reforms. Yet his case is far from isolated. People have died from physical illnesses that have got worse after being subject to a Work Capability Assessment or having their benefits cut, and some have even taken their own lives.

In August 2015, after a number of Freedom of Information requests, the government released mortality statistics on people who had died after being declared fit for work. The data did not cover how they died, and the government warned against any causal links being made between the deaths and the assessments, but the episode prompted calls for ministers to commission analysis so that any potential connections could be understood.

In the UK, suicide rates rose in 2011 and 2012 (the most recent data available).Men especially seem to be at risk: the male suicide rate is the highest it’s been since 2001 and, for men between the ages of 45 and 59, the highest since 1981. After five years of austerity in the UK – and with billions of pounds more of budget cuts on the way – families, charities, mental health professionals, campaigners and researchers have been highlighting what they regard as the profound effects of austerity on mental health. In May this year, the chief executive of one of the biggest mental health charities in Britain warned that cuts to service provision along with welfare reforms tied to austerity were “driving people to the edge”.

But what evidence is there for a link between economic difficulties and mental ill health? What is it about UK austerity measures – namely cuts and changes to public services put in place to reduce government borrowing – that is raising so many alarm bells when it comes to mental wellbeing? And what lies in store if the direction of travel stays the same?

Life and death in austerity Britain image 2

© Alexander James Wood

Hitting home

Above a row of shops in a bustling high street in south London are the offices ofCoolTan Arts, a grassroots mental health charity. Inside is a small group of men and women, sipping tea and eating biscuits around the kitchen table.

Everyone here has first-hand experience of living with mental health problems and some have multiple disabilities. When we meet, the UK’s general election has just taken place and everyone present is anxious about what will happen. The new Conservative majority government has pledged to shrink social security spending by an additional £12 billion – on top of the billions already cut since 2010. In July 2015, the Chancellor’s second Budget in four months outlined plans for a raft of new reforms, including a freeze on working-age benefits for four years and cuts to Employment and Support Allowance for new claimants deemed capable of “work-related activity”.

People living with mental health problems are among the vulnerable groups that have found themselves at the sharp end of austerity measures introduced after the biggest recession and worst recovery in almost a century.

The cuts to mental health budgets and changes to the benefits system, including tough “back-to-work” policies ushered in by the coalition government formed in 2010, are never far from the minds of those at CoolTan. Punitive financial sanctions, where proportions of benefits are withheld (sometimes for years if people can’t comply with strict rules for finding a job), have been adding to ever-greater anxiety.

“My worst enemy is the postman,” Adam* says, describing what it’s like waiting to hear if he has been sanctioned. “When I hear the letterbox go, I tell you it’s just like earthquakes. I can’t bear it.” Often, Adam says, he doesn’t open the envelopes when alone because he is terrified of having a panic attack. “What they don’t realise is they keep putting you through the mill.”

With fewer places to turn for help, George* says he fears for the future. The others around the table nod. They agree that, in a climate of continual cuts and political rhetoric that classifies people who don’t work as outcasts, they would be “lost” without the help of CoolTan, collateral damage in a society that no longer values them.

The experiences of the people at this one small charity are far from an anomaly. Research published in September by Mind, the UK’s largest mental health charity, reported that for people with mental health problems the government’s flagship back-to-work scheme, the Work Programme, made their distress worse in 83 per cent of cases.

My own research interviewing hundreds of people across the UK during the first wave of austerity produced consistently similar insights. I encountered people, usually but not always in more deprived areas, living in daily dread of losing their benefits, homes, livelihoods and, in some cases, their ability to cope as the mental strain overwhelmed them.

Typical comments people made in interviews between 2012 and 2015 include this from Dec*, a single parent in Luton who was struggling to find work. “There’s people who are suicidal,” he told me, holding back tears. “There’s people with mental health problems – and if they didn’t have mental issues before, they have them now because they are being so degraded.”

