Please trust the workers, Mr Dobson

The new mental health policies rely too much on dirigiste managers, argues Andrew Cooper

There is a seeming contradiction at the heart of Frank Dobson's Commons statement to launch the government's new mental health strategy, which involves more beds, better access to new drugs, more and better-trained staff, and helplines. He says, in effect, that a few have spoiled it for the many - that the small minority of mentally ill people who are "a nuisance or a danger to themselves and others" have proved beyond the capabilities of the community care system, and so the whole edifice must be rebuilt. The fear was that concerns about risk and community safety - suicides and homicides - rather than care for the mentally ill themselves would drive the new policy. Most of what Dobson said in a rounded and compassionate speech confounded that fear. This one comment went against the grain. Why the contradiction?

The answer lies in an understanding of both the particularities of mental health policy and practice, and this government's approach to social policy in general. In a recent New Statesman essay David Marquand brilliantly captured the unresolved tension between its centralising, dirigiste head and its devolutionary, pluralist heart - a tension that threatens the coherence of the whole new Labour project. This week's white paper on modernising social services is definitely in the first mould, a political triumph for managerialism: higher standards and more standardisation; national objectives for social care agencies; more inspectors and more monitors to ensure better "safeguards". There are no people to be found here, no sense that compassion or anger has prompted the proposed changes. We get an instructional, headmasterly tone in which the main message is "must do better". In the wake of so many revelations of poor and abusive practice, we cannot argue with this. But it is not enough.

Recently, a colleague described his experience of running a course for managers in community mental health work. Over ten weeks, not one of them initiated discussion of a patient. Their preoccupations were with organisational stresses, conflicts with other professionals, their own isolation.

These staff show the same difficulty in getting to know patients and their families as the basis for what mental health "management" might mean, as the policy-makers do in working out what good policies might look like. What both need to address is the extreme emotional difficulty of working with mentally ill people. Dobson hinted at it this week when he said: "Mental illness is extremely disturbing to sufferers and their families. It can leave people without insight into the consequences of their actions. That is very frightening." Actual suicide or violence apart, there may be continual gnawing worry about the possibility of it, a perpetual struggle with chronically withdrawn or inexplicably hostile patients.

Good treatment and care lead to some seriously mentally ill people improving and managing better much of the time. But many remain disturbed and disturbing for long periods. The psychiatrist and psychoanalyst John Rickman once said: "Mental illness consists in not being able to find anyone who can stand to be with you." Yet we ask carers and professionals to tolerate sufferers through months and years. Small wonder they sometimes "fail", over-look simple gestures like talking with patients properly, and miss the vital clues to impending disaster.

When community care became official policy, it was linked to the closure of the old Victorian "bins", and few mourned their passing. With hindsight, we can see that this entailed an idealised vision of community as a warm and welcoming place that would receive the afflicted with concern. But for the mentally ill and those caring for them, the community often proved to be alienated, fearful and hostile. Without the bricks and mortar of the hospital, professional networks became more complex to manage and sustain, and although we continued to use psychiatric institutions as a last resort, we had denigrated the value which resides in the original meaning of "asylum", a place of safety. Suddenly there was no hiding-place, no protection for sufferers or mental health workers. The disasters began, the media pounced, public and political anxiety mounted, and so "risk", safety and control became the watchwords.

A new and poorly trained workforce emerged to support care in the community. Good training must include the development of capacities to both withstand, and understand, the intense emotional forces involved in the work. But even highly trained and experienced professionals now feel that "safety first" is their main motto. Not the patient's or the community's safety, but their own: they fear the stigma of blame for a professional failure.

New Labour's social policy is the same as the Tories' in one important respect. Behind the rhetoric about driving up standards, setting targets, monitoring and inspecting, there is a fundamental mistrust of the workforce. The message is not "we know you have an impossibly difficult and contradictory job, and we want to help you all we can, even if we occasionally have to weed out the odd miscreant", but something more like "prove yourselves, or we will slam you". Good outcomes in welfare work can only be achieved by creating conditions for staff in which confidence breeds confidence.

Policy-making, like good management, should be neither "top down" nor "bottom up", neither dirigisme nor pluralism. It should be a dialogue between the policy-makers and those who know the terrain first hand, genuinely adaptive and responsive to local knowledge and conditions. It's about trust. Trust the workers Mr Dobson, trust the people.

