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Thursday, 19 July 2012

Interview with Mark Brown: The New Mental Health (2)

More views of - or before - Cambridge Film Festival 2012
(Click here to go directly to the Festival web-site)

20 July

If you have followed a link, it should have brought you here: to an interview with Mark Brown about The New Mental Health

1. Mark, you've called this The New Mental Health - what are you hoping for from that choice of name?

I think that is often really difficult to discuss broader shifts in thinking without giving them a name. Giving something a name allows you to discuss what fits in under that name and what doesn't, who is doing it and who isn't, whether the name fits a particular thing or not. Without a name that brings things together what you get is lots and lots of disconnected things happening, with no way of bringing them together so that people can discuss them.

At the moment we have 'mental health' as a category that covers everything from forensic inpatient wards to national funded-to-the-tune-of-millions campaigns like Time to Change to you and a couple of mates sitting around your dining table trying to work out how to run a local advocacy or arts group. Beyond telling us who you're aiming at – people with mental health difficulties – it doesn't reallly tell us much else.

What I've noticed is that there has been a shift in mental health or at least a shift in the way some people look at doing 'mental health stuff'. See, we run into the problem of not having a name for things that means that 'mental health stuff' is the only way I can describe the wide variety of projects, activities and services that people are carrying out directed towards making life with mental health difficulties better or more fulfilling.

I started from recognising the broad similarities that I saw between these people, projects and services, because they're actually there. There has been a shift both on the part of some organisations and services and on the part of some people with mental health difficulties related mainly to two things: the idea of people with mental health difficulties actually being in control and in people with mental health difficulties not accepting the idea that only others can do things on their behalf to make life more viable and liveable.

From recognising what was already happening, it seemed sensible to give that a name as a way of bringing this shift together into a form that people could actually debate, discuss and put into action.

I think choosing a name like 'The New Mental Health' gives us a way to talk about this change by escaping from older ideas like the division between 'professionals' and 'people with mental health difficulties' or the idea that the only way to bring about mental health change is to become a campaigning activist.

So, instead of saying 'we're talking about lots of different projects and people across the country (and the world) that don't have a connection with each other' we can say 'we're talking about organisations, people and projects that we can recognise as sharing these New Mental Health ideas to a lesser or greater extent'. It opens up a space for discussion.

I think, more broadly, we're moving into a period where people have far greater access to ideas (Hello, Internet!). If you look at where large numbers of people are coming together to make stuff happen, they tend to be people choosing to arrange themselves around ideas rather than people joining organisations then being mobilised and regimented by hierarchies. The stress is less on whether people believe entirely the same things as each other (see things like the Tea Party movement on the US right of centre or UKUncut on the UK left of centre) and more on whether they can come together at specific times to do specific things.

Defining an idea and then setting that idea free lets other people come across it and use it as a way of understanding what they're already doing or as an inspiration to do something that they aren't already doing.

When you're doing things and making change happen, or wishing for change to happen, it can be hard to see where what you're doing fits in with what other people are doing.

I'm hoping that The New Mental Health will help people to see where others have been thinking similar thoughts to themselves about the next step for people with mental health difficulties taking control of our services and where people have already been doing just that.

To me, that seems like a pretty clear statement of what using the name can do.

2. Was launching this new approach in your mind before your strong speech in Perth, Australia?

Was there a flow of energy, in both directions, with writing the speech itself and gauging how people related to you and to you giving it?

The speech in Perth was really an attempt to distil about two years' worth of work, talking to people and thinking into one snappy easy-to-respond-to package.

A lot of the time, if you're suggesting anything a bit different in mental health you have the problem that no one will give you a public opportunity to speak about it until you've proved that what you're saying is useful, which obviously means that there aren't that many opportunities to get anything new out in public!

I originally pitched an article called 'The New Mental Health' to a magazine about two and half years ago where I'd already spotted the shifts in thinking and practice based on organisations and people I'd already met then doing mental health projects. Over 2011, I co-wrote 'Better mental health in a bigger society?', a pamphlet initially commissioned in the final months of the National Mental Health Development Unit, which came about from me trying to work out what 'Big Society' and austerity policies might mean for people with mental health difficulties and what non-NHS mental health services and projects might need to keep going through a period of public spending reduction.

So, the speech itself was the upshot of hundreds of conversations, much reading and lots of research and head scratching.

It went down fantastically in Perth. I hadn't quite realised what giving a keynote speech actually meant, so it was an amazingly odd experience to find myself addressing about 300 people, with three people after me giving speeches in response.