And this from Maria, a severely disabled young woman from London who required 24-hour support: “There were many occasions when I wanted to stop existing and didn’t know how I would get through the day,” she said, explaining how she felt after being told by her local council that funds were being cut and that she had to be reassessed for care.

Both the coalition government of the Conservatives and Liberal Democrats formed in 2010 and the Conservative government in power since the 2015 election have defended cuts in a number of areas, including welfare, as being necessary in order to tackle government borrowing.

They have also said that the most vulnerable are offered protection. Responding to concerns raised about the mental stress associated with changes to welfare, a spokesperson for the Department of Work and Pensions said: “It’s important we don’t simply write off people who have a health condition to a life on benefits, which is something that has happened in the past.

“We provide unconditional support to those who can’t work, and jobs support to those who can – for example through the £40 million we’re investing in Jobcentres for people with mental health conditions. Our reforms are fixing the welfare system to ensure it promotes work, helps people lift themselves out of poverty and puts public spending on a more sustainable footing.”

The price of austerity

No matter where in the world you are, look at the research and the evidence is clear: economic strain contributes to mental health difficulties – especially during recessions, when unemployment and poverty tend to jump.

What’s more, people already living with mental health difficulties are likely to suffer disproportionately in times of recession – not just because funding for services might be cut, but also because they are at higher risk of losing their jobs.

The so-called Great Recession showed just how serious and widespread the impact of economic turmoil on mental health could be. One US study found a “significant and sustained” increase in major depression among adults between 2005–06 and 2011–12, during which time millions of Americans lost their jobs and their homes.

Another study exploring the effects of the 2008 financial crash reached some stark conclusions. Analysing data from 24 EU countries, the USA and Canada, the researchers reported that, by 2011, the economic crisis had already led to over 10,000 more suicides than would have been expected – which they called a “conservative estimate”. The downward trend in suicide rates seen in the EU before 2007 went into reverse when the financial crisis hit, rising 6.5 per cent by 2009. In the US the rate increased by 4.8 per cent over the same period.

Yet the study also showed that the trends were not uniform: many countries did not see any increase in suicide rates. The researchers suggested that a range of interventions – from back-to-work programmes to prescriptions for antidepressants – may reduce the risk of suicide during future economic downtowns.

What of the specific effects of large-scale government cuts? In The Body Economic, Sanjay Basu and David Stuckler examined health and economic data over decades, concluding that austerity was bad for both physical and mental health. “If austerity were tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects… One need not be an economic ideologue – we certainly aren’t – to recognize that the price of austerity can be calculated in human lives,” they wrote in the New York Times.

They went on to argue that countries that have chosen stimulus over austerity, such as Germany, Sweden and Iceland, have had better health outcomes than countries such as Greece, Italy and Spain, where austerity measures have been used. “If suicides were an unavoidable consequence of economic downturns this would just be another story about the human toll of the Great Recession,” they concluded. “But it isn’t so.”

Greece – a country with traditionally lower suicide rates than other European nations – has felt the impact of austerity more than most. A landmark study led by Professor Charles Branas of the University of Pennsylvania incorporated a 30-year month-by-month analysis of suicides in Greece, ending in 2012. The researchers looked at possible links between suicide data and particular prosperity- and austerity-related events over the three decades, including the acceptance of Greece into the EU, the 2004 Athens Olympic Games, and the passing of austerity measures by the government.

While cautious not to link the cause directly to austerity, the researchers found “a significant, abrupt and sustained increase” in suicides following austerity-related events like announcements of spending cuts and violent protests against them. Across the decades studied, 2012 was the peak year for suicides in Greece.

Life and death in austerity Britain image 3

© Alexander James Wood

Warning signs

From as early as 2011, the charities Sane and the Depression Alliance were reporting concerns about links between financial woes, austerity policies and rising stress and depression.

