Mental Health Services: Six Awkward Questions
| Date | 01 December 2003 |
| Published date | 01 December 2003 |
| Pages | 4-6 |
| DOI | https://doi.org/10.1108/13619322200300032 |
| Author | David Pilgrim |
| Subject Matter | Health & social care |
David Pilgrim
Professor of Mental Health, Department of
Sociology, Social Policy and Social Work,
University of Liverpool
4The Mental Health Review Volume 8 Issue 4 December 2003 ©Pavilion Publishing (Brighton) 2003
Mental Health Services:
Six Awkward Questions
Personal Perspective
his article has a simple aim. It is to pose
six questions about the nature of mental health services
in contemporary developed societies. The broad
intention is to challenge a core and common assumption.
The latter is that, subject to greater government funding
and public tolerance, a mental health workforce could
respond to the expressed needs and interests of people
in our midst who are mad, miserable or frightened. For
the reasons given below any such assumption is
fundamentally flawed.
1. Are mental health services about mental health?
The answer to this must be in the negative. Only the
most optimistic or self-deluding politician, clinician or
service manager could come to any alternative
conclusion. Mental health services do not exist to
promote mental health but are a devolved localised state
response to the actions of people with mental health
problems (Pilgrim, 1997). Like the National Health
Service, which, overwhelmingly, is an illness service, so
too with the activity of mental health services.
2. Do mental health services primarily serve the
interests of people with mental health problems?
Again the answer must be ‘no’. The key word here is
primarily. It is true that the outpatient wing of mental
health services in primary care or hospital settings does
respond to people wanting psychological and psycho-
social interventions, which are anxiously sought and
gratefully received. However, most of the budgets of
secondary and tertiary mental health services are bound
up with inpatient facilities, the statutory aspects of
mental health work and, increasingly, assertive outreach.
TThese priorities reflect the interests of third parties, ie
relatives, neighbours, voting citizens in public spaces and
the criminal justice system.
The recurrent coercive role of mental health services
may be obscured semantically by phrases such as ‘being
treated under the Mental Health Act’, but coercion, by
definition, negates the freedom to choose or the right to
be left alone. In these circumstances, mental health
services may be more or less beneficent, but this is at the
discretion of staff, not patients. The latter are thus at the
mercy of the former and so are part of a staff-centred, not
patient-centred form of organisation. Genuine patient-
centredness is a pipe-dream, while ever more coersive
forms of mental health law exist.
3. Do mental health services contain expert certainty
about mental health problems?
Again the answer is ‘no’. While a strong current of bio-
reductionism has characterised the field since mad-
doctors wrested control of the asylum system from lay
administrators in the mid-19th century (Scull, 1979),
psychiatry has been recurrently characterised by dispute
and dissent. Questions of the validity of applying disease
models to behaviour and the ethical problems of coercive
treatment and loss of liberty have been at the heart of
these disputes. The leaders of ‘anti-psychiatry’ (eg
Laing, Szasz, Cooper), critical or ‘post-psychiatry’ (eg
Basaglia, Bracken, Thomas), social psychiatry (eg
Shepherd, Leff, Falloon) and the biopsychosocial model
(eg Meyer, Engel, Clare) were, or are, all psychiatrists
(Clare, 1977; Pilgrim, 2002). This point about internal
conflict needs emphasising because the psychiatric
profession has not only been the victim of attack from
disaffected users (Rogers & Pilgrim, 1991) and aspiring
professions seeking to encroach on its territory. It has
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