Simon Wessely: “Every time we have a mental health awareness week my spirits sink”

We read with interest your recent interview with Simon Wesley titled “Every time we have a mental health awareness week my spirits sink”.1 Wesley suggests that mental health awareness leads to increasing numbers of people engaging services for help in times of crises that are already overstretched.

This argument in part captures a wider culture prevailing within the current discourse on mental health, that the solution to providing support for people in distress lies simply in better funded mental health services.

“Mind the Gap” a Bristol based group of mental health supporters feels there is an onus on those that are working with or advocating for people in distress to move the conversation on from a dichotomous health and illness paradigm. We feel strongly that conversations about emotional health, distress or psychosocial disability may benefit from a different approach. Moreover these conversations should be driven by the people they claim to serve. This is an approach that avoids language of exclusion and that proactively widens our gaze as a society as to who can support us in times of distress or crisis.

Emotional distress is an undeniable aspect of being human. Groups in our society that experience longer term distress often face barriers, including stigma and discrimination that can result in disability that has greater consequences for living a good life than symptoms of any illness can.

As the causes of distress and disability are often located in wider society’s attitudes and actions to people with certain experiences or ways of communicating then so are the solutions. The wider community has a key role to play in supporting those facing challenges with their mental health, and in furthering the narrative that, facing challenges in life and asking for support is not a sign of weakness.

Mental health policy and strategy should not be a fiefdom ruled by mental health services. Our current services have a responsibility to help build capacity within their local communities, putting families and people with lived experience at the centre of driving change rather than an over reliance on exclusively medical or service based approaches.

Nowhere is this more important than in the lives of young people, whose sense of control over their life can be stripped by negative interactions with mental health services. Mind the gap have been working with a number of schools in Bristol to start different types of conversations with young people on mental health and wellbeing. Young people across the city are actively engaging with explorations such as the power of vulnerability as well as examining body image from a wider societal standpoint. From our experience these themes introduce vibrant discussions on mental health while encouraging young people to consider that emotional distress is part of being human and that through adversity we have the opportunity to develop resilience. The young people we work with continue to cite sources of support such as family, teachers, pastoral staff and peers as those they find most helpful. Rarely are services offering the lasting relationships that they feel they need to recover.

By avoiding a narrative of the sole responsibility of experts we have the opportunity to build upon existing capacity that exists within our communities to support young people in crisis. By offering teaching and pastoral staff in schools reflective groups, shared understanding of challenging situations can foster shared solutions that think about a young person in a wider context that just an illness. These professionals demonstrate that schools around the country have experts supporting young people in distress working already on campus. With support they can be even more effective in building lasting and stabilising relationships with young people in crisis.

This does not represent a replacement for direct interactions between young people and their families with mental health professionals when required. However this should be complimentary to support structures in built in our society rather than acting in isolation. The growing focus on mental health in the media is an opportunity to think differently about how we as a society wish to support people in times of need or crisis. The growing anxiety about capacity to support emotional distress and psychosocial disability must be addressed. However the conversations must include all of society to offer wider solutions than just growing mental health services.

1. Arie S. Simon Wessely: “Every time we have a mental health awareness week my spirits sink”. BMJ 2017;358:j4305 doi:https://doi.org/10.1136/bmj.j4305