Many organisations, including one run by disability activists, began flagging up how a plethora of local government cuts and welfare reforms such as the Work Capability Assessment were creating unnecessary and sometimes intolerable stress for both physically disabled and mentally ill people.

The Work Capability Assessment in particular was generating widespread tension, according to many frontline welfare workers and campaigners. The reasons were complex and multiple. Among them was, as in the case of Mark Wood, the fact that the assessment did not take into account medical evaluations by GPs before decisions were made about a person’s fitness for work. The assessments often led to a reduction in benefit payments. So many decisions were being overturned on appeal that campaigners called for a complete overhaul of the system.

Nick Dilworth is a frontline welfare advice worker and longstanding critic of the government’s back-to-work strategy who also monitors and analyses welfare statistics. He summed up the reality of dealing with the consequences: “People are coming in with multiple problems. You get grown men crying. What you see are broken lives.”

In addition, sanctions, which were causing significant stress, soared after 2010, while Jobcentre workers began speaking out about what they say was an increasingly punitive regime that was adding to the mental stress of both claimants and workers. As Angela Neville, a Jobcentre worker who went on to write a play about it, explained to me in February 2015: “From my own experience, staff are subjected to constant and aggressive pressure to meet and exceed targets. Colleagues would leave team meetings crying.” On the fallout after sanctions were applied, she said: “It was very distressing to have customers literally without food, without heat, without resources – and these are unwell [and] disabled customers.”

Life and death in austerity Britain image 4

© Alexander James Wood

Picking up the pieces

Mental health services in the UK are notoriously underfunded and are often referred to as a “Cinderella service”. According to the Centre for Economic Performance, mental health services receive just 13 per cent of the total NHS budget, while mental illness is responsible for 23 per cent of the loss of years of healthy life caused by all illness nationwide. Under the coalition government of 2010–15 there were numerous moves to place mental health at the top of the wider health agenda. A variety of pledges and initiatives were made, many championed in particular by the then Deputy Prime Minister, Nick Clegg. Proposals that included, for the first time, specific waiting-time targets for people seeking treatment from mental health services were widely seen as a step forward. So too was a commitment to invest more in young people’s mental health provision.

However, mental health provision was hit hard and early by austerity measures. Despite rising demands for help, including from people in crisis or feeling suicidal who were turning up at A&E departments ill-equipped to deal with them, mental health services and the people relying on them were feeling the impact. Organisations from Oxfam to activist groups such as Disabled People Against Cuts and War on Welfare warned of an unprecedented “perfect storm” of falling incomes, rising costs and the removal of vital safety nets, including for mental health and disability, just when the pressure on individuals and families was skyrocketing.

The numbers back this up. In 2011, three years after the financial crisis, the number of prescriptions for antidepressants rose sharply, up 43 per cent on the previous year. One investigation found that more than 2,000 acute mental health beds were lost in England between 2011 and 2013. This meant that many people in crisis who didn’t have a safe place to be had to be transported hundreds of miles to wherever a bed became available. Some patients were even held in police cells.

By 2015, funding for mental health services was estimated to have fallen in real terms by 8.25 per cent over four years. Three-quarters of children and young people with a mental health issue could not access treatment when they needed it. Charities warned that this was also storing up problems for the future because it prevented early intervention, something proven to be crucial for young people’s recovery prospects. In June 2015, Liberal Democrat Norman Lamb, who as Minister for Health until the election in May was a key proponent of improving investment in mental health, warned that if the new government failed to stick to pledges to increase funding, mental health would remain “the poor relation” in the health system.

Meanwhile it was reported that calls to mental health helplines from people citing financial problems shot up in line with personal indebtedness. Reports, including a number from the Centre for Welfare Reform, catalogued how policies such as the “bedroom tax” (where benefits can be reduced if someone is deemed to have a “spare” bedroom in their council or housing association home) were “savaging” people’s mental health. GPs reported a surge in patients with stress and anxiety due to worsening economic predicaments and joblessness.

