After homo economicus, is homo biomedicus next?
A trained psychologist myself, I took great interest in today’s call of the British Psychological Society for a departure of the biomedical model of mental illness. And, to my delight, so did other colleagues – read a great blog post from Social Brain’s Emma Lindley here, where she writes that we might be right now witnessing a bona fide revolution that may change mental health services so radically, ‘they will be unrecognisable to the children of my generation.’ As Emma points out, the debate is as much driven by differing concepts of human nature as it is by politics, and the struggle for professional relevance and power. It is the latter aspect that I want to focus on in this blog post.
The RSA has long taken an interest in professions and their future (including this project in the early 2000s), and is currently managing an independent review of the Police Federation. Further international projects with other professions may follow soon.
Interestingly, even though Psychiatry is the younger term, it is the arguably the older science, and literally means ‘the medical treatment of the soul’, whereas Psychology means ‘study of the soul’. Psychology and, specifically, its subdomain Clinical Psychology, have always had a hard time standing up to their medical cousin. Part of the reason for that one can find in the etymology; isn’t medical treatment is just so much more tangible than mere study? Thus, in more than one hospital of the world (including one I interned in a long, long time ago), Psychologists have not been much more than overeducated sidekicks to doctors. This may change soon.
The main reason for this is that over the last decade, and particularly since 2008, Psychology has arrived in the scientific establishment. It did so by using a strategy applied by underdogs since the advent of mankind: collaboration. (And, of course, the emergence of discipline rockstars like Steven Pinker has helped.)
Not having enough leverage itself, Psychology entered functional marriages with up and coming disciplines like neuroscience and traditional ones like economics, a process that led to the creation of new interdisciplinary fields like behavioural science. A prominent victim of this process was homo economicus – the notion that humans are wholly rational and narrowly self-interested. Homo biomedicus (not an official term, my inadequate creation), the similarly reductionist paradigm underlying present day psychiatry that acknowledges only the physical side of human existence, but leaves aside the social and psychological aspects, may very well be next.
There are two reasons to be concerned about the potential revolution of mental health services given that professional battle lines are drawn:
Firstly, while for Psychology there was the possibility of a non-threatening complementary relationship in the mutual interest with economics or neuroscience, with Psychiatry it is different. Here the question is ‘who runs the show?’, or, if you will, one of professional hegemony. Still, one hopes that the critical voices on both sides steer the process away from the zero-sum-game it is in danger to become, which certainly would leave everyone worse off.
Secondly, the homo biomedicus model is not entirely wrong, just as the homo economicus model is not completely off the mark. The concept has its merit and adequate areas of application, and it will need to be taken into account when designing future services based on a richer, more complex understanding of man as Homo biopsychosocialis that is embedded in a capabilities-based approach. Throwing out the baby with the bath water would be just as wrong.
Josef Lentsch is Director of RSA International – follow him at @joseflentsch
Complex problems: simple solutions, or how an umbrella can cure constipation
‘The best ideas are simple ideas.’ This was the assertion of a friend I met up with earlier this week for a pie and a pint, with a side order of his own-recipe barstool wisdom.
I found his stance difficult to agree with at first – it reminded me too much of my terrifying old English teacher gesturing at my waffly essays and barking, ‘What’s your argument? If you can’t explain it in ten seconds then you don’t have one!’ Yet over the course of this week I have come to see that he has a point. While we must always be mindful of the complexity of the problems we face as a society, if an idea cannot be expressed or enacted in a way that is meaningful to others then it is of very limited value.
Last Tuesday’s launch event for the new ‘Science, Medicine & Society Network’ at University College London served as a lesson in this principle. The Network is a new international academic partnership bringing together experts in health from a range of disciplines, and I had been worried that I would understand little of what the distinguished panel of medical clinicians, political scientists, lawyers and anthropologists would be discussing. Refreshingly though, the central, easy to comprehend message of the event was that although the challenges to global public health are complex and varied, the solutions must be grounded in simplicity, attainability, and relevance to the communities they affect.
