NHS Mental Health Services and “The Embargo on Thinking”. Or “Le crepescule du penser”

It is an interesting paradox that a state service the primary function of which is, at least theoretically and publicly, to solve or mitigate problems of mind paralyses its staff with a covert embargo on thinking. Older staff, being the notes and therefore unable to hear the music of cultural and organisational change, will complain about ticking boxes and the ever-multiplying domains which they have to complete on the latest electronic recording system taking them away from time spent with patients (refusing to cross the bridge into the land populated by “service users”).  With a sense that what they believe they have to offer - expertise and experience – is being devalued almost as quickly as the Venezuelan bolivar, they feel alienated and disaffected without quite understanding why and tend to leave, querulously, under their own personal cloud of unknowing. 

Younger staff, groomed by prescriptive multiple-choice education and the painting-by-numbers regime of most mental health training, learn to churn with one eye and scan the considerable financial rewards of obedience with the other. Uncontaminated by a desire to engage and interact they slump without protest into the call-centrification of care, mediated by protocols, rating scales and scripted responses.  Quaint notions of autonomy, imagination and intuitive engagement are overwhelmed by the easy shibboleths of “postcode lottery” and standardisation as staff are readied for the rule of algorithm in which they become conduits for the message instead of agents drawing on inter-corrective elements of training, experience and humanity. 

Early, unremarked evidence of this development is that entries on individual patients’ records increasingly look the same, collocations or stock phrases replacing discursive, informative accounts which bring the individual to life.  Staff must now be interchangeable and indistinguishable from each other, acting as a medium for rote interventions whether in the maelstrom of the psychiatric ward or in the quieter reaches of the admission block applying acronymic therapy under the gaze of NICE and other watchmen of the state.

A further paradox is that mental health institutions, one of whose central functions is to detect and treat paranoia, have themselves developed a systemic paranoia, a state of mind which is often dangerous in individuals but  always highly inefficient in organisations.  Instead of standing up to the collective, public fantasy of idealisation and a culture which is energised by the absence of God and a powerful transference to the State-as-parent and whose radar scans the public realm for figures to blame, they see (just as child protection agencies see) catastrophe in every case and headlines (and lawsuits) in every decision not to intervene. Thus, the belief that “doing something” is intrinsically a lesser evil than “not doing something” becomes institutionalised, the fact of intervention habitually and necessarily taking precedence over the goal of intervention.

Systems which are preoccupied by risk in this way actually increase risk because filters which should be establishing caseness are switched off and finite capacity is swamped by volume – in line with the adamantine law of economics that where there is a weak or non-existent brake on demand, supply will always be overwhelmed.  While an adaptive system will give priority to managing the boundary between it and the external world (a task carried out in the individual by the ego), thereby ensuring that the work or activity which it allows has at least a chance of being optimised, maladaptive systems tend to react to their failure, or rather incapacity, to sift and select at the boundary by gathering data (which subsequently is mistaken for knowledge) and gathering yet more data when this defensive approach inevitably fails.  This tendency is encouraged and reinforced by inquiries and mis-directed inspections which, when things go wrong, demand more of the same or greater efficiency in being inefficient, oblivious to the truism that more work is not the answer to too much work.

Again, paradoxically, the concreteness of this approach is also found in paranoid illness. The attack on thinking in mental health institutions which it generates can be seen as wholly consistent and internally, at any rate, logical – as can the banishment of older staff who think too much to early retirement or the gig economy of sinecure and consultancy.  NHS mental health Trusts - and town halls, for that matter - have necessarily become temples of surveillance, shoring up the project by blaming and shaming staff who are data-dilatory and distracted by an instinct to make things better for patients by engaging and working together with them.

In this world, experience has no currency since know-how can now be digitised, packaged and transmitted in branded rating-scales and formulaic pseudo-therapies such as CBT, their initial placebo effect being mistaken for efficacy.  Underneath, the clinical imperative is slowly asphyxiated by a bureaucratic one to the extent that the cataloguing of deficit (in the form of symptomatology, pathology and risk) has made clinical skilfulness and dexterity all but redundant. An ingrained preoccupation with means shuts out any dynamic and informed consideration of ends, a lack of interest in which lies behind the puzzling phenomenon that it is never said that “x has really good results with patients”, while the managerial mind is transfixed by concerns about whether “y and z are behind with their data”.  Obedience, a pre-thinking state of mind, can be seen to be prized above everything else.

In fact, the collection of data in mental health services is now so industrialised and, more important, fetishised that to question its premise is seen as somehow being in favour of suffering.  Yet, there is no evidence to demonstrate, for example, that the thousands, perhaps millions, of person-hours spent on squeezing patients into essentially random diagnostic “clusters”, by means of attaching a score to dozens of elements of their behaviour and functioning, have directly led to a single person being relieved of their depression, say, or schizophrenia.  And even if the occasional patient did benefit, perhaps by ending up in the service most attuned to his or her difficulties, the reallocation of those person-hours to direct contact between patients and professionals liberated from the alienating drudgery of the keyboard would transform mental health care. 

If every member of staff directly, physically involved in the care of patients was asked to devise a system to provide and optimise such care, it is almost inconceivable that a single person would come up with one that was even remotely like that which is foisted on them currently.  This is down partly to the triumph of politics over pragmatism (“we need something which is aligned with our beliefs rather than something which works”), partly to the power of vested interests (the IT industry, mainly) promoting their wares, and partly to the magical, defensive belief, which is both institutionalised and unconscious, that gathering information relating to scary, messy, confounding conditions necessarily controls and neutralises them. And, of course, data is now collected so widely and relentlessly simply because it can be.

Any random visit to a 21st century mental health or social care team-base will confirm that the collation and logging of such information is carried out by banks of operatives, still with the traditional titles of nurse, social worker or psychiatrist and many of them near the top of their generous professional pay-scales, engaged in banal and menial gathering in order to feed the machine.  Thus, the best-educated perform the most trivial tasks while not-so-well educated and much less experienced staff are drafted in to fill the vacuum around the patient.  Leaving junior nurses, often female ones, to hold the ring in lawless acute wards and enlisting transient Australians and South Africans to try their luck and build up some UK work experience in mental health hostels (the direct descendants of early nineteenth century madhouses), where disaster is only a contentious drug-deal away, may seem bizarre and perverse to the outsider but is consistent with the allocation of priority and status to administrative functions which create no added value of any kind. Having the right people in the wrong place – the most egregious failing of NHS mental health services and in some ways the most easily corrected – is a direct consequence of the demotion over time of cognitive and emotional intelligence and the promotion of information farming.

Use of self, once a defining element of the professional task in mental health, is a collateral casualty in the move from relationship-based approaches to a control-based culture in which transaction, now so easily prescribed and measured, has replaced interaction.  All staff are depleted, demoralised and deadened by this process but those on the wrong side of the fault-line, and whose creativity and imagination are disparaged as malware which threatens the project, may first move on to forgotten havens of autonomy and self-expression but eventually, if not always explicitly, clock that it isn’t just they who have become redundant but their minds as well.

No profession is an island, of course.  The coup of the machine has replaced autonomy with automation in every public service as it has in the private sector, every target now being a soft target.  People will become like machines more easily and naturally than machines will become like people.  Contingency will be neutralised and subjectivity will be ironed out, mind becoming brain and non-thinking collapsing frictionlessly into the convergent, concrete world of AI. The endgame will see the epithet floating off without protest, intelligence being replaced by Intelligence - irrevocably.