On the front line of mental health, the strain of five years of austerity became such that hundreds of health professionals took to writing to newspapers about it. In one highly critical letter to the Guardian on the government’s public health record, senior physicians linked austerity policies to rising suicides, concluding that “over the last five years, there have been avoidable deaths and much unnecessary damage to health”.

In another letter, published just before the 2015 election, 442 professionals ranging from psychologists to epidemiologists wrote: “The past five years have seen a radical shift in the kinds of issues generating distress in our clients: increasing inequality and outright poverty, families forced to move against their wishes, and, perhaps most important, benefits claimants (including disabled and ill people) and those seeking work being subjected to a quite new, intimidatory kind of disciplinary regime.”

Psychologists Against Austerity, a new alliance of mental health professionals, had formed with the aim of directly challenging the cuts and welfare changes that they said were adding to mental distress. The group produced a briefing paper that includes five “austerity ailments” it believes contribute to worsening mental despair. These are: humiliation and shame, instability and insecurity, isolation and loneliness, being trapped or feeling powerless, and fear and distrust. The authors conclude: “Mental health problems are being created in the present, and further problems are being stored for the future.”

One group of researchers believes that a serious political-cultural shift is taking place within the welfare system, and that it is having serious ramifications for mental health. In a paper published in 2015, Dr Lynne Friedli and colleagues documented their findings on the impact of back-to-work policies, notably psychological assessments of unemployed individuals’ fitness for work.

“Psychological explanations for unemployment… isolate, blame, and stigmatise unemployed people. They reinforce myths about ‘cultures of worklessness’,” Frieldli wrote. “They obscure the realities of the UK labour market and the political choices that underpin it.”

Life and death in austerity Britain image 5

© Alexander James Wood

Life and death

When the impacts of austerity are discussed in the UK, deaths feature prominently. Like Mark Wood, some of the people who have died had a history of mental health problems. Others didn’t. And there are many, many stories. In one case, a man doused himself in petrol outside a Jobcentre after being declared fit for work and experiencing benefits delays. Police arrived in time to save him.

A woman died two days after trying to take her own life. Her doctor told the inquest that a letter stating that her incapacity benefits were to be withdrawn had precipitated the suicide attempt.

A pensioner in his 70s was believed to have killed himself due to fears about the “bedroom tax”. Witnesses testified to the inquest that he was frightened by news reports that said people might lose their homes if they couldn’t pay it.

The issue of deaths related to welfare reform and austerity, be they a result of suicide or otherwise, is complex and controversial. There have been escalating calls from families and campaigners for a full public investigation into deaths that followed cuts to benefits or the implementation of sanctions in order to find out what connections there may be. And when, in September this year, a coroner in north London concluded that the suicide in 2013 of 60-year-old disabled man Michael O’Sullivan was a direct result of having been wrongly found fit for work, there were yet more calls for the Department for Work and Pensions to overhaul fitness-for-work assessments. The coroner said: “[His] anxiety and depression were long-term problems but the intense anxiety that triggered his suicide was caused by his recent assessment… as being fit for work, and his view of the likely consequences of that.”

Journalist John Pring, who lives with a mental illness and runs the websiteDisability News Service, has been one of those labouring for full disclosure of “internal peer reviews” conducted by the Department for Work and Pensions into deaths (49 cases had been reviewed by June 2015). Some details have been released, he says, but not full reports, which would facilitate a better understanding of the circumstances and, he argues, how to prevent future deaths.

More research and better data are needed to ascertain fully the connections between recessions and austerity and suicide, but mental health strains are clearly exacerbated by economic factors, according to Joe Ferns, Director of Policy and Research at Samaritans.

Part of the problem, he says, is that stresses such as financial pressures or losing a job make people feel “disempowered” and “less able to cope”. But people can be affected by the community around them too. “What the research does show,” says Ferns, “is that people living in deprived areas are about ten times more likely to die by suicide… I think it’s fair to say that an economic recession creates ripples. The social impacts spread far wider and last far longer than the economic ripples.”

