When the Scottish Government announced its ten year strategy on mental health at the end of March, bureaucrats would have known exactly how it would be received. The first draft mapped the next 120 months of life for citizens affected by mental ill health, and ran 12-pages. It was roundly criticized for its pointlessness, even by the Government’s most trusted acolytes in the national charities whose existence is predicated on replacing Government oversight with cash. With no mention of eating disorders in a health strategy supposedly geared to reducing mortality, no mention of substance abuse and few targets, the expectations game was almost perfectly engineered. The final document runs to almost forty pages, with almost as manyrecommendations — though only six have timeframes and only one has a budget.
Nobody will care about the document itself or its effects. Absolutely nobody. Readers of this piece will be interested in the political or philosophical mores of policymaking in late capitalism. Civil servants nailed their colors to the mast with a first draft so bereft of ideas it astonished even the most cynical observers within Scotland. Politicians will realize the lack of political capital here and move on to “real” issues like fracking. CEOs of national charities will roll their eyes and sigh quietly in their offices. Workers in smaller charities have barely any time to absorb the failure — those who do will mutter profanely about the inevitability of it all. And people with mental health problems? Well for them it’s easier. They’re in two camps now: the lost and the losing.
It’s a commonly-cited statistic in the UK that 1 in 4 people will experience a mental health problem at some point in their lives. Up to a point, that’s true. 1 in 4 people will experience something profound enough to interrupt the regular rhythm of their daily lives which isn’t physical in nature. But dig a little deeper and you’ll find that around 1 in 28 people will access secondary mental health services, the second of four tiers of healthcare used to distinguish work; from primary care’s general practitioners, then secondary services which support people in the community, through the tertiary level of inpatient psychiatric care to tier four’s specialisms in the myriad complexity of mental health problems. In the overdeveloped, Anglophone world, there’s been a tendency over the past 30 years to emphasize the importance of community care. In the past 20 years, there’s been a trend to endorse the goodness of general services as a way of keeping people out of the specialist system. The rationale all along has been choice for the individual. For people with mental health that means being offered the choice to live in the community rather than a hospital, to participate in society.
Quite how that tendency started is debatable but its effects are not. From the Clubhouse movement of the post-war United States to the anti-psychiatry movement of Europe and the enthusiasm for therapeutic communities, there is a rich modern history of people organizing against the psychiatric establishment and its machinery. In many ways psychiatry was an easy target for countercultural ire; making science out of the abject horror of mental ill health seems like a long shot even to most of its practitioners and the brutality of physical treatments always seemed tenuous when employed to counter problems nobody could fully grasp with their eyes. Foucault told us how madness had been seen through the ages, how its treatment told us more about the societies which diagnosed it than those poor souls who suffered it. Szasz, Laing and Cooper showed us, practically, what it might look like to treat people in other ways — human ways — and at the same time transgress one of the most thrilling taboos, that quaintest liberal fantasy — helping some humans while judging others for judging the people they choose not to judge. Guattari took Lacan’s staid intellectualism and turned it against itself in Capitalism and Schizophrenia in the 1970s, psychoanalysis had found the molotovs behind the chaise lounge.
But then Foucault moved on to other spectacles. Laing kept drinking and got intellectually sloppy. Guattari was forgotten in the shadow of Deleuze. The trend passed, madness’s momentary glamour slipped by, and established psychiatry continued its dominance that, on reflection, was never really threatened. Everyone was so busy focusing on the people around them they forgot to build a revolution. It’s easily done — this writer holds himself in similar contempt. Faced with the abjection of mental ill health, it’s all we can do to focus on the people around us: nothing promotes anarchism like a stretch in a setting that deals with mental ill health.
The meta-modern medical apparatus, at least in countries like the UK with a comprehensive welfare state, finds its purpose in assessing the productive potential of the citizenry and acting accordingly. Those with productive potential can expect the requisite care to realize it, those without will be isolated. The formula isn’t precise, but the means are all there. Looking at mental health the emphasis is simple — the new strategy in Scotland celebrates things like “wellbeing,” “primary care,” and “early intervention.” The aim is to prevent people from becoming unwell, with literally no planning to care for people who are already unwell, or who will become unwell in the future. When we think about mental wellbeing we think about the ways ordinary people, just like you and me, get by in our ordinary lives. Are we able to go to work? Are we too depressed to produce? Is the quotidian horror of late capitalism offset by your access to credit to buy the stuff you like for the house you live in?
When we think about mental health we open a whole other can of worms. To start with, you might not live in a house. You might live in a hospital, or just not have a house. You might not have produced economically in years — if at all. Most horrifyingly, you might have an advanced degree, have worked in a highly productive position, and still collapsed for reasons which remain unclear years after the event. The 2017-27 strategy places not knowing why you buckled at the heart of public policy. There’s already an armada of services to keep you working, to support you to bury your discomfort. Mindfulness, the art of wading through the bloody sea to find your own hopeful pebble in the instances of your life you choose to pay attention to, should have prepared you for this. So too should work-life balance, reflective thinking or managerial supervision; all spokes of the cog in the machine that the machine allows you choose to be a part of. See? This paragraph started talking about mental health, already we’re back to talking about mental wellbeing: it’s easier to care about things when you can recognize their effects in yourself.
For mental ill health there’s no carrot, only stick. You still have options — you can subject yourself to the medical apparatus; take medications which are suspected of lowering life expectancy (not that it means much, it’s not like you’re going to work), spend time in and out of hospitals and accept benefits. You could fall foul of that, and have your absence painted to varying degrees as a choice. Other fates: homelessness, addiction, death. The medical apparatus will take into account all of the factors of your life and begin treatment with a quickness; it’ll be a slow, grinding process, and there might be nothing of you left at the end, but you’ll get to live, albeit for less time. The prospecting looks much the same as an oil company’s — a nebulous assessment of cost versus benefit, with the likelihood of success being offset against the enormous investment required. For those who find the analogy too impersonal, remember that Scotland literally conceptualizes employment services in its jurisdiction as being part of an “employability pipeline.” Foucault would have found it too obvious and gone back to the stacks for something more cryptic.
The distinction between those who are mad and those who are sane used to be about social relations. Today it relates to production, potential or otherwise, and any care investment is expected to pay economic dividends. At a time when the welfare state’s existence is being questioned across the overdeveloped world, the world of mental health care is acutely, artificially, divided. Governments like Scotland’s have spent years dismantling their own capacity for dealing with the problems they face. A plethora of private-public investment structures have laid waste to the division between the state and private interests. Then there has been, in Scotland at least, the amalgamation of health and social care budgets, thereby absenting the Government from a Mexican standoff of its own creation, between two worlds it knows it literally cannot afford to pay attention to at this stage of capitalism. For people with mental health conditions, whose productivity is too far off to merit investment, the alternative is simply abandonment. The Scottish Government has, in this policy document, codified its disavowal of its own citizens when the capital gains of caring look to be in doubt.