Mental health is everywhere. The phrase reverberates from nurseries to nursing homes, and hushed conversations once held out of the earshot of children and polite company are giving way to a more open dialogue about psychological wellbeing. But are we seeing the full picture? And does the vogue for wellbeing distract us from a long-overdue conversation about individuals with serious mental illness?
I work as a consultant psychiatrist in assertive outreach, a specialty that aims to help those who have struggled to engage with psychiatric services. While they too have mental health problems, you don’t hear a lot about some of the people I meet.
Harry is in his late 60s. We met many years ago at the local asylum before it finally shut. Now in the community, he lives in a surreal world in which he is at various times a forensic psychiatrist, an archbishop and a member of the royal family. He moves nomadically, trying to escape clandestine government agencies intent on silencing him with some kind of laser beam.
His poor mental and physical health isn’t helped by his squalid surroundings or a lifetime of chain-smoking and heavy drinking. Too paranoid to venture out, he relies on us to reach his local shop. Occasionally he comes into hospital but his admissions are brief and don’t achieve much. He’s had a couple of heart attacks but, fearing euthanasia, he won’t see his GP. So we monitor his physical health and try to extend the much-reduced life expectancy that he, as someone with a severe mental illness, can otherwise expect.
Vinny was previously diagnosed with paranoid schizophrenia. He has also spent much of his life locked away, in his case in forensic psychiatric facilities. It’s true that he’s been violent but only when very ill, suffering from what is undoubtedly a bipolar illness and not schizophrenia at all.
Two decades ago he tried in vain to seek help from psychiatric services but, since that time, years of sectioning involving the police, forced injections and secure care – in his view all brutally imposed by racist institutions – have bred a deep mistrust of the system. Out of hospital at last, he is one of many black men currently subject to a community treatment order. He is nine times more likely to be subject to such an order than a white counterpart, which is just one of the striking racial disparities in mental healthcare.
Leanne is in her 30s, and has three children who were all taken into care. Her own childhood was marred by horrific abuse, which left her with deep emotional and physical scars. She hears voices and has visions that are waking nightmares.
Despite imagined tormentors that sometimes command her to kill me, she accepts me as her doctor, yet mistrusts the psychiatric services she feels have spurned her. She’s tried to kill herself many times, and doesn’t feel lucky to be alive. I fear her next attempt will be her last. She is detained in hospital under the Mental Health Act. I hope she is not destined, like so many others, to end up warehoused out of sight and out of mind in a locked psychiatric facility many miles from home.
These people’s faces don’t fit the glossy anti-stigma campaign posters. Mindfulness apps are not their bag any more than workplace massages, and they have experienced no nirvana from mindful skiing or cold water swimming. It’s good that self-help strategies work for many, but we must be realistic about their effectiveness for those with profound psychosis. The celebrity narratives about mental health that inspire so many fail to resonate with them: those experiences don’t mirror the crushing poverty caused by benefit reform, the homelessness exacerbated by the decimation of supported accommodation, or the exclusion from the digital revolution which is leaving the most vulnerable stranded in its wake.
The recently announced NHS long-term plan talks of new models of mental health care for those with severe mental illnesses and interventions including psychological therapies, physical healthcare, employment support, trauma-informed care, medicines management, and support for self-harm and substance use. As a frontline clinician I remain cynical: the harsh reality is that, for this group of patients, services designed specifically to meet their needs have been axed across the country in favour of short-term crisis-driven interventions. My plea is that as policymakers strive to deliver on the NHS long-term plan, they give serious mental illness as much prominence as promoting positive mental health – and that they spare a thought for those whose voices are so seldom heard.
Harry, Vinny and Leanne are pseudonyms for an amalgam of the author’s experiences of patient care
Dr Nuwan Dissanayaka is consultant psychiatrist at Leeds and York partnership NHS foundation trust
In the UK, Samaritans can be contacted on 116 123 or email firstname.lastname@example.org. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.