However, more research will take time and, as epidemiologist Sanjay Basu has pointed out, there is already considerable evidence of serious and deleterious effects, which, as a matter of urgency, require robust policy responses, not least because people’s lives are on the line. Basu says his work has persuaded him that the stakes of austerity for mental health are very high indeed. “I think the real decision for us is whether we want to pay now or pay later. I think we can either pay now in terms of creating the social safety nets in order to avoid a real dismantling of some of the key parts of our communities or we’ll face the consequence for many years.”

Charities, healthcare professionals, academics and those on the front line agree: act now, or suffer more later. The Department of Health told me that they are tackling “historic underfunding” in mental health, increasing investment in the area by £300 million last year. They mentioned that “more people than ever before” are receiving talking therapies and that the government’s Suicide Prevention Strategy is backed by £1.5 million funding for research.

But will this be enough to stop people dying because, at least in part, of the UK’s austerity measures? At CoolTan Arts, one woman makes a point that’s hard to ignore. “I think it’s going to get much worse,” says Jane*. “This government has got another full term and you don’t know what their plans are.”

Back in Oxford, Mark Wood’s sister Cathie says there is only one thing to do: keep fighting. “We are now trying to get answers and just keep the pressure up so people know the human cost of the cuts, and that we are becoming a crueller, more backward society in terms of how we treat our most vulnerable people.”

* Some interviewees’ names have been changed.

Social Action Therapy

“From private symptom to public action”

Social action therapy is a little-known psychological model, which uses activism as a means of treating mental distress. Libcom’s pamphlet Class Struggle and Mental Health championed the view that capitalism and state oppression cause psychological suffering. This is true, but it the flipside of this is that resisting capital and state power can potentially lead to better mental health. This is the premise on which social action therapy is based; that any political action which relies on mutual support, consciousness and solidarity is essentially therapeutic for the activist. For the oppressed, political and economic oppression is not just a matter of theories and statistics but is a deeply personal experience. In line with this, social action therapy is at once a method of direct action and a form of treatment; it is a way to fight oppression on both a personal level and a political one.

In terms of methods, the libertarian and anarchist movements and the service user/patient liberation movements both arrived at similar conclusions. Both schools of thought reject representation, so-called professionalism, charity and help ‘from above’ in favour of direct democracy and self-management. Indeed, a popular slogan for the disability rights movement in the 1980’s was ‘piss on pity’, a middle finger to the care system and a move to politicize needs and demand rights instead of charity. It’s a sentiment that many activists can doubtless relate to. Social action therapy reflects this; a central feature of the model is the individual’s transition from being a ‘patient’ in professionally-led services (i.e. in treatment which comes ‘from above’, with the backing of the state) to being an activist in a user-led campaign, fighting from the bottom up.

The implications of social action therapy could have been world-changing, not just for the psychiatric patient/survivor movement but for anyone whose experience of injustice and discrimination has pushed them into psychiatric services. The idea was first outlined by a radical feminist psychologist called Sue Holland in her 1992 article ‘From Social Abuse to Social Action’. However, Holland’s writing never got mainstream attention, and today social action therapy is almost unheard of among conventional psychologists. It’s easy to see why the powers-that-be wanted Holland’s work ignored; professionals tend to hoard their skills, and a theory that puts service users in control would put therapists out of a job. Holland herself wrote “Whilst other psychologists advance their careers by writing about radical psychology, I find that actually doing it leaves little time to meet editor’s deadlines.” Apparently, the caring professions are not kind to their dissenters.

Holland’s initial therapy project was with a group of women from a low-income estate in London. Many of the women were struggling with money, housing and childcare, and had experienced racism and sexism, including domestic abuse. All of them were being treated by mainstream psychiatric services, and all were taking medication for a range of mental illnesses when Holland first started working with them.

