The case for open-mindedness, curiosity and multidisciplinary collaboration
Nick Webb, who joins Innovation Unit as lead for mental health, reflects on contemporary explanations for our worsening mental health, and the need for new solutions.
Theresa May's speech this week announced greater national focus on and increased funding for mental health services. It's the latest response to a broader national anxiety about our worsening collective mental health. How do we explain our mental ill health at a time of unprecedented focus, energy and creativity in the world of mental health services and support? What is happening?
Like most areas of public life, there isn't a single, simple account on which we can all agree. You might be familiar with one or more of the following, which tend to get repeated most often and most loudly:
- Investment. There has been a chronic and historic lack of investment in mental health compared to physical health. Underinvestment means that only a small proportion of people get the help they need, and many of those people get it too late. Investment is wrongly weighted, with too much or not enough in acute/crisis services and not enough in early intervention and prevention.
- Culture and society. Norms and values make it difficult for us to talk about mental health openly, acknowledge problems and seek help. Particular groups are held back by inequality, discrimination and unhelpful traditions for dealing with mental ill health. Stigma needs to be tackled.
- Services. Many service models are still provider-led and have not been designed from the service user perspective. There is not enough asset-based design, genuine co-production or shared decision-making. Clinical, biomedical models emphasise management of ill health rather than hope and recovery.
- Commissioning. Too much commissioning for mental health is short-termist. Mental health is a lifelong journey; people often get worse before they get better. Commissioning typical six to eight-week therapies or well being interventions is a sticking plaster that won't fix underlying distress or address wider determinants of mental health.
- Systems. There are structural problems in the way that services and the links between them have been designed and organised. Services (and commissioning) are fragmented, complex and confusing for service users. The historic separation of health and social care is an iconic example.
Are there other explanations?
- Lifestyles. Modern, Western lifestyles undermine mental health. Unhealthy diets, lack of physical exercise, loneliness, family break up, childhood neglect and trauma, the pressure of competition in schools and the workplace — the list goes on. Increased investment and improvements to services will never be enough to repair the damage caused by the way we live today.
- Data, evidence and impact. At national and local levels, data on service spend and impact is patchy. The level of investment in mental health research and development is significantly lower than for physical health. Often we simply don't know what works and what doesn't.
- Language and labels. A culture of measurement and classification, created by professional clinicians over the last 50–60 years, has problematised and pathologised much of the everyday experience of being human and led to a 'medicalisation of suffering'. This is embodied most of all by the Diagnostic and Statistical Manual of Mental Disorders (DSM), which lists and classifies a growing number of mental health disorders in ever greater detail and variety.
- Over professionalisation. The mental health 'industry', particularly in the NHS, has created an overly professionalised approach to supporting people with mental health problems. This is striking because mental health is a deeply personal, intimate experience of relating to oneself and others, and is characterised by intensely felt and profound feelings, anxieties and fantasies.
- Workforce. Many mental health professionals lack the time and personal and professional resources to properly establish the 'therapeutic alliance' between themselves and patients/service users. Workloads, stress, burnout and repeated cycles of financially driven organisational change (particularly in the NHS) have drained the system of compassion for service users and self-compassion among staff.
It's tempting to say that everything in my list (which is not exhaustive) is more or less important, that mental health is complex and varied, and while it's interesting to question, we need to stop over thinking and get on with the job of helping those in need. That would be OK if our current responses were producing great results everywhere, but they are not. Something needs to change.
What happens, for example, if the investment explanation in mental health is allowed to dominate? What gets left out of the conversation? On one level it makes perfect sense to argue for more money in areas such as child and adolescent mental health services, but on another it doesn't. There are strong arguments that a) underinvestment in those services is not among the most important reasons for worsening mental health among children and young people, b) demand for those services will always outstrip investment, and c) increased investment is likely to reinforce service dependency.
What other kinds of new solutions should we be developing and supporting? We know there is a huge opportunity to strengthen preventative, community-based approaches. These require more than financial investment alone. They draw on the power of 'softer', untapped resources including personal relationships, local networks and community assets. Innovation Unit's system redesign work with Lambeth CCG over the last five years has helped shift investment and energy away from secondary/acute services towards early intervention, community interventions. The new model, including the innovative Living Well Network, is successfully addressing mental health problems before they become serious enough to trigger demand for specialist care.
Redesigning whole systems of services and support will be fundamental to improving outcomes. But at the moment there is not enough creative collaboration across disciplines and organisations to imagine and then deliver new, more effective solutions. Clinicians, academics, policy wonks, commissioners, service providers and user-led movements seem more divided and tribal than united and collegiate. The marketplace for mental health services is complicated and fragmented. Services are under increasing strain.
It's hard to innovate or improve in a world like this.
We need open-mindedness, curiosity and, crucially, multidisciplinary collaboration to improve our understanding of why our collective mental health is getting worse, and to use this understanding to create new and radically different models of care and support that have the potential to reverse the distressing trends we see all around us, and enable people and communities to thrive.
In my next blog, I'll start to sketch out the Innovation Unit's ideas and plans for creating new, collaborative solutions in mental health in 2017.
Nick Webb has recently joined Innovation Unit to lead our work in mental health. Nick has experience in organisational and leadership development, strategy and policy in both local government and the charity sector.