Bullshit redux or Guru Syndrome
Last year Cambridge University’s mental health service was severely criticised (‘ineffective’, ‘untargeted’ and ‘unsustainable’) following the deaths of five students in a six month period.[1] The situation made the national news and the University reported that it had ‘embarked on a significant programme of change’ because "we wanted to be really confident that what we were doing was the best we could possibly do for our students".
There’s also been a recent spate of high-profile scandals involving neglect or abuse at mental health institutions following an exposé by Panorama of conditions at a psychiatric hospital in Manchester.[2] Cue strong statements from across the mental healthcare community, like this: “The Royal College of Psychiatrists is alarmed by the disgraceful scenes on Panorama showing unacceptable behaviours towards vulnerable adults with a mental illness…We absolutely deplore what we saw, it was inhumane and simply unacceptable. These patients have been failed by mental health services”.
Of course, everyone is upset when they hear about things like this, it’s shitty beyond words that young people kill themselves or that people suffer abuse in care environments but there’s something very bogus about the way this gets treated.
For a start, there’s the pretence that these are outliers. There’s no real justification for singling out Cambridge’s mental health services: it’s comforting to imagine that the organisational failings identified here were exceptional but it’s not true – a few months ago a coroner criticised Exeter University’s wellbeing service for serious shortcomings, which included an inability to respond to urgent attempts to contact it due to IT problems.[3] Mental health services are not well-run organisations. It’s very likely that the death rate at Cambridge was more to do with it being Cambridge: too much expectation, too much pressure, too much insecurity, too many kids from abroad away from home, just altogether too much.
What’s also bogus is the implication that this will all be made OK by following the recommendations of a review. ‘Really confident …the best we could possibly do for our students’ sounds like something really good is going to be provided. The assurance that makes you feel derives from the idea that mental healthcare knows what it’s doing (in the same way as, say, oncology or orthopaedics) and that its treatments are effective. But that’s not true: when the NHS treats people suffering from anxiety and/or depression, three out of four don’t get better.[4] So the impression, which mental healthcare professionals are happy to foster, that mental health treatment is reliably effective is pretty dishonest, or bullshit.
Even that outrage from the Royal College of Psychiatrists doesn’t sit entirely well. It is extremely difficult to care for people who have serious mental illness: it is not the same as oncology or orthopaedics. These patients are people whose own families - the people who were supposed to love them most – couldn’t be with them. It’s naïve to imagine that everything could be made OK by putting them in the hands of strangers on minimum wage levels. Not that it’s not simply a matter of money in the system: one of the exposé films was of a dementia patient being abused in a private care home reported to cost nearly £100,000 a year.[5]
If mental health professionals were genuinely surprised by what these reports revealed, they must have been very distanced from front line care and pretty selective about where they were looking round the system, they’re working in.
Pretence and self-deception aren’t confined to quality of care or outcome measures (effectiveness of treatment). There is something theatrical about that careful, thoughtful, modulated veneer of resolution which is so often a feature of the way mental health professionals present themselves. And that is, officially, how you are supposed to do it. The focus should be exclusively, and intensively, on the patient/client: it’s their therapy. Therapy should be a neutral, blank space into which the patient/client can bring the ideas and behaviours that are causing them trouble in the outside world; the clinician’s circumstances and experiences shouldn’t intrude into the room.
But, of course, the therapist is in the room and right in the patient/client’s face and the impression this tends to create is of an empathic but detached guide who is personally far beyond the issues being discussed in the therapy. You don’t get that same sense of being in the company of an exalted existence with your obstetrician or gynaecologist but they’re also trying to fix you.
There is a certain logic at play here: regulation of emotion is a fundamental feature of mental illness, so you might plausibly expect a studiedly thought-through approach to be something to do with health. There just isn’t any hard evidence to support that as an element of effective treatment of mental health issues. But the thing is, it looks good. It’s a very seductive idea: to be imperturbable like that, above the fray. Isn’t that’s how they always portray heaven - peace, certainty, serenity?
And, actually, this, this idea of what mental health looks like is mental healthcare’s care’s most successful export. 20% of the adult population in England may be on psychoactive medication[6] but this is much more influential in terms of culture and the ideas surrounding us. Clinicians themselves forget it’s just a presentation that was developed for the consulting room and try to inhabit it more completely. It’s become as tied up in aspirational lifestyles as the gym-body: no picture of success is complete without the dispensation of guru style psychology-based insights and tips. When everything else is taken care of, head towards self-improvement, as if you could acquire a resolved self like a Miele kitchen.
The problem is what they’re after isn’t real. It is based on something which is just a clinical technique or, in fact, a by-product of a clinical technique (for which there isn’t even any hard evidence) which was adopted for treating mental health problems. It is theatrical. It’s a role. No-one is really like that. It’s bullshit.
At some level, wishful thinking is at the root of all mental health issues. It’s about difficulty coming to terms with reality: delusion, fantasy, fairy stories, lack of self-awareness, repression, defences, denial, inauthenticity, pretence. And our approach to mental health is full of wishful thinking too: wishful thinking about what we know about mental illness and how effective we can be at responding to it.
Last month a 17-year-old was convicted of manslaughter after stabbing an Afghan refugee his age in a London park.[7] Just hours before the stabbing, the defendant had received a youth rehabilitation order at the Magistrate’s Court as a result of being found with a knife a couple of months earlier. It was reported that he had attacked two other young offenders whilst in remand and bragged about one of the incidents in a phone call like this: “Me and (the other youth) got into a scrap with some youth from Luton. We fuck him up, he’s still in hospital.” What do you do with that? I don’t know but mental healthcare professionals and social workers are generally quite happy to go along with the impression that they do.
