Don’t turn away—a book not just to be read, but to be acted onBMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2803 (Published 18 November 2022) Cite this as: BMJ 2022;379:o2803
- Iona Heath, retired general practitioner
In John Berger’s book, A Fortunate Man, Dr Sassall says: “All diffidence in my position is a fault. A form of negligence.”1
Diffidence is perhaps the least culpable manifestation of turning away, but it remains a kind of dismissal and a failure to pay attention to the detail of another’s distress.
The injunction Don’t Turn Away is the title of a new book by Penelope Campling which is borne of her forty years of working as a psychiatrist and psychotherapist, twenty of which were spent running the NHS therapy services for people with personality disorder in Leicester.2 It is a book that tells the story of an increasingly brutal turning away from the most abused and damaged people who struggle to survive within our complacent society. This story of a professional life incorporates these many other voices that are almost never heard and yet hold up a mirror to all of us who have the good fortune to consider ourselves sane. These voices tell the stories that Penelope Campling listens to every working day, stories that are invoked by the novelist Sebastian Barry:
There is a moment in the history of every beaten child when his mind parts with hopes of dignity—pushes off hope like a boat without a rower, and lets it go as it will on the stream, and resigns himself to the tally stick of pain.
It is these beaten children who turn up repeatedly over subsequent years in emergency departments, general practices, psychiatric wards and mental health units, all too often to be greeted by an unequivocal and unmissable turning away.
Campling’s book is subtitled Stories of Troubled Minds in Fractured Times and it seems no surprise that the turning away has become more prevalent as society has become increasingly fractured by inequality, injustice, and xenophobia, all compounded by the ideological imposition of austerity. She writes:
Surely, as a society, we owe something to people who have been abused as children and should want the very best for those who have been brave enough to seek help? This has to mean a thorough assessment and sensitive accommodation to each person's needs.
Yet, so very often, it does no such thing.
Like mine, Campling’s career began around the time when the incarceration of people with mental illness in huge remote institutions was finally being undone and real attempts were being made to reintegrate patients back into society. It was a time of optimism, but the hopes were not to be fulfilled. There were lots of slogans, but no genuine commitment. Slowly, inexorably the optimism evaporated within:
… a demoralised institutional culture that is clinging to the false comfort of rigidly following bureaucratic guidelines while losing the capacity to think independently, to assert that mental health services are different, and to advocate on behalf of its patients.
The huge asylums closed but, without the necessary investment in better futures, the neglect and marginalisation implicit in the notion of turning away continued and, indeed got worse as our prisons became populated by people with mental illness or learning disability, resulting in the largest prison population in Western Europe.
Penelope Campling knows from experience that we could have done so much better witnessing how much was achieved for some of the most damaged patients within a residential therapeutic community and how much care and wisdom was generated within patient groups themselves once trust could be established.
We live in a culture that sees positive thinking as the answer to most things. We vote for politicians that take this to the point of denial—as if denying suffering, denying threat, denying complexity will make it all go away.
Campling writes beautifully in a way that manages to illustrate the commitment and respect that she brings to the care of her patients while also revealing the rage she feels against those in power who have made no serious attempt to properly fund the care of those with the most serious mental illness over the past forty years, leaving the most damaged people to sink or swim and not apparently caring when so many of them sink.
A huge amount of energy is focused on keeping patients out of the system: devising exclusion criteria to restrict access; limiting clinical engagement by restricting length of sessions and duration of contact; and endlessly driving bed numbers down even further.
The book provides a lucid and much-needed articulation of the frustration shared by so many struggling to keep the NHS afloat in the face of the short-sighted target-driven cost-cutting culture which wastes so much on the futile and fails to deliver the most important.
I worry that as “treatment” becomes more formulaic, there seems to be less and less scope to tailor therapy to a particular person's situation, symptoms, and personality. We increasingly rely on volunteers, trainees, and people who are prepared to work for less money, with less training, less experience and fewer skills.
This book is, in many ways, a continuation of her previous book, Intelligent Kindness, written with John Ballatt.3 Like the first book it needs not just to be read, but to be acted upon or the suffering of those with chronic and enduring mental illness with continue unabated. It is so easy to turn away and so hard not to, but there can be much reward in finding the courage, both personally and institutionally, to turn towards rather than away.
In 1942, the French philosopher Simone Weil wrote:
Those who are unhappy have no need for anything in this world but people capable of giving them their attention. The capacity to give one’s attention to a sufferer is a very rare and difficult thing; it is almost a miracle; it is a miracle.
So few of those with severe mental illness have ever been given the attention they need, least of all by mental health services and those, like Penelope Campling, who try to do this are hemmed in and systematically undermined by the way services are structured and delivered. Turning Away is the opposite of giving attention. It is what successive governments have done while presiding over the increasing fracturing of our society. Those in government give no attention to the moral injury sustained by these mental health professionals let alone to the troubled minds they are asked to help. This is indefensible, the spiral is downwards and something has to give.
Yet it is too easy to blame the government. All of us, to a greater or lesser extent have colluded in this worsening neglect. Change will only really happen if a determination to reflect, understand and change occurs at every level of society. This book requires us all to do better.
Iona Heath is a former President of the Royal College of General Practitioners
Competing interests: none declared
Provenance and peer review: not commissioned, not peer reviewed.