I’ve thought about writing this blog a few times. I even started it once. The reason I binned the first draft was because it strikes me as almost something that doesn’t need to be said. Nevertheless, my recently re-hearing the phrase “Scarin’ the Community” – a phrase I’ve heard so many times in relation to our current social approach to mental health issues – cause me to think again. One often hears pejorative or disparaging terminology about community based care following offences being alleged against service users where purported failures in this model of care are blamed for the creation of victims. I also received a tweet recently blaming the whole notion of ‘Care in the Community’ for the suicide of a patient – as if suicides never happen within psychiatric hospitals or other places of detention like prisons.
So against this backdrop, I decided I should put down my thoughts about this. Before I do, can we agree that unless involved, none of us know many, if any, stories about the successes that community care has brought? … people who have been supported through illness, stigma and adversity who have recovered through excellent care to lead full lives, full of responsibility and employment, parenting and joy, etc.? Not reported is it?
I will be honest: it winds me up a treat that a community based model of care is sometimes blamed wholesale following a distinct non-sequitur which assumes the alternatives to are better or even that they are possible. Also that we should address the problem of specific risks by a minority of people with mental health problems OR shortcomings in funding of services by some kind of mass incarceration exercise that is far more expensive than just funding community care properly seems highly unusual, at least to me.
There will always be a place for inpatient for care and in comparatively few cases for secure inpatient care, especially following this commission of serious offences and this may have to mean detention for long periods of time. This should be as limited as is necessary to balance autonomy and liberty with risk and restriction. Perhaps the case which best demonstrates this, is the infamous murder of Jonathon Zito at Finsbury Park tube station in 1994. He was killed by Christopher Clunis and it made the balancing of risks and liberties a political issue. It is only in 2009 that Jonathon Zito’s widow Jayne wound up the charity that she established in his honour after achieving one of the Trust’s last objectives: to have untreatable personality disorder incorporated into the Mental Health Act 1983. This was done when the 2007 Mental Health Act brought about a range of amendments to our principle law. Of course, the case of Christopher Clunis and debate on community care will come into sharp focus in the next few years because he is reported to have already been moved to a medium secure unit, the first ‘step-down’ from his detention in Broadmoor (high secure) hospital. Jayne Zito regards his eventualy release from hospital is ‘inevitable’ and she regards both Clunis and her husband as victims of a dysfunctional care system.
But why did we move to a community based care model where possible? Very many of the county asylums in this country were appallingly desperate places. They were often home to various undesirable and unfortunate individuals who were socially excluded but not necessarily mentally ill, they were often dumping grounds for the unwanted. History shows that violence was rife; that many single, uneducated mothers and other social ‘inadequates’ were incarcerated for decades; and that ‘treatment’ was highly questionable. Ending our social reliance upon such institutions to lock up those who caused concern and – let us be honest – inconvenience, is something that has taken root all over the world. Now, older psychiatric asylums would be regarded as places of intolerable human rights violations that would disgrace us all. Let’s be honest, it’s also an extremely expensive way of doing something very badly – parallels with prison? – and detention for treatment quite blatantly ignores the psycho-social dimension of mental illness; it’s more about a biological ‘fix’ that we’ve moved away from in recent decades now that mental health care is delivered by multi-disciplinary teams comprising psychiatry, psychology and social work along with occupational therapy and so on.
If it seems a common reaction to stories of offending by people who suffer from mental ill-health to question the whole approach to community based care, sometimes termed “de-institutionalisation”; it may be because what it replaced was not sufficiently understood; maybe it wasn’t sufficiently funded or resourced; maybe it still rests heavily on subjective interpretations of necessity or where one draws the line between autonomy and liberty, risk or restriction. None of this means that current community-based mental health care is sufficient – nor does it mean we should lock people up, en masse. We should remember that most patients with mental health problems don’t commit serious offences or any offences. They live with illness that affects many aspects of their lives and to different degrees, often without posing raised risks to anyone but themselves.
We know that one of the major criticisms of community care was inadequate resourcing and that this remains true today – some people have difficulty accessing community services out of hours; we know that there have been omissions in the provision of care that have led to crisis and highly predictable incidents where patients have taken their own lives more than those of others. We could list various perceived problems from the point of view of patients and their families about current provision and we can even link this to the unnecessary criminalisation of vulnerable people through reliance upon the police and the justice system and still none of this would mean, that the care model we started shifting from around fifty years ago was inherently better. In contrast, many studies would argue the opposite in terms of rehabilitation and recovery, notwithstanding the imperfections.
One question I do have concerns about when considering the community based model we know have is the criminalisation of vulnerable people. If the community based model means people are relying upon policing services for crisis care; if people are being prosecuted for behaviours that are caused by their conditions or are at least coincidental to living with the social exclusion that arises from mental illness, then can we claim that the model is adequately providing care? If you get around to reading the book I’ve been recently mentioning - Mental Health and Crime by Professor Jill Peay – you’ll see a powerful argument that the relationship between mental illness and crime is far more tenuous than is often argued. What does this mean for the criminalisation debate? I’ve argued before based upon research over the last few decades, that the criminal justice system under-criminalises the mentally ill, compared to the general population so I admit to being more or less content with the balance that is provided, most of the time. Could it be better balanced through greater funding of community care? Very obviously so – but that doesn’t mean we’re unnecessarily criminalising people.
If we considered this issue from a personal point of view – how would we wish to see our relatives cared for were they to develop serious mental health problems – we would probably quite quickly agree that compulsory detention in a hospital should be low down the list of ways that we’d like to see care given. It is against the backdrop that I want to try to push back against those who argue that community based care as a whole has failed. We can think of several spectacular failings in all of our public services if we try hard enough: policing is certainly far from perfect as we have seen during just my career. Education, health and social services too.
Are the problems with the reality of delivering a community based care model sufficient to take us back to a place where we lock up for inordinate lengths of time? Only where this is consistent with ensuring public safety in my view. This does not mean that I think we’ve got the balance right. There are, in my own humble opinion, still far too many cases where we learn of tragedies involving suicide and homicide where we appear to keep reading the same thing over and over – but that is an argument for improved risk assessment about whether inpatient or outpatient care is the way forward and how we fluidly move between the two. It is an argument for better funding and for improved community services which operate 24/7, supported by the police where this is needed.
It is not an argument for any return to larger scale incarceration of people with mental illness. Perhaps unsurprisingly – this is a complex argument about shades of grey: not a simple identification of black and white.