So it feels as if it can only be a string of incredible, catastrophic failures that could have resulted in the reports last week of the discovery in her home, three years after she died, of the mummified body of a 38 year old woman who had suffered from schizophrenia.[8] There was string of failures but it’s a different perspective if you’re led to believe there was something that should have saved her, should have made things OK, and she was deprived of it. To her family, who were unable themselves to help her and from whom she had become completely estranged, the only possible explanation is a complete failure of support for her mental health. Because they are under the impression that there was some form of effective support available, that things could somehow have been made OK by experts and professionals.
And you get Harry and Meghan receiving human rights awards from New York socialites for telling the Royal Family they couldn’t maintain their misunderstanding about mental health.[9] Because somehow, everyone’s got the idea there is an understanding (and good people get it, even if they can’t actually tell you what it is).
A degree of guru syndrome is unavoidable in this territory. Telling people about themselves (it’s in this piece too) is intoxicating because there’s a vein of superiority involved which can easily get enlisted into defending against the same ideas which plague people who suffer from poor mental health – ideas about incompetence, not knowing what you’re doing, not being good enough. And it’s empty because three-quarters of the adults the gurus treat don’t get better and a 2022 systematic review concluded there’s no evidence that the interventions made during childhood have any long term effect (and long term here just meant beyond two years): ‘the long-term benefits of psychosocial and pharmacological childhood interventions appear to be small at best, while long-term harms of pharmacological and psychosocial treatments cannot be ruled out’.[10] So, mental health professionals should and, somewhere do, feel at least as incompetent in their professional lives as their patients and clients do in most aspects of theirs.
Psych responds to that the same way people do: by trying to avoid confronting its own feelings of incompetence. Sometimes it outright says it knows things it doesn’t or claims to be more effective than it is.[11] More often, it just allows that impression to be created that there are, somehow, solutions somewhere behind the scenes and its just a matter of resources. And as well as exaggerating its effectiveness, it sanctifies itself: according to the literature they produce for themselves, mental health professionals are invariably motivated entirely by a desire to help, to reduce suffering and they represent a perpetually undervalued, unacknowledged but absolutely vital resource for society, selflessly supporting countless people who would go under without them.
In the same way as teachers risk becoming infantilised by spending all day with children, mental healthcare falls into the same hole as the people its dealing with. Mental healthcare professionals are meant to be the experts at looking under the bonnet, uncovering the dirty scraps of motivation people don’t want to acknowledge and own. But Psych’s picture of itself is superficial and self-serving (whilst holding other people, who are often in great distress, to account, scrutinising them to make them recognise truths about themselves they don’t want to see).
There’s something a bit repulsive about that but the cruellest aspect is the effect on people when they start to realise they’ve been misled. No-one comes to help, like they always imagined would happen, because there isn’t any help, not in the way they were invited to think there was. Here’s an award-winning essay by a young journalist about encountering mental healthcare when suffering from serious mental illness and discovering there’s nothing really there.[12]
This is an extract from a post on social media a few days ago by a woman whose partner is suffering severe mental health issues:
‘My partner is now at the point where he feels he can no longer deal with this alone. I have tried to help and be there to support but ultimately there’s only so much I can do..
Where are the mental health services? Where are the nhs?
I’ll explain!
We’ve been to the hospital, we’ve called and ambulance.
We’ve asked for him to be assessed.
I’ve called 111 because he’s fallen into a state on the floor after falling off the toilet head first.
The response:
“Go back to your gp, they will be able to help you if he’s not feeling well”
I am a mother of three girls who are watching their dad struggle and there is nothing I can do the stop it.
We’ve got sertraline, makes him feel worse and doesn’t stop the attacks.
We’ve tried everything.
I now have to find £400 for a decent psychiatrist because no one will deal with him as he’s not an emergency.
I now have to try to find money to pay for a scan of his head to make sure this isn’t something medical because the gp won’t get him looked at because his bloods were ‘fine’
When will I get help??
When im burying my children’s father myself because he’s had enough of not knowing what’s wrong with him?
Because he feels trapped in a mind that isn’t working how it should be?!
Where does it end for him?!
Does it end for him?’
[1] https://www.bbc.co.uk/news/uk-england-cambridgeshire-62306091
[2] https://www.theguardian.com/commentisfree/2022/nov/10/england-mental-health-services-compassion-scandals-patients
[3] https://careappointments.com/education-training/187692/coroner-criticises-university-for-failing-to-respond-to-students-cry-for-help-before-death/
[4] See https://jonathancoppin.substack.com/p/a-sanity-test-for-talking-about-mental
[5] https://www.theguardian.com/society/2022/oct/13/ann-king-video-abuse-reigate-grange-care-home-surrey
[6] More influential in terms of culture and the ideas surrounding us than the psychoactive medication used by 20% of the adult population of England
[7] https://www.theguardian.com/uk-news/2023/jan/24/manslaughter-verdict-17-year-old-stabbed-afghan-refugee-twickenham-london-park?CMP=Share_AndroidApp_Other
[8] https://www.theguardian.com/uk-news/2023/jan/26/woman-lay-dead-in-surrey-flat-for-more-than-three-years-hearing-told
[9] https://www.telegraph.co.uk/royal-family/2022/11/19/duke-duchess-sussex-receive-human-rights-award-heroic-stand/
[10] https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13677
[11] See
or https://jonathancoppin.substack.com/p/are-mental-health-professionals-crooks
[12] https://www.theguardian.com/society/2018/jun/30/nothing-like-broken-leg-mental-health-conversation