British healthcare moves in pendulum swings between one extreme and another, often without much material improvement for patients. Just look at how maternity care swung from mostly at home and assisted by midwives before the start of the NHS, to highly-medicalised and doctor-led by the 1960s, and back to a focus on ‘normal birth’ and reducing caesarean rates in more recent years. Very little of that has really helped the women and babies at the centre of the debate. The same is true in mental health, where we have swung from institutionalisation to care in the community without proper resourcing for either, and from stigma and silence to social normalisation, all without many material improvements for the people suffering from severe conditions. Quite often these pendulum swings tend to happen because there isn’t a proper debate about the right form of treatment: they are swift, knee-jerk reactions.
The social pendulum swing on mental health has been so extreme that a decade ago, people still weren’t particularly open about their illnesses. Today, they seem to turn up with worrying regularity as personality traits on dating profiles and as reasons someone can’t work. The happy medium between the two didn’t seem to exist: we went straight from prime ministers giving a mental health speech where they said some saccharine words about it being ok not to be ok and suggested the government might do something positive at some point, to politicians of all stripes now arguing that too many people are seeking diagnoses for things that really are personality traits or just the struggles of daily life.
Yesterday’s Fonagy review into mental health, ADHD and autism is an attempt to find the middle ground that no-one settled on in the rush from one end of the pendulum swing to the other. Prof Peter Fonagy was commissioned by then health secretary Wes Streeting last winter to look into why demand for the services treating these conditions is rising, and whether they are being over-diagnosed. His report finds that at a population level, the prevalence of these conditions is broadly stable, but that mental distress has ‘increased substantially among children and young people’. It recommends overhauling the diagnostic process for autism and ADHD (so that it is regulated by the Care Quality Commission) and banning direct advertising of NHS-funded ADHD and autism assessments so that people have confidence that their assessments are high quality as opposed to just giving them what they want.
It is a nuanced report that very much pushes against the tendency in today’s mental health discourse to regard a diagnosis as a destination or reason that someone can’t do something. That sense of futility hasn’t been helped by the poor availability of care for people with mental health and neurodevelopment conditions, which suggests that they really can’t recover from or learn to live a full life with the problem they’ve been diagnosed with. The reaction that is building in the popular debate to this is to suggest that people who really are struggling are just making it up, and a pendulum swing return to the stigma of decades gone by. It would be far more productive if, for once, we managed to settle on the middle ground.
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