Social action therapy as Holland first practiced it had four stages, which I’ve outlined below. All quotes are from Holland herself unless otherwise stated.

     Stage 1) Patient on Pills. “Women often feel so bad about themselves that they can’t  face their everyday life. They go to the doctor complaining of ‘nerves’ and get pills to calm us down or cheer us up. We then see ourselves as having a ‘medical’ problem […] we see ourselves as a ‘psychiatric case’, waiting to be cured.”

 

The neoliberal psychiatric model atomizes patients with individualistic diagnoses and treatments, and denies the social and political causes of suffering. The rationale is that poor mental health originates from individual flaws, essentially blaming the patients themselves for their own oppression, blinding class consciousness and internalizing their legitimate anger as guilt in the process. The ‘patient on pills’ is someone who is stuck in this self-blame trap.

Any kind of stigma or exclusion leads to feelings of guilt and shame, especially in capitalist societies that claim meritocracy and sneer at the victims of their system. Anyone who has ever had to count pennies until payday knows how frankly embarrassing poverty can be sometimes, and how much other people can judge you and make assumptions about you. When Holland talks about ‘feeling bad about ourselves’, this is what she means. ‘Feeling bad’, feeling guilty and blaming yourself for what’s happened to you are incredibly damaging to a person’s mental health. But this is political as well as emotional; when powerless people have these feelings it stifles the potential for solidarity and makes them easier to control. A psychiatric system that turns angry workers into ‘patients on pills’ is collusive in this exercise in power.

      Stage 2) Person-to-person psychotherapy “talking to a woman     therapist […]reveals our buried feelings, such as anger and guilt.”

The aim of the one-to-one therapy in stage 2 is to counter the self-blame and despondency felt in stage one, to help clients see past personal guilt and to begin to accept themselves as ‘wronged’ by the system rather than somehow ‘wrong’ within it. Holland states that this one-to-one therapy focussed on a few issues that were identified in partnership with the client, and this point is important. In my own experience of counselling, I’ve seen therapists tell clients what their own issues are. A client will say something like “I’m depressed because I’m in arrears on my rent, and my husband has left me”, and the therapist will decide which of these two issues to talk about. This is almost always a pretext for an exercise of power, often with a statist agenda, since if the therapist avoids talking about the client’s rent arrears or their housing and instead focuses on the personal/relationship issues, then they will distract the client’s attention away from the social and political issues that may be affecting them. Naturally the therapist’s judgment is influenced by their own bourgeois values; the social and political are ignored in favour of the narrow and personal, and the client carries on looking inward rather than outward to try and improve their life.  Holland’s therapy is different to this, because it lets the client not the therapist decide which issues are important and which issues aren’t.

Holland also specifies that her women clients should work with a woman therapist, and this is important. The end goal of this model is solidarity, and clients across the spectrum of the working class, minorities and other oppressed groups should ideally work with a therapist from within their own community. Women clients would not learn how to stand up to male patriarchs if they had to rely on a man to do it for them. The best therapists draw on personal experience as well as state-backed training; ideally, working class former patients should learn the skills to support each other.

A client should be allowed to “explore the meaning of her symptoms, which frequently mask grief, oppression, rage and loss”. In her report, Holland noticed that “towards the end of this one-to-one work, the woman is expressing a greater social interest in the world around her”. This is not surprising.. They stop accepting the world for what it is, and begin to think about how that world can be changed. This is where Social Action Therapy becomes distinct from other types of therapy; ending self-blame is the first step not just towards better mental health but also towards direct action.

     Stage 3) Talking in groups. “Now, freed from our personal ghosts, we can get together in groups and discover that we share a common history of abuse, misuse and exploitation […] as women, as working class women, as Black women… Now we can see, and say together what we really want.”