For example, Lord Nigel Crisp, the former NHS senior manager and author of Turning the world upside down: The search for global health in the 21st century, spoke about his discussions with public health officials around the world on the question of how to reduce maternal mortality. An Indian government minister had presented a complicated series of rubrics and metrics, lofty policies and programmes, and a confusing mishmash of approaches that Lord Crisp struggled to follow let alone imagine being implemented. In contrast, an official at BRAC, the hugely successful Bangladeshi NGO, responded to Lord Crisp’s question simply: ‘Empower the women’. In recent years, this radically simple approach has contributed to a dramatic fall in Bangladesh’s maternal mortality figures.
Another speaker at the event offered a different example. Professor Cyril Chantler shared a story that he likes to tell his UCL first year medical students. When he was a consultant to Guy’s Hospital in the 1970s, a young boy was brought to see him with rectal bleeding apparently caused by a small cut on his skin – a straightforward diagnosis, one might think. However, Prof. Chantler suspected that the underlying cause was more complicated than this, so he began to investigate further. Why did he have this cut? Because he was constipated. Why was he constipated? It transpired that the boy’s family, who lived in a poor neighbourhood, did not have an indoor toilet and instead shared a communal lavatory with other households in the street. The roof above this communal toilet leaked, and the little boy didn’t like getting his head wet, so he stopped going to the toilet. Prof. Chantler said that he likes to challenge his students to suggest a solution to this problem: many say that the family needs an indoor toilet. This may be correct, but Prof. Chandler is not a plumber. The more politically-minded students might suggest that the socioeconomic situation is the problem, and that the boy’s family should not have to be so poor that they share an outdoor toilet with other people in their street. This also has the ring of truth, but again it is beyond Prof. Chandler’s capacity to change this from his clinical consulting room. So what did Prof. Chandler do? He gave the boy an umbrella. The boy no longer had to get wet when he needed the loo, he stopped getting constipated, and the bleeding went away.
I was again alerted to the potential for apparently simple ideas to help solve complex problems when the RSA, in partnership with Kingfisher PLC, hosted a seminar this week on the subject of building ‘sustainable, stronger communities’. Luminaries from business, the public sector, think-tanks, and charities discussed the potential for businesses to help promote community cohesion and social change through initiatives such as those pioneered by Kingfisher, including the online local networking website StreetClub. Much of the debate centred on whether initiatives like these should be high-concept, ambitious attempts to organise society and ‘create new cultural norms’, or whether a simpler, lighter touch was called for, striving to ‘do one thing very well’. Personally, I found the latter option more compelling. StreetClub’s core strength in encouraging neighbours to share tools is reminiscent of that other simple idea I blogged on recently, the Big Lunch. Both of these schemes harness the latent potential for communities to become more connected around a simple excuse to get together; to borrow a ladder or to share a lunch. As one attendee at our seminar sagely observed, successful initiatives like this ‘don’t change communities; they create the platform for change’.
Simple ideas which create the platform for change are what the RSA’s Connected Communities programme is all about. Our research found that some older people in South East London have low wellbeing because they are isolated and don’t have any way of transporting themselves away from their homes; we’re developing a project that will provide them with a social environment a free lift in a minibus to help them get out and about. We found that people’s mental wellbeing can suffer when there is a lack of social support; we’re going to identify key members of local social networks and train them as peer support counsellors.
Complex problems: simple solutions. My friend in the pub swears by this equation, and so, presumably, did the little boy who trotted down the street with an umbrella every day. It’s an equation I’m coming around to too.
Communities: The omitted third dimension?
Here is an interesting Guardian piece on a transnational YouGov-Cambridge study. The research compared attitudes towards responsibilities of the state versus those of individuals in the UK, US, France and Germany.