The writer is professor of social work at the Tavistock Clinic and the University of East London

This article first appeared in the 11 December 1998 issue of the New Statesman, Plato rules, OK?

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The New Times: Brexit, globalisation, the crisis in Labour and the future of the left

With essays by David Miliband, Paul Mason, John Harris, Lisa Nandy, Vince Cable and more.

Once again the “new times” are associated with the ascendancy of the right. The financial crash of 2007-2008 – and the Great Recession and sovereign debt crises that were a consequence of it – were meant to have marked the end of an era of runaway “turbocapitalism”. It never came close to happening. The crash was a crisis of capitalism but not the crisis of capitalism. As Lenin observed, there is “no such thing as an absolutely hopeless situation” for capitalism, and so we discovered again. Instead, the greatest burden of the period of fiscal retrenchment that followed the crash was carried by the poorest in society, those most directly affected by austerity, and this in turn has contributed to a deepening distrust of elites and a wider crisis of governance.

Where are we now and in which direction are we heading?

Some of the contributors to this special issue believe that we have reached the end of the “neoliberal” era. I am more sceptical. In any event, the end of neoliberalism, however you define it, will not lead to a social-democratic revival: it looks as if, in many Western countries, we are entering an age in which centre-left parties cannot form ruling majorities, having leaked support to nationalists, populists and more radical alternatives.

Certainly the British Labour Party, riven by a war between its parliamentary representatives and much of its membership, is in a critical condition. At the same time, Jeremy Corbyn’s leadership has inspired a remarkable re-engagement with left-wing politics, even as his party slumps in the polls. His own views may seem frozen in time, but hundreds of thousands of people, many of them young graduates, have responded to his anti-austerity rhetoric, his candour and his shambolic, unspun style.

The EU referendum, in which as much as one-third of Labour supporters voted for Brexit, exposed another chasm in Labour – this time between educated metropolitan liberals and the more socially conservative white working class on whose loyalty the party has long depended. This no longer looks like a viable election-winning coalition, especially after the collapse of Labour in Scotland and the concomitant rise of nationalism in England.

In Marxism Today’s “New Times” issue of October 1988, Stuart Hall wrote: “The left seems not just displaced by Thatcherism, but disabled, flattened, becalmed by the very prospect of change; afraid of rooting itself in ‘the new’ and unable to make the leap of imagination required to engage the future.” Something similar could be said of the left today as it confronts Brexit, the disunities within the United Kingdom, and, in Theresa May, a prime minister who has indicated that she might be prepared to break with the orthodoxies of the past three decades.

The Labour leadership contest between Corbyn and Owen Smith was largely an exercise in nostalgia, both candidates seeking to revive policies that defined an era of mass production and working-class solidarity when Labour was strong. On matters such as immigration, digital disruption, the new gig economy or the power of networks, they had little to say. They proposed a politics of opposition – against austerity, against grammar schools. But what were they for? Neither man seemed capable of embracing the “leading edge of change” or of making the imaginative leap necessary to engage the future.

So is there a politics of the left that will allow us to ride with the currents of these turbulent “new times” and thus shape rather than be flattened by them? Over the next 34 pages 18 writers, offering many perspectives, attempt to answer this and related questions as they analyse the forces shaping a world in which power is shifting to the East, wars rage unchecked in the Middle East, refugees drown en masse in the Mediterranean, technology is outstripping our capacity to understand it, and globalisation begins to fragment.

— Jason Cowley, Editor 

Tom Kibasi on what the left fails to see

Philip Collins on why it's time for Labour to end its crisis

John Harris on why Labour is losing its heartland

Lisa Nandy on how Labour has been halted and hollowed out

David Runciman on networks and the digital revolution

John Gray on why the right, not the left, has grasped the new times

Mariana Mazzucato on why it's time for progressives to rethink capitalism

Robert Ford on why the left must reckon with the anger of those left behind

Ros Wynne-Jones on the people who need a Labour government most

Gary Gerstle on Corbyn, Sanders and the populist surge

Nick Pearce on why the left is haunted by the ghosts of the 1930s

Paul Mason on why the left must be ready to cause a commotion

Neal Lawson on what the new, 21st-century left needs now

Charles Leadbeater explains why we are all existentialists now

John Bew mourns the lost left

Marc Stears on why democracy is a long, hard, slow business

Vince Cable on how a financial crisis empowered the right

David Miliband on why the left needs to move forward, not back

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times