I thank everyone who has taken the trouble to reply to the points raised in Sophie Arie’s interview with me (BMJ 2017: 358: j4305). This was an “exit interview” on the occasion of my stepping down as President of the Royal College of Psychiatrists, and covered a wide range of topics. Most attention has naturally focussed on the more eye catching content – that is the nature of good journalism. It is clear also not just from rapid responses, but elsewhere, that there are a wide variety of responses, both pro and anti. However, I think that the differences are more than outweighed by points of agreement, and that actually what we are talking about is more about the question of priorities and emphasis than fundamental disagreements.
As ever in our business, words and definitions so often lead to misunderstanding and misinterpretation. Are we talking mental illness, mental disorder, mental health or mental well being? Are these different - surely they must be. But they are so often used interchangeably – often to avoid the stigma that still accompanied mental illness/disorder. Whilst that is understandable, it is not always helpful.
So let me start with mental disorder. The most recent iteration of the Adult Psychiatric Morbidity Survey (https://www.gov.uk/government/statistics/adult-psychiatric-morbidity-sur... ) , the gold standard when it comes to knowing what is happening in population terms, now reports that most people who fulfil criteria for mental disorders are aware that they have a mental health problem. If true, this represents progress, but also is I think occasion to reflect. If that is so, then raising awareness in the admittedly narrow sense that I was using the term, may no longer be the most pressing priority. As Isabella Goldie correctly observes, most people still don’t seek help for the commonest mental health disorders. But I suggest that this is no longer due to lack of awareness in its simplest sense, but issues such as shame, guilt, stigma, beliefs about untreatability, lack of access to acceptable services and so on, may now be playing a major role. I agree with Isabella Goldie that “raising awareness of any health issue is the crucial first step towards ensuring that people take action to improve their health”, but if we are getting close to achieving that goal, then it is time to think about the second and third steps. Randomised controlled trials of mental health screening, such as the one we have just concluded with the UK Armed Forces, did not fail because of lack of awareness, but for many other reasons 1
I accept the point made by several commentators that increasing awareness campaigns are also about reducing stigma. The problem may be as Dr Martino wryly observes, “awareness” has become something of a “bingo term” these days. Certainly in my interview, research and in much of my writings as President, stigma and the need to reduce it raises its ugly head on a regular basis. Recent research such as Time to Change and our own in the Armed Forces is starting to show small, but hence believable, reductions, but there is a long way to go. And if “raising awareness” is a short hand for “raising awareness and reducing stigma”, then all well and good.
My second point is simple, and I doubt many would disagree.. If we encourage more people to seek professional help, either by raising awareness or decreasing stigma, this has to accompanied by increasing resource. In the context of mental disorder that largely means more staff, since in 90% of our work no longer takes place in expensive hospitals, we have very little reliance on costly kit, and the drugs that we use when we have to are very cheap compared to other areas. Although there have been some welcome investments (lAPTS, liaison and perinatal come to mind) I am afraid that this is a case of the facts speaking for themselves. Services are increasingly over stretched, investment has yet to reach where it is most needed, patients with the severest illnesses continue to be bussed around the country, and so on. And we are indeed seeing increased sick absence, early retirement, burnout etc, just as we are in general practice. Indeed, when Emma Richardson talks about the rising level of sick leave amongst NHS staff, and the problems of falling recruitment across the board in those who work in mental health, I think this is supporting my case. Improving recruitment was one of the main objectives of my three years as President, and ways to achieve this was probably the longest part of my conservation with Sophie Arie.
But note that I am being very specific when I say “encouraging people to seek professional health”, whether it by from psychiatrists (my obsession for the last three years), psychologists, social workers, nurses and so on. And that seems to be right when the goal is to able to deliver interventions and treatments of proven benefit for those with defined mental health disorders. But of course, that is not the goal for most of the population most of the time, Just as services get overstretched by increased demand, we also need to make sure that we do not over stretch ourselves by either extending the boundaries of mental disorder into the realm of normal emotional reactions and/or variations in personality. In the world of psychological trauma we know that there is a long historical tradition that shows that people are more resilient than professionals, politicians and planners give them credit for 2. We also know that if people like me get involved too early in the aftermath of trauma (by which I mean hours and days), we can actually make things worse. Instead the best resource remains a person’s own social network – their family, friends and colleagues, and it is something of a relief to have shown that this is exactly who people do turn to in adversity as we showed in the aftermath of the 2005 London Bombs 3. One of the most important things we can do to improve population mental health after such tragedies (note I am now not talking about mental disorder) of people is to assist in mobilising social networks. This might mean ensuring that mobile phone networks continue to function after disasters, or that relief centres have an adequate supply of power leads and landlines, or alternatively combating loneliness or homesickness in students by promoting volunteering, sports, drama, peer support or whatever.
And this can be facilitated by programmes such as Mental Health First Aid, which do not seek to create more mental health professionals, but just giving some very basic knowledge to the kind of people you already meet in your normal life – teachers, colleagues etc. We helped pioneer exactly such a system in the Armed Forces 4. I sometimes think that the training is not just about imparting information, but more about saying it’s OK to talk to people in distress, and no, you won’t make things worse as some seem to think. And I read Isabella Goldie as saying much the same. And if encouraging peer support and its variants also comes under the broad heading of awareness, then yes, I am in favour.
I could not help a wry smile when Dr Browker talks about the new alienism which he links to the the rise of “counselling services”, simply because I used almost the same title in an essay in the BMJ 21 years ago 5. And this has indeed come to pass – with psychiatry becoming increasingly seen as dealing only with the severest of mental illness. My prediction that this would lead to a slow but steady shift of resources away from the most severely ill, has also been fulfilled. As the Chief Executive of our largest mental health trust recently observed, mental health funding is like a soufflé which is gradually expanding, but leaving the core weaker and weaker until it suddenly collapses.
One final point that has been picked up by Twitter and also by the BMJ’s own star columnist, Margaret McCartney, is the issue of unintended consequences. I teach medical students that anything that works, no matter what it is, will always have side effects. If something genuinely has no downside, then there is probably no upside either. The question is simply the balance between the two. And I would argue strongly that this must be true of raising awareness, just as it is true of any other public health intervention. Here I am talking about the dangers of professionalisation or medicalisation of normal emotional reactions and/or personality variations. I expect that the benefits will outnumber the risks, but I am certain that risks there will be, and that all of us should know about them