Two of those were psychiatrists and the third was a young woman who is a mental health worker who also hears voices. What was most heartening for me was that her speech started with the words 'that's exactly how I feel'.

After giving the speech, I went from conversation to conversation with people who wanted to tell me how they were making community-based mental health stuff happen and telling me that I'd definitely put my finger on something, namely the idea that traditionally run medical mental health services, in Western Australia at least, still held most of the power, but didn't manage to answer all of the problems.

What was also heartening was that a number of world-famous mental health campaigners told me that there was something about the idea of The New Mental Health and moving from an oppositional model to a pragmatic doing model was the right way forwards.

From talking to people in Western Australia, as I have with some people in the UK, I got the strong feeling that people were glad that someone had finally managed to bring together the threads of what they'd already been thinking and, importantly, doing.

3. Your magazine, One in Four, seems to distance itself from whether 'mental health difficulties' arise from - and are the field of - medicine by using those words.

For you, will that still be the preferred term in talking about The New Mental Health?

For me, if you're not providing actual medical services, the question of where mental health difficulties come from isn't as useful as 'what are we going to do today that makes it less shit having one?'

I think
mental health difficulties
is a good way of phrasing things because it escapes the trap of arguing about diagnosis and validity of diagnosis and just gets the nitty-gritty of 'do things exist that happen in our heads that get in the way of doing stuff?'

You can have difficulties with your mental health for years before you have a diagnosed condition and a diagnosis in a lot of ways is only a means by which you are allowed to access certain forms of support.

Even if we came up with a definitive 'cause' for mental health difficulties, that wouldn't reduce the challenges they can pose to getting on with your everyday life.

There are lots of vigorous and exciting debates to be had about the causes of mental health difficulties but they're not ones I have time to get involved in. Having lots of problems in your life, your living situation, your relationships and your economic circumstances might result from mental health difficulties or might be the cause of them, but that isn't as interesting to me as trying to do stuff that removes or reduces the effect of those problems.

4. Providers of services in 'old' mental health are usually hospital trusts, and, although separately set up, are part of the NHS.

Do you think that the NHS links bring with them a tendency towards being averse to risk or to a truly creative input into services from those who receive them?

I think you've put your finger on one of the fundamental challenges for anyone wanting different stuff to happen in mental health from what is already happening.

I think that the reduction and management of risk is absolutely vital in the provision of medical treatment. But I think that a lot of things that are done in mental health aren't actually medical, even if they are being provided by medically trained staff. There's a kind of weird idea that if you fall under the heading of 'someone with a mental health condition' then you need to be treated at all times as if you are a patient and somehow 'under the care' of mental health service providers.

One of the ideas agreed on by most people who like the social model of recovery in mental health – the idea that you don't necessarily just get cured by medical intervention – is that one of the important things about getting your life back is finding an identity that isn't defined by your condition. If this is correct, then it's a bit odd to think that services run on a medical model, that only have dealings with you because you are defined by a condition, could be the ones that best support you to think beyond that condition. In other words, it's a bit weird that the service that defines you as a service user will be the one that helps you not to think of yourself as a service user.

So what I see is a lot of non-medical services continuing to be delivered by medical-oriented thinking, which makes it very, very difficult to get them to try things that don't have a huge evidence base. It does happen, though, and sometimes the NHS does take brilliant risks. I’m
interested in how it decides to take them, who is involved and what happens because of them.

What I will say is that it's incredibly hard to get NHS commissioners to commission things that look different to things that have gone before because they aren't just thinking about risk in terms of people's welfare but also in terms of financial risk, too. Again there are places in the UK where great mental health stuff has been commissioned by trusts. The question is, I suppose, why some commissioners feel able to take risks and other don't?

5. Conversely, and maybe potentially, how might The New Mental Health differ, and what innovations in services and how, where and when they are available are likely?

I think The New Mental Health will look different in different places and for different people.
The New Mental Health spots gaps and then finds ways to fill them. What people in rural Cumbria need or want or are interested in setting up for themselves might be very different from what people want to do in Bristol. This is where the principles set out in the launch speech (
available on the website : come into play. I think what we'll see is services that meet a specific need or which come about from a certain set of people having a certain set of interests.

The thing is: The New Mental Health is already here, it's just not evenly distributed yet.

Some result from the difficult demise of existing services who have had their funding cut. Others come into being to meet a particular gap in a particular area.

What they share is a proper partnership between people who have direct experience of mental health difficulty and those that don't and, I think, they'll be more likely to find ways doing either new things that are different from traditional services or new ways of doing things that services have been doing in the past.

They might even have been doing The New Mental Health for decades without anyone really noticing.

