Putting the users in charge

There is an alternative. Maureen Hutchison reports on community mental health centres

With political will, alternative services and collective acceptance, this century should herald the demise of the archaic psychiatric institutions that have long since needed to be consigned to history. Many of us working in mental health believe that closing these outmoded hospitals should mark the end, not only of frequently degrading and dehumanising methods of treating people, but also of viewing those with mental health problems as a purely medical phenomenon, devoid of any social, family or community context.

The establishment of mental healthcare in the community and, in particular, the setting up of community mental health centres (CMHCs), could enable this to happen. But without a radical change in attitudes and ways of working, large institutions will be closed and mini-institutions will be opened and, sadly, nothing will have been learned and nothing will be changed.

At present there is no accepted blueprint for CMHCs and examples of those in existence run the entire gamut of possibilities from providing an office base for mental health professionals to a centre that concentrates on mental health promotion and preventive work. Even within one county CMHCs may differ widely in their operational policies; policies which appear to owe more to the vision and philosophy of key mental health planners in that area than to any recognised dogma on good practice.

It does seem obvious that any mental health centre working ‘with’ rather than ‘on’ the community¹ must be seen as a community resource with good links with other community resources — schools, churches, voluntary groups, etc. — and which places mental health problems in a community rather than a hospital context.

Siting a mental health centre in the community gives the opportunity to appreciate people’s problems, however long-standing, in a broader framework. Language inevitably shapes the way we think, and those working to eliminate racism and sexism have done much to raise consciousness about its impact. However, there is a risk of complacency: adopting the phrase ‘people with mental health problems’ rather than ‘the mentally ill’ is not the end of the story. It is, in fact, only the beginning. Using terms such as ‘manipulative’, ‘attention-seeking’, or ‘hysterical’ hardly implies a high regard for people diagnosed as having some kind of mental health problem. They say much about our own prejudices and values.

New-style services offer an opportunity to challenge old-style labels. Otherwise, much of what is unacceptable about traditional attitudes to people with mental health problems will be perpetuated.

In addition, CMHCs make it possible to depart from existing practices by actively seeking and genuinely valuing the involvement of those who use the centres. ‘Involvement’ takes many forms and is underpinned by a need for good information. How can people make informed decisions about treatments or therapies if they do not know what they involve? It would seem essential to provide a comprehensive and comprehensible leaflet giving information about the various therapy options and personnel within the centre, including information on diagnosis and medication, however contentious that might be.

Regular community meetings could be held to allow people to voice concerns, criticism or praise. However, if there is no mechanism for incorporating these views into the centre’s practice, users will come to regard them as a cosmetic exercise and they will be boycotted in body or spirit.

One possible way of implementing change is for the centre to have a straightforward, accessible complaints procedure with the right of access to an advocate. Again, the mechanism for responding to complaints needs to be established and advertised.

How about developing a team spirit, a partnership, where the ‘team’ includes the users and there is a sense of co-operation, equality and mutual respect? How about patting paternalism on the head once and for all?

CMHCs can also be more accessible than psychiatric services have been to date, although this will not be achieved if a cumbersome referral procedure is adopted. In discussions, mental health service users voiced a unanimous opinion—- there should be a self-referral system based not on the opinion of a mental health professional or a GP, but on the people’s perception of their needs at that time. As John McKnight² points out, there is considerable power vested in professionals who are in a position to define both need and remedy. Should a self-referral system exist alongside a formal referral system, care would have to be taken to ensure equal weight was accorded to both referrals.

In considering the ‘therapies’ offered at a CMHC it should be noted that while evidence about the effectiveness of various psychiatric interventions is equivocal, anecdotal and subjective evidence is not — purely physical methods of treatment such as drugs and ECT are not popular with users. A CMHC could break out of the straitjacket of conventional therapies and provide more variety and choice, including alternative therapies, more imaginative and creative activities, a base for equally valued user-run services and for other voluntary agencies. A proportion of funding could be used to ‘buy-in’ specialist services — a music therapist, a keep fit expert, etc, rather than assume that existing staff can turn their hand to a ‘spot of drama’ or whatever. If funding was allocated for use in this way it would enable the centre to respond more readily to users’ requests for additional types of activity.

CMHCs do have the potential to be lively, innovative, invigorating places with an informal though caring atmosphere offering truly accessible service for a wide range of needs and putting the user centre-stage. Alternatively, they may be formal, clinical and repressive with an antiquated ethos handed down from the decaying edifices which, partially at least, they could be replacing.

The writing has been on the wall for a long time - shouldn’t we all read it?