Shifting mental health policy

I've mentioned the Beyond Pills All Party Parliamentary Group (APPG) in a previous post. It has recently launched a report entitled Shifting the Balance Towards Social Interventions: A Call for an Overhaul of the Mental Health System. There is a YouTube video available of the excellent launch event of the report, which included presentations by Dainius Pūras (see eg. previous post) and Michelle Funk (see eg. another previous post). 

Mental health practice does need to be rethought (see previous post). Understanding about mental health problems needs to be improved, including what children are told about mental illness (see eg. previous post). The Mental Health Act also needs to be reformed (see another previous post). Rights and recovery-orientated services need to be at the centre, not the margins of mental health services, as currently.

Mental health services need to be realigned with better strategic direction to make them more functional and integrated. For example, there needs to be a mental health hub and community mental health team (CMHT) in each Primary Care Network (PCN). CMHTs have become too large and need to be devolved more locally, alongside non-medical services in the hubs.

Asperger’s autism

Kevin Rebecchi has provided a first English translation and introduction to Hans Asperger’s 1982 chapter ‘Early childhood autism, Asperger type’ published after his death in 1980 (see History of Psychiatry article). Asperger distinguishes his use of the term ‘autistic’ from that of Eugene Bleuler, who gave the name to the apparent impenetrable wall that separated schizophrenic from other people. Leo Kanner separately described what Asperger thought was a rare form of early infantile autism. Asperger differed by seeing people generally as having the ability to behave in an ‘autistic’ manner.

Asperger children were noticeable at school where they were very difficult to discipline and often failed because of their so-called different psyche, being intelligent, highly reflective and observant, seemingly devoid of feelings and yet able to have subtle emotions. Most importantly, it was the visibly limited and self-centred, very idiosyncratic way of dealing with people that was labelled ‘autistic’.

As Rebecchi points out, Lorna Wing introduced the concept of the autistic triad of difficulties in social interaction, communication and imagination and coined the term Asperger’s Syndrome. The study Wing based the autistic triad on was mainly of intellectually disabled children. She disagreed with Asperger and said these children lacked common sense, were not creative but merely logical, did not have high intelligence (several with IQ < 70) and would only repeat things by rote. Asperger’s autism in fact was not really characterised by the autistic triad at all.

Asperger thought the term ‘psychopathy’ applied to the children he described and they were seen as difficult both at home and school. He thought, nonetheless, they should be respected for who they are, and that it was quite wrong to see difficult people who are out of the ordinary as of inferior social value. As far as Asperger was concerned, some autistic people bring much to the world and are “the salt of the earth”. 

As I have said before (see eg. previous post), there is a need for a rethink about autism. It is now seen as part of the umbrella term ‘neurodiversity’ (see another previous post). Its meaning may well have become too vague and restoring understanding, I think, will benefit by looking again at its historical origins, as does Rebecchi.

The origins of the charity Mind

I’m now into my second year of being a Trustee at Norfolk and Waveney Mind. Not many people know about the roots of Mind in the UK, but they go back to Clifford Beers’ book (1908) A mind that found itself. There’s a very good, inclusive biography of Beers available (Dain, 1980). He died as a patient in a psychiatric hospital in 1943.

William James sent a letter to Beers encouraging him to publish his book manuscript. Beers had described his mistreatment by staff in psychiatric hospitals, not dissimilar to the scandals of recent times (see eg. previous post). He wanted to campaign for psychiatric reform and set up the Connecticut Society for Mental Hygiene. Mental hygiene was a movement to prevent insanity by providing information to the public. The term ‘mental hygiene’ was suggested to Beers by Adolf Meyer, Professor of Psychiatry at Johns Hopkins University and commonly seen as the Dean of American psychiatry in the first half of the twentieth century (see eg. my 2007 article). These days we tend to use the term ‘mental health’ in much the same way as ‘mental hygiene’, meaning the conditions and practices that help to maintain mental health. Meyer also sponsored A mind that found itself with William James. There was tension between Meyer and Beers and establishment psychiatrists were very much part of the mental hygiene movement, although Beers wanted more of an advocacy organisation for the insane, more like the modern survivor/user movement in psychiatry since the 1960/70s.

Beers went on to become the secretary in the USA of the National Committee for Mental Hygiene, a voluntary agency for which he raised millions of dollars. The International Committee for Mental Hygiene was formed in 1919 and its name was changed in 1947 to the World Federation for Mental Health, an organisation that still exists today (see its website).

There had been no British equivalent of the lay critique of psychiatry by Beers. However, the link between mental hygiene and the social psychiatry of the Second World War and postwar reconstruction (see my 2015 talk) was already apparent in a 1935 letter for peace drafted by the Netherlands Medical Association and signed by 339 leading psychiatrists round the world. The psychological ideas related to mental hygiene came together in the formation of the World Federation for Mental Health (WFMH) in 1948 at an International Congress in London, of which J. R. Rees (see Wikipedia page), who had been Consulting Psychiatrist to the British Army and co-founder of the Tavistock Clinic (see Wikipedia page), was President. As the original deputy director and then medical director, Rees built the Tavistock into Britain’s most important centre for the study of holistic medicine (see his obituary). He resigned from the Tavistock in 1947 and thereafter was Director of WFMH from 1948-61.

Toms (2010) describes the formation in 1946 of the National Association for Mental Health (NAMH), which became Mind, in the context of the mental hygiene movement. It was formed from three organisations: the National Council for Mental Hygiene (NCMH), the Central Association for Mental Welfare (CAMW) and the Child Guidance Council (CGC)

NCMH had been formed in 1922 by members of the Medico-Psychological Association (see BMJ article). Mental hygiene had also been promoted by the overlapping membership in the origins of the Tavistock clinic in 1920 as the way to prevent mental health problems. The tension about how much mental hygiene was really about lunacy reform, rather than just the prevention of mental illness, mentioned above in the conflict between Beers and Meyer, is also reflected in a 1924 BMJ letter from Lionel Weatherley. 

CAMW was established in 1913, the same year as the Mental Deficiency Act to ascertain the mentally defective population in England and Wales. The Act also founded a Board of Control to oversee the whole mental health system and the Board assisted in the creation of CAMW. Mental deficiency was associated with social inefficiency and social problems. 

CGC was founded in 1926. Both NCMH and CAMW thought child guidance clinics to be central to providing comprehensive mental hygiene for the community to prevent more serious problems later in life. 

Adoption of the brand name Mind signalled the shift to a campaigning organisation for patient rights in 1972. National Mind has listed its main achievements since its formation (see webpage). Local Minds, which are unique and independent charities, deliver services for people with mental health problems and run charity shops which meet the Mind Quality Mark and are part of the Mind Federation. A priority for National Mind in its current restructure is the policy of Federation First.