To summarise, when it comes to the role of the state on issues like ‘a decent minimum income for all’ or ‘helping poor children get ahead’, British views are significantly more continental than atlantic. With the exception of company pay – on inequity of salaries, Britons are more liberal than Germans and French, if not as liberal as Americans – the results put the US on the individualist side, and UK, Germany and France broadly on the statist side; which highlights once again that the conversation on public services in the US is a very different one to this side of the pond.
What is just as interesting as the results, however, is the way the study is structured. It takes a classic two-dimensional approach: state versus individuals.
What about views on the responsibility of, and for, communities?
They are a pillar of social power just as much as the other two dimensions. And given fiscal pressures on both sides of the Atlantic, an increasing amount of challenges will need to be dealt with via this ‘third dimension’ (e.g., as my colleague Matthew Parsfield pointed out recently, in Mental Health, or as our CEO Matthew Taylor has argued, in Care).
But as so often, communities get left out of the equation – what statisticians would call an omitted variable. Arguably, without taking this third dimension into account, there is a lack of depth in the insights generated.
My hunch is that we would see a picture emerge that is more complex and informative than the binary US/Europe divide. But perhaps there is already some comparative data out there, maybe even longitudinal – might a reader point me in the right direction?
The RSA is well positioned to work across all three dimensions internationally, as we have strong Fellowships in all four countries (altogether we have Fellowships in 101 countries, the US being the largest one with almost 800 Fellows), as well as Fellow- and staff-led projects in the US and Germany. I will elaborate on these in my next blog posts.
Also, I am looking forward to the upcoming RSA Lecture with Tim Smit, CEO and Founder of the Eden Project, who asks the very question: ‘Where does responsibility for community lie’?
Communities: a solution to the ‘global mental health crisis’?
Mental health is a globally pressing issue. Conservative estimates suggest that 400 million people worldwide suffer from various mental illnesses, while the World Health Organisation predicts that by 2030 depression will be the world’s leading cause of the burden of disease, with mental health problems already exacting a greater toll than tuberculosis, cancer, or heart disease.
Yet look at this global picture more closely, and to some observers it appears as though this burden might not be spread evenly around the world. With recovery rates for schizophrenia and depression in the USA, UK, and other wealthy countries worse than those in Nigeria, India, and other developing nations, it looks as though the poor world is outperforming the rich when it comes to dealing with some mental disorders.
Theories as to why this may be abound. These range from the perhaps outdated and stereotypical idea that there is a greater tradition of family and community solidarity in economically developing nations, to the social anthropologist Tanya Luhrmann’s theory that a combination of greater stigma and “disgraceful” normative care practices in the West often mean that sufferers of devastating mental disorders like schizophrenia concurrently experience a range of other afflictions – ostracism, homelessness, poverty, substance addiction and a set of humiliating interpersonal experiences that she calls ‘social defeat’.
Last night, in his RSA lecture entitled ‘The Global Mental Health Crisis: What the rich world can learn from the poor’, Professor Vikram Patel of the London School of Hygiene and Tropical Medicine offered a slightly different perspective. Focussing on access to care, he gave examples of the relative ingenuity of mental health care practices in countries like India, where he has done extensive work.
There is, he said, no shortage of psychiatric professionals in wealthy Western nations; for example California alone has more psychiatrists than the whole of South Asia. Despite this, some 60% of people with mental illness symptoms in the USA do not access any form of psychiatric care. The UK, even with its free-of-charge National Health Service, only performs slightly better, with 40% of sufferers not seeking or receiving treatment. As explanations for this he pointed to the sometimes alienating, over-complicated professional culture of DSM-influenced approaches to mental illnesses in the West, and the remoteness of psychiatric practitioners to their patients in both lifestyle and outlook as reasons for people not knowing about or feeling they can access services.
By contrast, he presented a model of public health in India that, with limited resources in the form of professionals or pharmaceuticals, utilises lay community health workers to provide collaborative, locally appropriate community-based care. Specially trained lay workers operate under the direction of psychiatric professionals to provide outreach services, ‘psychiatric first aid’, and social interventions based in the home, in a Wellcome Trust-funded controlled trial, documented in a series of documentaries available online.