1. Rona R, Burdett H, Khondoker M, Chesnikov M, Green K, Pernet D, Jones N, Greenberg N, Wessely S, Fear N. Post deployment screening for mental disorder and tailored advice about help seeking in the UK military: a cluster randomized controlled trial. Lancet 2017: 389: 1410-1423
2. Jones E, Woolven R, Durodie W, Wessely S. Civilian Morale During the Second World War: Responses to Air Raids Re-examined. J Social History 2004: 17: 463-479
3. Rubin J, Brewin C, Greenberg N, Simpson J, Wessely S. Psychological and behavioural reactions to the bombings in London on 7 July 2005: cross sectional survey of a representative sample of Londoners. British Medical Journal 2005. 311: 606-610
4. Greenberg N, Langston V, Iversen A, Wessely. S. The acceptability of a peer group support system “Trauma Risk Management (TRiM)” within the UK Armed Forces. Occupational Medicine 2011: 61: 184-189
5. Wessely S. The rise of counselling and the return of alienism. Br Med J 1996;313:158-160

The problem we have is that any discussion around mental health invariably becomes a discussion on mental illness. Someone who is overweight and smokes may not necessarily be ill, and seeking advice from their GP or elsewhere doesn't mean they'll automatically be referred to a diabetes or CVD specialist - but they could still take steps to improve their health, and may need some support or advice in doing so. It's the same with mental health and wellbeing.

Considering the example of the student survey, I agree that it's unlikely 78% of them were mentally ill, even if you factor in responder bias - but it's quite plausible that they had sub-optimal mental health, given that they were in a new and potentially stressful situation.

Raising *awareness* (which I admit is a bit of a bingo term these days - too much *awareness* and not enough action) isn't about encouraging people to diagnose themselves with problems, or to seek medical help. It's more about being able to recognise what affects mental health and wellbeing in ourselves and others, and to take steps to improve it before professional intervention becomes necessary.

It is most unlikely that, in the short term at least, recruitment to psychiatry will increase. The disastrous move to separate mental health trusts from general medicine has created the modern equivalent of the alienist, associated with the stigma of isolated facilities, and consequently with trainees losing touch with colleagues in other branches of medicine.

There is always likely to be some stigma especially with the more severe mental illnesses, because of the changes in personal behaviour which occur and the difficulties in engagement associated with this. Partly, this is best countered by good well -staffed attractive in-patient and community services - not by over crowded sometimes frightening wards and less than 24 hour cover outside hospitals. Perhaps many of us are not fans of campaigns to reduce stigma by force of argument as this approach always runs the risk of inceasing awareness to new recruits of the very stigma one is seeking to diminish.

I do not have any inside information on whether the move to isolate psychiatry into Mental Health Trusts was strongly resisted by the College. Perhaps some psychiatrists thought that having separate services with an identified budget, when previously some infrastructure and services had been shared with other specialities, would be preferable: however, it is possible that the outcome was that the move simply identified discrete budgets which could be raided more easily for other purposes within the NHS or simply cut. When 'mental health' services became the new mantra for a system which included psychiatry it was evident that the latter's core services would be curtailed in the development of services for less serious conditions - including ordinary unhappiness - coupled with the promulgation of counselling in its broadest sense for problems in living - a mammoth, impossible and undesirable task for the NHS, as noted now by Simon Wessely.

A more troubling development, from the experience of some brief contacts, is the seeming lack of history taking by some of the new generations of doctors. We may all feel a little guilty in retrospect by noting as early trainees before specialisation, that the CNS was ' grossly intact' (perhaps this was just a nod to those formative neurolgists who eschew 'soft' signs) but unless awareness of and recording of the mental state is part of all clerking, it is most unlikely that recruits will be attracted to a speciality where a careful history is particularly necessary in leading to a more useful diagnostic formulation and subsequent treatment.