What a relief to hear Chris Whitty and others finally start to talk about the balance of risk. This concept seems to have been sadly lacking from the public discourse over the last few months when it should have been fundamental to our understanding and strategy. Bear with me as I use an example from my professional career.
As a psychiatrist, I had to make difficult decisions about detaining individuals’ liberty under the Mental Health Act – a process commonly referred to as ‘sectioning’. This decision is taken very seriously, with many safeguards in place to protect the individual. Voluntary admission is always encouraged if at all possible. Patients are discharged from the ‘section’ as soon as it is considered safe to do so. There are appeal processes at every stage and prolonged detention involves a Mental Health Review Tribunal. Removing an individual’s freedom, in the first place, feels like a weighty responsibility, but the hardest part is deciding when to release the patient from legal detention. For some patients, the decision is easy, as the boundary between being ill and being well is obvious. But, for most, this is much less clear cut. Psychosis, mood disturbance, dangerousness and insight are difficult to assess and can change very quickly.
Risk in mental health patients is never eradicated. But the long-term social and psychological consequences of ongoing detention in an institution have to be weighed against the risks of allowing someone to walk free. Some patients react particularly badly to having their liberty curtailed and become more dangerous in hospital. With these patients it is too easy to respond with ever increasing levels of security, creating a vicious circle that is difficult to break.
Sadly, of course, a minority of patients with very severe illness need long-term detention, but most will be able to pick-up their lives and carry on more or less as normal. Such an outcome is enabled by modern treatments but also a positive attitude towards recovery that was absent in the past. The history of psychiatric institutions, where individuals admitted rarely regained their liberty and became progressively institutionalised, serves as a warning about what happens when there isn’t a strategy to get back to normal. Good mental health teams will start to plan towards recovery early on in an admission. This – getting back to normal – requires imagination, vision, experience, skill and hard work on the part of everyone involved. It also requires a certain amount of courage and the capacity to hold one’s nerve. It doesn’t just happen.
Without the will to focus on healthy functioning rather than just pathology, things can move rapidly in the wrong direction. Without a strategy, the mental health team becomes simply reactive and risk averse. Vitally important therapeutic risk-taking will not happen. The ‘command and control’ leadership, often essential in the eye of the storm, has to change to a more consensual style of authority, where power relations are made explicit, recognised as dynamic and re-negotiated. A shared understanding of responsibility and accountability are all important in this difficult conversation between patient and clinician. Some patients are left feeling mistrustful towards the team who ordered their incarceration and reparative work may be needed. Others will be resistant to taking back responsibility for their lives and a program of encouraging, facilitative work, breaking down the process into small manageable steps, will be necessary.
Back to the pandemic. Like John in his last blog post, I worry that there is too little understanding of the need for such a recovery process at the higher echelons of Government. There is little evidence of a strategy based on balancing risk to take us forward, and numerous examples of reactive, knee-jerk responses to the latest ‘crisis’ running in parallel to gung-ho attempts to pretend things are back to normal. The fear engendered back in March/April may have been appropriate at the time, but fear only works as a constructive prompt in the short-term. There seems to have been an absence of sensible thinking about how to move the country forward, and if there is a strategy at all, it clearly lacks any thinking about how to repair the psychological and social problems that are part of the lock-down legacy. True, there have been some somewhat ad hoc economic incentives, but these have little chance of making an impact unless the social and psychological issues are addressed. Crucially, we are now at a point where we need to be encouraged to use our intelligence to think sensibly together about balancing risks in our own communities and institutions. This would be a better contribution to recovery than anxiously trying to get our heads around the latest command from a government seemingly detached and worryingly unaware of our experience and concerns.