I think you get a very different answer if you ask the question 'What do you need?' rather than 'What do you think of our existing service?' I think what we'll see is more projects based on what people with mental health difficulties want to do and more that actually try to solve some of the real-life problems and challenges that we face. Direct experience gives you a very different perspective on what the needs of people with mental health difficulties actually are, doesn't it?

I believe that it does (even if some organizations do exploit being able to say that they have that perspective, without actually allowing the people with that perspective to influence how things are run in any significant way).

6. Other than money, and enthusiastic participants, what else do you think
that The New Mental Health will need to thrive?

I think one of the things that is needed for The New Mental Health to move forwards is an active and equal partnership between people who have experienced mental health difficulties and those trying to do stuff that helps.

I think there's more people who are in both categories at once then there ever have been before.

This is where pragmatism rather than opposition comes in – we need a strategic and practical relationship between people who want to make having a mental health difficulty less challenging and awful, regardless of where they come from on the professional/patient/policy maker axis. I think a coalition of people who work in mental health services and people who don't but who all agree that what we have now isn’t quite right and ask 'why can't we have something else?' is vital.

In The New Mental Health, people and knowledge are the biggest assets. There are currently so many people in the public sector who have brilliant ideas and are fed up with doing the same old stuff that they know isn't really working. Similarly, there are so many people slugging it out in the community with brilliant ideas and who are struggling from day to day for money and resources. If we can come together and ask 'why can't we do something else instead?' then we'll be a strong force to reckon with.

One of the things that will need to happen is people being prepared to just give things a go – the principle of FIJD – with the leanest way of doing so. So people will need to be starting small and cheap and making things happen with what's to hand. But there will need to be more money available to be risked on just giving things a go. The biggest danger is that sources of funding will continue their move away from looking at ways to make things happen in different ways or with different people and just get funnelled toward front-line medical services aimed at more severe instances of mental health difficulty. As this will reduce the cash available to things that might make it less likely that someone becomes severely ill over a long period of times it risks constituting a self-confirming situation.

It's an uncomfortable fact that for The New Mental Health to happen for everyone who wants it there's going to need to be money. At the moment the NHS gets the huge amount of mental health money. For new things to happen, the NHS is going to have to decide to spend some of its money on things that are different from what has come before, so in some senses it's going to have to 'step aside' and recognise there there are lots of mental-health-related things that it is not best placed to provide.

7. Do you also expect any opposition from entrenched old approaches, and, if so, do you yet know how to challenge it?

I think The New Mental Health has always been in thorny territory with this. For a long time, we've had the conception of mental health in the UK as being on one side people who use services and on the other side organisations that provide them. The belief has been that the traditionally funded public sector staffed by traditionally trained professionals is the only way to provide mental-health-related services. In some ways, this is true; medically trained staff are the best people to provide medical services. However, it's also true that more people with direct experience of mental health difficulties now work in mental health already, so even that division is gradually breaking down.

What we have been seeing is a growth in different kinds of services and different kinds of organisation outside of those medical services. This is challenging.

It's challenging to campaigners who see the role of the mental health voluntary sector as being, in part, to campaign for the improvement of publicly funded services. Someone once asked me: 'why would you campaign to keep bad services?'. I think, often, because we're afraid that any loss of services will not be replaced with something else, we can work very hard to try to keep a hold of services that we don't, in fact, find useful or which don't fit with our wishes and ideas. Suggesting that the answer might be to create alternatives is hugely challenging, I think, even if people have based all of their activities on opposing worst aspects of existing mental health services.

It can be very challenging for some already involved in delivering mental health services because people doing The New Mental Health ask the question very directly 'is your service the best way to meet this need?'.

I think it's really challenging to a lot of people because it asks 'what do people with mental health difficulties want and need?' rather than 'how can we modify what's there to bring it more in line with the changing wishes and needs of people with mental health difficulties?'.

I also think it can be a little bit challenging for people in general when we're used to 'take what you're given and think yourself lucky' services.

8. Yes, the dreaded question, but let's make it three years: what do you believe the place of The New Mental Health will be in providing services by then, and why?

I think it can sometimes be really hard to see mental health services as anything other than what we have at the moment. Often when we think about the future of mental health services, we think of the future as being the services we have more, but run by different people or run in slightly different ways. When we look toward the future it always seems to look more like now than it does like anything else.

Three years will take us up to the next general election. Make no mistake, there will be changes to mental health services by then. For many of us they're already happening with cuts to local charities and voluntary organisations reducing the amount of stuff that's available in our communities. Add to that changes in the way that the NHS is run and what we're looking at is going to be different, at least on the level that there might be less of it.