Holland said that going from one-to-one counselling to talking in groups led to a ‘sistering’ experience between the women. Meeting other women in similar circumstances allowed them to realize that their symptoms (and the hardships that caused them) were not unique to them, but actually something that they had in common with each other. They also realized that they shared strengths as well as problems, and because of this mutual support, the women began to realize that, together, they could stand up and change their circumstances rather than shutting up and accepting them.  Through mutual support, class consciousness was developed.

The purpose of the group is to provide mutual therapeutic talking. It is in this stage that the therapist begins to take a back seat, and the individuals involved slowly begin to counsel each other rather than relying on help from above, and the whole project goes from being professionally driven and representative to being self-organized and user-led. Psychiatric power is challenged, and mutual aid has replaced formal treatment.

     Stage 4) Taking Action “Having changed ourselves from patient to person, from  depression to self-awareness, we can now use our collective voice to demand  change.”

In step three, the women realized that their problems were bigger than just themselves. In step 4, they realized that if they work together they have the strength to tackle them. Holland said this started when the women told her they wanted to break away from state care and start their own neighbourhood advocacy and counselling service, using the skills they’d learned in their group.

Holland wrote that the women were initially stopped from realizing their dream by the powers-that-be in the local NHS, who presumably considered the prospect of having too many happy women doing meaningful work to be some sort of affront. The women struck back, illegally occupying the flat that they had been practicing out of and demanding the recognition of their skills and the right to work. After a long struggle, they won, and the Woman’s Action for Mental Health (WAMH) group was formed.

Social Action Therapy works independently from the State and the Psychiatric system and is founded on the principles of mutual support and direct action; this makes it the perfect starting point for anyone interested in a Libertarian alternative to coercive psychiatry. Service users can do it for themselves, and activist groups, with or without professional allies, can use this model to achieve genuine separation from the old system of drugs and locked wards. For patient liberation groups in particular, this model is particularly important; they can move beyond campaigning for better services and begin to provide the services themselves.

But the struggle for better mental health doesn’t exist in a vacuum. It is a luxury to be able to separate the personal from the political; for most of us, they are one and the same; our oppression affects our mental health, and in turn our mental health affects our ability to fight back. The powerful have always benefitted from the self-doubt, hopelessness and guilt felt by the powerless. For anyone who has ever been stamped on, the fight for freedom is an internal battle as well as an external one. Social Action Therapy is relevant not just to the service user/survivor movement and the struggle against psychiatry, but to every struggle for social justice.

In social action therapy, solidarity and struggle become an end as well as a means. It’s easy to see why no-one wants to talk about Holland’s idea; it has the potential to change the world.

For anyone who wants to know more, Sue Holland’s original article is called ‘From Social Abuse to Social Action: A Neighbourhood Psychotherapy and Social Action Therapy for Women’. It was published in a book called ‘Gender Issues In Clinical Psychology’, edited by Jane M Ussher and Paula Nicolson, published by Routledge in 1992  

“Do we help to sedate, or to activate?”

Written by Apsych. Please distribute freely.

 

 

I just wanted to keep everyone updated on what’s happening with Apsych since we’ve been quiet for a few weeks now. I recently took a job as a social worker in a mental health team, and although I’m excited about this, I wanted to publicize it here for the sake of honesty since me holding this professional position raises questions about whether or not Apsych can still claim to be genuinely user-led.

I’ll continue to publish material on this blog, and will continue offering solidarity and support to any other users or organizations who want it. However, Apsych’s campaigning aspirations will be put on hold, at least in the short term, whilst I think about what the right thing to do is. For now, this is purely a blog, not a campaigning group or direct action network.

I’m finding this decision difficult, since it is as much a dilemma about who I am as a person as it is about what Apsych believes as an organization. It seems like not very long ago that I was in services myself, and although I feel guilty for taking the job. like I’ve ‘switched sides’, part of me is worried that not taking the job will affect my recovery. Any advice or fresh perspectives would be really appreciated.