Inclusion without cure will liberate us all

Journal of Mental Health Promotion, Mar 2004 by Faiers, Adrian

Social inclusion is the motherhood and apple pie of the caring professions. But when does social inclusion become social control? And where do mental health promotion and cure fit in the murky continuum between the two?

Professor Richard Bentall, author of Madness Explained (Bentall, 2003), ended his MACA 2003 Henry Hawkins lecture with a compelling anecdote. His book finishes with the same story. Bentall, who holds the Chair in Experimental Clinical Psychology at the University of Manchester, described an encounter with the Dutch psychiatrist Marius Romme. It was Romme who discovered that large numbers of people in Holland hear voices without needing psychiatric treatment. In the middle of a conversation between the two of them, the psychiatrist said something that had a great impact on the UK psychologist. 'I really like your research on hallucinations, Richard,' he said, 'but the trouble is you want to cure hallucinators, whereas I want to liberate them.'

This may appear to raise old issues of medical versus social models of mental ill health. But perhaps it does more. Perhaps it raises issues of social inclusion versus social control. We may regard cure, whether by medical or psychotherapeutic means, as an early step on the road to inclusion, but it may also be part of bringing people into line with the rest of society.

In his book Bentall himself argues that 'people can sometimes live healthy productive lives while experiencing some degree of psychosis'. he further argues that 'the boundaries between madness and normality are open to negotiation' and that 'psychiatric services are imperfect and sometimes damaging to patients'. On this basis he asks: 'Why not help some psychotic people just to accept that they are different from the rest of us?'

This would also, of course, require society to change: society would need to accept that psychotic people are just different. The argument could also be extended to what society currently regards as other mental disorders.

Bentall makes two important qualifying points: first, this 'does not imply that people in distress should not be offered the most effective treatment that is available (drug or therapeutic)'; second, it does not mean that society should not be protected from the very small number of patients who behave dangerously towards others'. Presumably he would also accept the need to protect patients who are a danger to themselves. Bentall's final assertion is that (what others might call) inclusion without cure 'would almost certainly make the world a better place for mad and ordinary people alike'.

It may not be an entirely new idea, and it would require considerable changes in modern western attitudes, but I believe it is worth re-considering some of the arguments in favour of such an approach:

* modern western society appears to be failing to promote positive mental health

* such an approach might help us all to better understand, accept and express (rather than repress) more aspects of our own personalities and mental make-ups - it may, adapting Romme's phrase, 'liberate us all'

* it could contribute to creating a more accepting and less controlling society, with benefits for everyone, not solely for people currently regarded as having mental health problems.

Modern western society is failing

There is an emerging consensus that the UK is experiencing an epidemic of neurotic disorders: notably anxiety and depression, as well as drug and alcohol-related mental health problems. World Health Organisation data suggest that mental disorders will exceed coronary heart disease in the global burden of disease in the developed world by 2020. Oliver James, in his book Britain on the Couch (James, 1997), argues that there is, compared with the 1950s, an epidemic of depression, irritability, aggression, paranoia, obsessions, panics and addictions. he sees these problems as the outcome of disappointed aspirations, encouraged by advanced capitalism's need to feed feelings of dissatisfaction and resulting in what James calls the 'low serotonin society'. While medication and talking therapies may help, only changes in the way in which society is organised can cure us from obsessively comparing ourselves with others and the enduring dissatisfaction that this generates. Such comparison is hardly surprising when two cornerstones of modern western society are status and consumerism and when we are not only under pressure to be part of such a society but also under constant pressure to climb up it.

This was well demonstrated by a report on BBC Radio 4 s PM programme on 5 September 2003. According to the report, nearly 50% of UK households with an income over £35,000 a year say they cannot afford everything they really need. More than 40% of UK households with an income over £50,000 say they can't afford everything they really need. Moreover, studies of lottery winners show that the more they acquire, the more they re-adjust their sights to higher levels: 'They may now have a Mercedes and a Porsche, a large home and no need to work, but if only they could afford the yacht, the even bigger home, the helicopter ...' (James, 2002).