Relationship-based and social approaches for understanding and responding to experiences of mental distress are highly valued by many service users and workers within secondary community mental health services. However biomedical interventions remain the dominant treatment approach, in spite of recent shifts towards social inclusion in the mental health policy narrative. This article explores this apparent paradox and explains why neoliberal reforms of statutory mental health services are a primary cause.
The UK government has recently closed its consultation on a new 10-year plan for mental health and wellbeing for England. This agenda will supersede the existing Five year forward view for mental health policy framework and extend the NHS Long Term Plan. The consultation documents reiterate an established policy narrative of governmental commitment to strengths and recovery-based mental health provision, while proposing to reduce the emphasis on negative risk management and cut administration and bureaucracy. My new book seeks to explain why such aspirations for statutory mental health services are unlikely to be achieved while the government utilises neoliberal organisational and policy mechanisms to implement them.
The core elements of the neoliberal reform agenda in mental health services over the past 30 years have been the creation of internal and external markets, and a target culture linked to revenue streams in NHS quasi-markets. These reforms have changed the nature of mental health work. Practitioners, including social workers, nurses and psychiatrists, are required to spend more time on ‘informational’ tasks, such as inputting data on a computer to maintain the income streams of NHS trusts. Consequently, spaces for mental health workers to engage in a practice built on relationships of trust with service users are increasingly pushed to the margins. The staffing and resource reductions resulting from austerity measures over the last decade have only intensified this longer-term trend.
Neoliberal organisational restructuring began to be implemented in the 1990s at a time of accelerating processes of deinstitutionalisation. However, the transition to community care was soon branded a failure by politicians primarily due to the purported risks and dangers posed by those discharged, a narrative that further intensified stigmatisation of mental health service users. As a result, risk has become a primary preoccupation within this service setting. In line with neoliberal thinking, these developments were followed by demands for greater accountability on the part of professionals, service users and NHS trusts. This has led to a defensive ‘inquiry culture’ in mental health services, with responsibility for managing risk increasingly devolved to individual practitioners and service users.
Two technologies of risk management have become particularly prominent pillars of this defensive culture. The first is the use of formalised risk assessment frameworks which have become omnipresent. These extend and embed the informational demands placed on practitioners while reinforcing an atmosphere of monitoring and restrictions for service users. The second is the deployment of psychotropic medication as a means of controlling risk (in addition to its role as a treatment intervention). This is apparent in the increasing visibility of defensive ‘work arounds’ in casework such as checking users’ biological risk indicators through ‘sleep, mood and meds’-type questions. These seek to manage the twin pressures on practitioners of time constraints and risk responsibilities. Alongside this, service users are enjoined to act as ‘responsible consumers’ and manage their own risk through medication adherence. However, if perceived to have failed to do so, they are increasingly subject to coercive and custodial measures.
Biomedical and custodial practices are, of course, longstanding elements of the mental health system. However, with the major mental health policy narratives of the last two decades emphasising recovery and strengths approaches, signs that social inclusion imperatives are beginning to eclipse these older and contested forms of intervention might have been expected. What my study shows is that the neoliberal reorganisation of services, and associated reshaping of everyday work in this setting, has actually taken community mental health practice in the opposite direction.
Though many practitioners aspire towards relationship-based and social approaches, they find themselves enmeshed in ‘situational logics’ within restructured organisations that constrain their scope to implement them. The spaces for relational, values-driven and community-based forms of support are limited by the dominance of market-oriented, computer-based tasks and an imperative towards service user self-management that prioritises brief medication and risk-oriented interventions. Even when social inclusion approaches such as recovery and strengths are integrated within provision, it is in a form that seeks to foster user self-reliance and enable rapid discharge from services to reduce costs. This empties these interventions of their progressive potential. Moreover, in this risk-averse environment, service users perceived as non-compliant with self-management injunctions increasingly face restrictive community interventions or referral to closed institutions.
In this way, the two most distinctive features of mental health provision to emerge under neoliberalism (informational demands related to marketisation and risk management, and a focus on individual responsibility) have proven highly compatible with long-established biomedical and custodial approaches. Consequently, in the distinctive ‘ecological niche’ of contemporary mental health services, the alignments between these newly emerged features and older remnants have squeezed out much of the potential for social and relational approaches.
However, while these neoliberal logics significantly limit practitioners’ activities, the book also explores resistance to these top-down constraints. Such challenges from below are frequently informed by workers’ ethical and political commitments. While efforts to preserve relationship-based casework at the individual level were the most common form of resistance, collective forms of action and campaigning to create or preserve relational and therapeutic spaces and challenge cuts also emerged. These included incipient cross-sectional campaigning alliances between mental health workers and service users.
Understanding Mental Distress illustrates how overwhelming administrative burdens and negative risk management are not simply lingering by-products of earlier forms of mental health service organisation and professional practice, but are generated and sustained by recent neoliberal policy agendas. It is highly unlikely that further top-down policy reforms by this government informed by the same neoliberal worldview will be able to transcend these limitations. An alternative with greater potential is the kind of activity from below embodied in nascent service user–worker alliances. Such activity, both within services and beyond, hints at possibilities for a transformative project to take us beyond the constraints and coercion of policy and practice under neoliberalism and create more democratic, inclusive and socially oriented forms of mental health support.
Rich Moth is Senior Lecturer in Social Work at Liverpool Hope University.
Understanding Mental Distress by Rich Moth is available on the Bristol University Press website. Order here for £17.71.
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