Back in the UK, the RSA is looking to draw upon a similar approach as part of its Connected Communities project, which seeks to explore ways of building resilient communities in which people’s wellbeing and life satisfaction benefit from social connections with their peers. Working with Nicky Forsythe of Positive Therapy, we shall shortly be launching an innovative Talk For Health peer support programme which will train key members of community networks as lay counsellors, giving them the confidence and knowledge to take the therapists’ skills of empathy, non-judgemental listening, and conversational support out of the doctors’ surgery and into the hands of the community. In Bristol, we’ve just launched an innovative tablet computer app called Social Mirror, which volunteer health champions will use to help people map their social networks and, where necessary, receive suggested social prescriptions. Simultaneously, we are working with Talk To Me London to launch an exciting pilot project in New Cross that seeks to encourage Londoners to engage in conversations with strangers, with participants identified by their ‘Talk To Me’ badges which show that they are friendly and willing to chat. The designers of the project promise that it will “be the most innovative, culture-changing campaign of our times”, so stay tuned for more on that.
With ever-increasing strains on public health and social care budgets, and worrying research that demonstrates links between social isolation and the risk of mental illness and death, it is hoped that we can learn much from Professor Patel and others in the ‘poor world’ who are demonstrating that innovative, ingenious social interventions can help manage the burden of mental illness by supporting connected communities. Keep checking this blog, follow #RSAConnected and @SocialMirrorApp on Twitter, or email matthew.parsfield@rsa.org.uk and ask to join the relevant email lists to keep updated with how this work progresses.
Disabled? Say hello to hard times
Today marks the beginning of the end of Disability Living Allowance. As of now, new applicants in the North East and North West will be assessed for the coalition government’s replacement for the non-means tested benefit, the Personal Independence Payment (PIP). Anyone whose award is up for review will go through the PIP assessment process, and the plan is that by 2018, more than 400,000 people who currently get DLA will not get PIP. This means that around 20% of people who currently receive DLA will lose the benefit all together.
Image via willstleger.wordpress.com
The narratives attached to the need for welfare reform and benefits cuts are powerful, and the government has done a reasonably good job of convincing the nation that it is essential to reduce spending on welfare if our economy is to recover. The particular focus on disabled people, and DLA especially plays into our distaste at the idea of anyone languishing on a ‘lifetime’ benefit with no checks to see if they continue to be disabled ‘enough’ to deserve it.
DLA is also ripe for being framed as unpalatable because of the fact that it isn’t means-tested. It makes no difference if you are a banker, barrister or a barista, your right to claim DLA remains the same. This was designed to reflect the fact that being disabled is expensive, whether you have a visible, physical disability like multiple sclerosis, an invisible, chronic condition like lupus, or an intermittent, unpredictable illness like schizophrenia. In any of these cases, and regardless of a person’s income, DLA can make the difference between being able to work or not, eat properly or not, get around or not.
It makes no difference if you are a banker, barrister or a barista, your right to claim DLA remains the same.
This excellent personal account shows how DLA has made it possible for Mark Harper to continue working and illustrates the many small ways in which it enables him to have a better quality of life in spite of living with a painful neurological condition. As Mark points out, the obsession with employment as the panacea for all our nation’s economic ills is actually undermined by removing the sorts of benefits that make it possible for some people with disabilities to work at all.
DLA certainly wasn’t perfect, and the one-size-fits-all approach to assessing disability has always been ludicrously inflexible. For example, one of the measures of disability the distance a person can walk. Under the old DLA structure, 50 metres was the crucial distance that determined whether or not a person was eligible for the higher rate of mobility allowance. The PIP framework is more than halving this to 20 metres, and there’s plenty to say about the arbitrariness of this heavy handed and unfair change, but to focus on that would overlook the ridiculousness of using the ability to walk a certain distance as a key way of assessing a person’s mobility.