What there is will probably be quite like what we have now, I think. There'll still be hospitals, crisis teams, community psychiatric nurses, and all of the other things that we recognise as 'mental health services'. And, the chances are, they way in which they are provided will probably look much like the way they're provided now.

What a lot of us have wanted in mental health for ages is more choice about what services we use to help us and more control over what those services actually are.

I see The New Mental Health helping to fill that gap. What I see is lots of little projects, organisations and even social enterprises across the country providing good mental health stuff that people actually want in ways that they actually want them.

I think the nature of The New Mental Health is to be pragmatic and to find gaps in what is already available or new ways of doing things that people want. This, for me at least, suggests that The New Mental Health will be about starting small but thinking big.

I think what we'll see is people giving things a go and trying to make them work and other people recognising that a small thing that helps a small thing might find out something that might be the basis of making a big thing that helps a lot of people.

If we are going to see increasing pressure on traditional mental health services, I want to see as many other things as possible to help people with mental health difficulties get on with what they want and need to do.

Some things will succeed and grow, others will find their natural level and other things will fail with good grace and good honour.

If you subscribe to the idea that only medical services can provide the answer to challenges that people with mental health difficulties face, then you're never going to be happy with anything less than total medical coverage. I'd suggest that medical services are good at providing medical care and treatment, a vital element to be sure, but not the entire story. I'd comment that, very often, medical mental health services just aren't that good at helping with the challenges that you have in your life or with the things that you want to do. They have waiting-lists, they're difficult to contact, they see everything through the prism of your condition. Not all do this, but the ones that don't often recognise that there are limits to what they can do and look to people and organisations outside of themselves to provide additional support and services.

I think that The New Mental Health, that is organisations and groups led by people with mental health difficulties, will be providing those outside services in some places.

In some senses, I think the people doing things that could be called The New Mental Health now are laying the foundations for a fundamental shift in the way that we think about mental health, because they're the first professional generation to completely reject the idea that having a mental health difficulty will always lead to you being inferior to someone who does not have one.

I also think that, in some ways, the organisations and groups of people trying to do things now with limited resources and by meeting the wishes of people with mental health difficulties more closely are doing the job of keeping the flame of hope going and also laying the ground for a shift in the way we do services.

People in the voluntary sector often complain that they are filling in for the public sector where the public sector isn't providing services or where services don't work properly, but that's exactly where I think The New Mental Health flourishes.

I think, at least in some areas of England at least, we'll see the public sector recognising that this isn’t a nice optional add-on, but a valuable contributing force in helping to make sure that people's mental health difficulties don't completely interrupt or de-rail their lives.

9. Finally, what message have you, both for those excited by The New Mental Health, and for the sceptically minded, who might be mindful of the tale of the monarch and his fresh wardrobe?

I think that thing about the New Mental Health is that it's just putting a name to a shift that's already happening and spotting some common themes and common concerns.

I think that, in some ways, the brilliant stuff that has been happening that has put people with mental health difficulties in control of services, and the brilliant stuff people have been doing to develop services and projects for ourselves, is being put at risk hugely in the current policy and economic environment.

The thing is, The New Mental Health, and this is why it's 'new', doesn't quite fit with either the traditional models of service delivery, or the traditional campaigning quality of other mental health organisations. Nor does it naturally fit well with the agenda of larger charities. Coupled with the fact that, without a natural 'home', people are often working away in isolation, ploughing their own lonely furrow, individual projects, organisations and people who make things happen are really vulnerable to wider forces.

The people already doing The New Mental Health run the risk of being washed away, almost before it's started. If The New Mental Health can be a way of bringing those people into contact with each other while being able to advocate for the vital nature of what they're doing, especially to those that have some money to invest, who can provide support or who can find ways of working with them, then it'll be doing what it's meant to.

If that helps people to feel less like they're soldiering on in the darkness, in isolation, then it'll have served its purpose.

Thanks to Mark Brown, Editor of One in Four magazine, for answering those questions and giving a full measure in doing so - it is good to end on an honest note of encouragement for those who can support, by no means just financially, people just getting to know each other, what is going on elsewhere, and maybe learning what helped them when the situation that they faced was grim!

If you want to leave a comment here, please do, and I will pass it on to One in Four, but I am sure that Mark would welcome receiving your enthusiasm about this interview directly, after he spent time giving what I found very clear and instructive answers to some difficult questions.

For those who haven't yet read his keynote speech at the Asia Pacific Conference on Mental Health (in Perth, Western Australia) last month, here is another link to it.

And, if you want to read through the questions in this mammoth session on their own, they can be found here...

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