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Mental Health Policy in BritainReview - Mental Health Policy in Britain
Second Edition
by Anne Rogers and David Pilgrim
Palgrave MacMillan, 2005
Review by Tony O'Brien RN, M. Phil.
Mar 21st 2006 (Volume 10, Issue 12)

The asylum casts a long shadow over psychiatry. Broad picture policy debates are frequently framed in terms of whether deinstitutionalization has 'worked', whether 'community care' is working, and whether, with the loss of the physical locus for the activities of psychiatry, the psychiatric professions have become merely another means of social control. Pilgrim and Rogers ask these questions (and others) of British psychiatry, and their answers are far from reassuring to the psychiatric professions, or to consumers of mental health services. Mental Health Policy in Britain is the second edition of this work. The first was published in 1996. I have not read the first edition, so I am not in a position to compare the two. The authors have worked in the area of psychiatry for many years, publishing a number of research papers, critiques, and books. Rogers is a sociologist, Pilgrim is a psychologist, so neither represent the mainstream of psychiatric professionals, providing an opportunity for a more critical view of the area than that found in most psychiatry journals.

The book begins with an overview of the process of policy formation. These two chapters are a useful reminder to take a broad view of mental health policy, and in particular, to note that mental health policy serves a range of interests and interest groups, and attempts to meet what are sometimes conflicting aims. The second chapter on the history of psychiatry is necessarily brief, but still a useful summary of a history that is still very much alive in the practice of psychiatry. A theme introduced in this section, and returned to throughout the book is the chameleon-like nature of 'institutionalism', and how inpatient services continue to dominate psychiatry both economically and philosophically. At least, that is Pilgrim and Rogers' argument. The extent that it holds true requires closer examination. The third section covers developments in the post institutional era. Given that in Britain, as in the US (but not in all western countries), some of the old hospitals continue to operate, albeit reduced in size and status, the term 'post-institutional' is necessarily provisional. This final section provides some useful discussion of new developments, such as mental health in primary care, and the reconceptualization of psychiatric services as 'mental health services.' Mental Health Policy in Britain provides a useful overview of policy development in Britain over almost two centuries. While readers would do well to respond to this book with the same critical eye the authors bring to their work, they will find much to ponder in Pilgrim and Rogers' analysis.

Mental Health Policy in Britain covers important issues that are unique to Britain as well as some that are easily generalizable to other contexts. The Care Programme Approach (CPA) is peculiar to Britain, even if some of the issues it attempts to address are encountered elsewhere. Originally designed to ensure minimum standard of care, Pilgrim and Rogers argue that the CPA soon became administrative rather than clinical. So inclusive is this policy that according to Pilgrim and Rogers 1% of Britons have care programs. The English mental health legislation also has some peculiarities not found in other jurisdictions, such as specific reference to 'psychopathic disorder' and powers of police to refer individuals, under compulsion, to mental health services. Issues which are more closely shared with other countries are integration of secondary and primary care, and questions of compulsion in the community.

A major strength of the book is that Pilgrim and Rogers take a critical view of the institutional interests of psychiatry, in particular its claims to authority and its right to dominate the discourse of mental health policy. They provide many examples of how the interests of psychiatry have come to influence policy, even when clear alternatives have been articulated. This discussion is not confined to the relatively recent past. Pilgrim and Rogers cite describe how debate in the 1930s around nascent idea of community care was effectively silenced by the consortium of political interests of politicians and psychiatrists. The supposed legalism of the 1983 Act is also shown to have been subsumed by clinical interests, something that has been noted in mental health law reform internationally. A commonly held view that institutions were downsized for economic reasons is questioned, with Pilgrim and Rogers showing how that explanation applied to a later period of deinstitutionalization, but was not an initial factor. Neither were the new psychotropic drugs decisive in reducing bed numbers, as is sometimes argued. Reviewing more recent developments, Rogers and Pilgrim comment on the difficulty of having an effective consumer lobby in policy development, in particular given the divergent views and interests of consumer lobbyists.