There are many serious physical disabilities which don’t affect one’s ability to walk. There are many disabilities which threaten people’s mobility even though they might be assessed as being physically the same as a non-disabled person. For someone with a learning disability, for example, being able to get around the world safely is not necessarily about moving one leg in front of the other so much as understanding dangers posed by traffic, navigating confusing routes through cities, and social vulnerability. What about a person with agoraphobia or extreme depression?
The transition from DLA to PIP is happening in phases, so those who were once promised ‘lifetime’ DLA support, or who are in the middle of a fixed term award have another couple of year’s grace before the major changes kick in, unless they experience a change in their disability. But the process has begun, there is no stopping it, and hundreds of thousands of disabled people are fearful for their futures because of it.
Care about care? Come on then, do some caring!
Matthew Taylor has recently written several blog posts about the need to reconsider care. His suggestion that secondary school pupils should be required to do 100 hours of caring as part of a compulsory work experience programme seems like a good one for lots of reasons.
Acquiring the skills of caring early in life can only be an advantage, and raising the profile and status of care are important likely benefits of such a scheme. In general I think working with young people in schools is a valid way to try to achieve cultural shifts across a generation.
Shouldn’t offering care be something that we all do, in some form, and continue to do throughout our lives?
But I also think that it can be an effective strategy for sidestepping our own responsibility to contribute in areas that we recognise as important, but might not want to engage with directly. For those of us who left school years ago and are busy working full time, developing our careers, or in Matthew Taylor’s case, running the RSA, the idea of doing a bit of hands-on care as well might seem unfeasible, not to mention unappealing.
If we are in broad agreement with Matthew’s arguments, shouldn’t offering care be something that we all do, in some form, and continue to do throughout our lives? It occurs to me that there might be scope for companies and organisations to set up schemes in which employees are encouraged to offer their time as voluntary carers during work hours.
There is at least one precedent in which a company has decided to donate employees’ time to charities. The housing association, First Ark Group, has recently made the decision to donate 500 days of staff time to volunteer in local good causes. In the Guardian’s report, published on Monday, First Ark explain that they see their responsibility to the community as extending beyond doing their ‘bread and butter’ work in the best way possible. Being a force for good and building genuine connections with the community are also key priorities and donating staff days is one way of making these things happen.
There is plenty of evidence to indicate that volunteering is good for us. It’s not just good for our communities and for the organisations, individuals and groups who receive voluntary help, it’s also good for the volunteer. In addition to the fact that volunteering brings the opportunity to learn new skills and build different kinds of relationships, it’s also good for our overall wellbeing. It has the feel good factor.
So, if an organisation were to introduce a caring scheme, what would it mean for the workplace? I suspect it would be likely to increase morale amongst staff, raise pride in the employer, develop a reputation for being a socially responsible organisation. If staff throughout organisations, from chief executives to managers to cleaners were all expected to participate, it would give the entire workforce a shared experience and sense of solidarity.
What about the likely costs? How could any company afford to donate staff time to offering care? What would the impact be on individuals’ time management and workload? According to First Ark, these problems are easily ironed out quickly, and all it takes is a bit of adjustment. Tot up the amount of time staff waste at the water cooler, and we already know that being present at work 100% of the time doesn’t amount to 100% productivity.
It will be interesting to see how First Ark’s scheme works out, and whether they continue with it beyond this year. It seems to me that if we really care about care, we should be prepared to demonstrate that by actually getting involved ourselves. The way working life is structured makes it a tall order to expect people to volunteer to care in their spare time, but I wonder how prepared we would be to do it if it became part of our working lives.
Fasting: fad or panacea?
Fancy losing weight, looking younger, living longer, fending off Alzheimer’s, Parkinson’s and even cancer, whilst eating whatever you want? This is only some of what the 5:2 fasting diet claims to offer, and the only catch is that you have to fast twice a week. The ‘fast’ days do not require complete starvation, but instead involve heavily restricted calories – 500 for a woman and 600 for a man. It’s up to the individual how to make up the calories, but the suggestion is that you eat breakfast and one other meal, either lunch or dinner.
