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