On the issue of language, the authors take issue with the use of the term 'consumer', principally because many psychiatric patients are treated under mental health legislation, and therefore have limited choice. However this is a rather doctrinaire interpretation, and a surprising one for a sociologist. In a highly contested area such mental health, language is used less literally than Pilgrim and Rogers analysis implies. "Consumer" is a term that recognizes the market model imposed on healthcare in the 1990s, and which seeks to appropriate the power of the market discourse. The term highlights important rights obscured by the more paternalistic term "patient", and thus serves an important rhetorical function. That said, Pilgrim and Rogers' critique shows up the limitations to such rhetoric.

A theme throughout the book is that of citizenship. This continues the evaluation of post institutional psychiatry, but broadens its focus from a narrow clinical view, to one based on a broader entitlement to the rights of citizens. I felt that this was a theme that could have been developed further, although Pilgrim and Rogers' task was to describe the process of policy development, rather than to outline a model for it. But as more mental health care is provided in the primary care sector, especially by non-specialists, the notion of 'mental health consumer' (or 'patient') becomes more problematic. Also, as much of Pilgrim and Rogers' discussion shows, provision of clinical services cannot be divorced from meeting the social needs of patients for housing, support, access to medical care, and employment, needs that are consistently rated higher by patients than by professionals.

At times Pilgrim and Rogers adopt an almost cynical view of health professionals as self interested, subverting concepts such as "need" to supplant the interests of patients with their own professional self interest. The authors talk of a professional assertion of "right to treat" although it is not clear that that right has been specifically asserted by any professional groups, except under conditions of compulsion. While there is no doubt that patients are at times persuaded, even coerced, into accepting professionals' views, in practice there are limits to professionals' powers of persuasion, even within the framework of legislation. Pilgrim and Rogers are convinced that use of legislation is inherently "repressive", and take every opportunity to present what they call "therapeutic law" in this light. Their view of professionals (especially doctors and nurses) allows them to construct the introduction, in the 1983 Mental Health Act of a nurses' holding power, as an extension of professionals' repressive powers, rather than a legal check on such powers through statutory accountability. Again, there is a sense that this view results from the authors' preferred philosophical approach to mental health law, rather than consideration of the possible consequence of their approach. As Elyn Saks noted in her book Refusing Care, solutions to the ethical issues of mental health law are unlikely to be found simply by appeal to principle. When Pilgrim and Rogers state that "mental health [legislation] glibly allows others to pass judgement and take action about the control of risky behaviour" (p. 197) they are surely guilty of talking up the powers of psychiatrists and diminishing the significance of legal accountability.

Pilgrim and Rogers contrast care in the community with that provided in inpatient services. Inpatients are offered less talking therapies, they are increasingly likely to be held under legal powers, drugs are used as a first option, and inpatient clinicians are less willing to negotiate alternatives than their community counterparts. In a somewhat depressing conclusion, Pilgrim and Rogers state that little has changed in inpatient care since the Victorian era. This combined with their assertions of continued medical dominance in British psychiatry might lead one to conclude, after Baudrillard, that deinstituionalisation did not take place. The authors succeed in their aim of showing how mental health policy, while it may be set centrally, is ultimately determined by a range of stakeholders with central policy makers having less influence than might be supposed. Whether professionals are quite as self interested as is argued here is open to debate. The recent campaign against the English government's draft mental health bill was resisted by an alliance of professional and consumer groups, with broad agreement that proposed powers such as anticipatory containment were a police, rather than a health matter.

Mental Health Policy in Britain will be of interest to British readers for its coverage of the mental health policy issues that impact on their work. Readers in the old Commonwealth will find it interesting to compare developments in their own countries with those of a country with broad similarities in its health system. For US readers, I suspect the book will provide a study in contrasts. Any US equivalent publication would have large sections on State vs. Federal funding, cost shifting, and insurance cover, not to mention the complexities of multiple mental health laws. But there will be enough of common interest to make the book useful reading. This is useful contribution to literature on mental health care, especially for those concerned to develop a critical view of the process of policy formation. It has broad appeal, to clinicians, policy makers, academics and researchers.

 

2006 Tony O'Brien

 

Tony O'Brien RN, M.Phil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz


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