The evidence is strong that it’s a very effective way to lose weight. But there’s more to it than that – much has been made of the link between this pattern of eating and increased longevity. Research conducted by the Baltimore National Institute on Aging indicates that levels of the hormone insulin-like growth factor 1 (IGF-1) are lowered by twice-weekly fasting. Controlling levels of IGF-1 can promote longevity as well as offering protection against a range of diseases.
High levels of IGF-1 are thought to increase the cell divisions associated with cancer, hence the possibility that reducing it may offer defence against it. Although this evidence is encouraging, the sceptical scientific community still feel that more extensive research needs to be conducted before conclusions can be drawn. Some critics have suggested that the extremes involved might result in the development of eating disorder, although there is no hard evidence for this either.
Could it be that eating hardly anything twice a week is doable because of the fact that, for the rest of the time, one is at liberty to enjoy whatever one fancies, be it cake, steak, or booze?
Since the BBC broadcast a documentary about it last year, the diet has grown hugely in popularity, with celebrity support coming from the likes of Hugh Fearnley-Whittingstall. Is there something different about this approach to reducing the amount we eat, or is it just another boom and bust fad diet like Atkins or Dukan? According to those who champion it, this approach to reducing calorific intake is much easier to sustain because of the fact that five days out of seven are unrestricted.
Could it be that eating hardly anything twice a week is doable because of the fact that, for the rest of the time, one is at liberty to enjoy whatever one fancies, be it cake, steak, or booze? However hungry you might get on the fast day, is the knowledge that you could have a full English breakfast the next day enough to get you through?
It seems to me that this particular approach to eating might not only be easier to stick to than others, but could also encourage deeper consideration of one’s relationship with food. Having not tried this diet myself, I can’t comment from first-hand experience, but I suspect that on fast days, you are more acutely aware of your body’s need for food than on days when you’re eating whatever you want. By deliberately depriving yourself of the ‘usual’ amount of food, you are choosing to make yourself somewhat uncomfortable which much have psychological and maybe spiritual effects as well as physical ones.
The Islamic month of Ramadan uses fasting as a way of teaching Muslims self-discipline, self-restraint and generosity, as well as encouraging reflection on the suffering of the poor, who may be forced to fast through poverty. Being hungry is used as a vehicle for nurturing the skills needed to maintain self-control – acting as a tool for sustaining mindfulness. Perhaps some of these benefits can be gained through regular intermittent fasting as well.
Advocates of the 5:2 diet talk about quite enjoying the feeling of hunger (knowing that it will be short-lived) and of feeling exhilarated on the fast days and liberated on the days when no restrictions are in place. From the various accounts I’ve read of doing the diet, I have not seen explicit mention of spiritual or psychological benefits, but I have a suspicion that impacts on these domains may go some way towards explaining its popularity.
Opening Minds through Shakespeare
This, believe it or not, is a photograph of a year seven pupil improvising Romeo and Juliet. Even more surprising is that this pupil was one of a group that started this Shakespeare workshop only a few hours earlier professing that they either knew nothing about Shakespeare or that what they did know of him was “boring”.
This was how my day began when I visited Windsor school in Germany last week as part of a partnership project between the RSA and SCE (Service Children’s Education). The aim of the partnership is to support SCE as two of its schools in JHQ Rheindahlen are due to close along with the Garrison. The focus at Windsor school is to teach the students about Shakespeare whilst also helping them to develop competences from the RSA’s Opening Minds framework which they can call upon during this challenging time and in their future lives.
The pupils’ initial reaction to a day of Shakespeare reminded me of the way in which I and many of my peers greeted Shakespeare learning at school. However, the workshop that followed could not have been more different. After watching the Globe’s promotional video Stand Up For Shakespeare, in which celebrities, such as Judi Dench, explain that Shakespeare is to be acted and not read, we followed their cue and began improvising scenes before even glancing at a script.
Following the truly inspirational facilitation of our lead partner, SCE’s Performing Arts Consultant Joy Harris, the students were led through a number of exercises that helped them to break through Shakespeare’s intimidating language and recognise emotions and scenarios that are common to all people of all ages and times: children and adults, Tudor subjects and modern day citizens. By mid-morning the students were leaping around the room, brandishing imaginary knives and reciting lines from the play, unscripted.
With the children’s excitement and imaginations ignited, my role – to introduce competences such as ‘risk taking’ and ‘feelings and reactions’ – was made much simpler. The children were fully engaged and able to relate the discussion to a present experience. They were, for example, able to put themselves in Juliet’s shoes and explore the risks that she took in marrying Romeo and taking the poison, and to debate whether her actions were admirable or plain foolish. Through the prism of the play and an exploration of the motives and emotions of the characters, they were able to develop a deeper understanding of the competences.
All of this is even more astonishing when you consider the uncertainty that these children face. Apart from the fact that they will not be in that school next September, many do not know much else about what the next year holds. It is hard to imagine the implications this has for them personally, as well as for engagement and morale within the classroom. A number of children will not be able to see the project to completion and, for one pupil, this was their last day in the school. Despite this, every child actively participated and the staff and the school’s Head fully supported the unique experience that they were able to gain that day.
I also learned a lot from the visit – and not just that Shakespeare is not as boring as I had remembered. The whole experience was an extremely powerful demonstration of how pupils become more engaged in learning if they are doing rather than just listening. This approach may seem more easily applicable to drama than other subjects, such as Maths, but maybe it is this pigeon-holing that we need to break away from.
As I approach the end of what is sadly my last day at the RSA (as I will be moving to a new role at Cubitt), my visit to Windsor has also helped me to reflect on the amazing experiences that I have gained here and to think about how I will utilise them in my next role. Perhaps, though, it will be twenty years down the line that I will draw on something that I have learnt here, and the people that helped form that learning won’t have any idea of its application. In the face of what could easily be a sad and demoralising year, the teachers at SCE remain passionate about ensuring that their students access unique opportunities that they can reflect on and use in the year and years to come.
Does ‘dual diagnosis’ have a place in a recovery agenda?
Having a ‘dual diagnosis’ means that someone who has mental health problems also has problems with one or more drugs, including alcohol. In my years as a substance misuse practitioner I would frequently work with individuals where underlying and undiagnosed mental health issues would have a significant impact on problematic drug and alcohol use.
The continuing issue in my experience was that mental health services would frequently be unprepared or seemingly unable to work with individuals that presented with substance misuse issues. This would create a huge gulf in service delivery with many being unable to access appropriate support to meet their needs. The relationship between dual diagnosis: substance misuse and dealing with mental health issues a research report published in 2009 aimed at addressing some of the finer issues relating to ‘dual diagnosis’, and although there has been an improvement in the relationship between drug and mental health services, red tape and referral processes can still often prove to be a block to treatment.
In February 2011 the government released a paper entitled No health without mental health. The paper outlines the government’s strategy and action plan for improving mental health and well-being stating;
“This Government recognises that our mental health is central to our quality of life, central to our economic success and interdependent with our success in improving education, training and employment outcomes and tackling some of the persistent problems that scar our society, from homelessness, violence and abuse, to drug use and crime.”
Unfortunately the paper does not detail the specific issues relating to ‘dual diagnosis’ and how this strategy can shape and improve service delivery for individuals accessing drug and alcohol treatment.
In 2011 I was involved in an eight week pilot, which enabled those accessing services and exhibiting potential mental health problems the opportunity to be seen and assessed in the treatment centre by a clinical psychiatrist. This allowed for immediate referrals to be made to GP’s and mental health services for treatment, the initial results were positive and fundamental to the successful completion of treatment for many individuals over that period.
So how does this relate to a ‘Recovery Agenda’? The ineffective treatment of mental health problems relating to people accessing drug treatment services could jeopardise the potential for meaningful recovery. If the ideal vision is for treatment is to be but a small part of the recovery journey, then surely a more integrated service focused on ‘dual diagnosis’ will be required in the future. The tagline for the above mentioned government paper is ‘Delivering better mental health outcomes for people of all ages’ maybe that should include ‘all backgrounds’ to achieve real success in improving mental health for all.
Central heating for kids, community learning for everyone
A popular brand of cereal was once accompanied by the slogan “central heating for kids”. In the television advertisements (which have become something of a classic) children leave the house with an uncanny red glow, the visual token of the benefits of a good breakfast.
It seems 70s ad executives knew more than they thought. There’s a persuasive body of research that suggests eating a healthy breakfast in the morning has a range of positive effects on a child’s ability to learn. Many schools have started to offer breakfast clubs, both in reaction to this evidence and in order to boost attendance.
RSA Fellow Laura Billings cites this evidence in the introduction to her short report Beyond Breakfast, which describes a project she’s undertaken in Willesden, North London with funding from the RSA’s Catalyst seed fund. She worked in partnership with charity Magic Breakfast, who provide free breakfasts to over 200 primary schools across the country (their generous support enabled Laura to work on the project).
Laura aimed to investigate whether a school breakfast club could create opportunities for learning in the wider community, as well as helping children get through the school day. As she puts it: “’fuel for learning’ [Magic Breakfast’s slogan] could be argued to include not only a nutritional breakfast, but also quality schooling, parental involvement and community social capital. And this involves us all”.
You can see Laura describe the project in the video above, but her idea at its simplest is to use the breakfast club as an excuse to ask parents a question: what would you like to learn? Drawing on the work of American academic Dr. Jerry Stein and his Learning Dreams project, Laura and Michelle (a teacher at the school) tried to connect parents who wanted to learn something with people in the local community who could teach them.
The first parent they met, for example, was Ngenarr, who said she wanted to dance. Laura and Michelle helped to find a local teacher who could teach a class at the school, and other parents at the school helped to organise and promote the sessions. As this suggests, where the project becomes really interesting is in its potential to create links between members of the community.
The relationship between a school, a child and their parent is necessarily focussed on certain kinds of activity, mostly related to formal education. Laura’s aim was to show that there are opportunities to create connections between parents and other members of the community that can support a different kind of learning, accessible to parents as well as children. What’s more, she hoped that this could point to a more sustainable model for breakfast clubs, as a collaborative undertaking between a school and its community.
In her clear-eyed evaluation of the project’s impact (which is concise and worth reading in full) Laura acknowledges that making connections isn’t an easy thing to do: building relationships of trust requires time and patience, and isn’t easily done in the confines of a busy school day. Laura’s suggestion is that creating a new kind of common space is the next step, with activities determined by the local community – with healthy breakfasts as a way to welcome people in and create a warm atmosphere.
This echoes the findings of the RSA’s Connected Communities work in New Cross Gate, where surveys and interviews indicated the importance of local community hubs – pubs, cafes and community centres – in sustaining local social networks, and providing opportunities for interaction between people who would otherwise not meet.
Of course, a ‘hub’ is only as useful as the people use it, and creating a physical space – no matter how well intentioned – is no panacea. However, what Laura’s project shows is that the idea of something universal and easily grasped, like the need for a decent breakfast, can start a chain of helpful social connections.
She admits she didn’t see the project ending up that way, which is perhaps the thing I like best about it. Beyond Breakfast began with the problem of a hungry belly and ended with something else entirely: the idea that learning can spread through a community like water through pipes. Perhaps the ad men weren’t so far off the mark, and even a little modest: a good breakfast can be central heating for all of us.
Sam Thomas is the RSA’s project engagement manager. Follow @iamsamthomas on Twitter.
Twitter feed of #theRSA- RT @la_gaia: *Really* interesting event with #theRSA @RSARecovery team "The Self-Tapping Screw : RSA blogs" http://t.co/3pQ4lO7sGJ via @the… May 20, 2013 DrEmmaLindley (Emma Lindley)
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