Hygenia Legere works in NHS mental health services in London. Hygenia Legere is a pseudonym.
Valdo Calocane was an unwell man. He had been involuntarily detained in hospital four times, believed that MI5 was spying on him, which caused him immense distress. He had an existing warrant out for his arrest when he stabbed three people to death in Nottingham last summer. “Mental health services should deal with it” is the most thought anyone seemingly gives to this social problem.
The reality, however, is that community mental health services are limited in what they can do for people like Calocane living with serious mental illness. The Mental Health Act requires us to assume capacity for any decision-making unless demonstrated otherwise through an assessment per decision that is impossible to perform if the client is not willing or able to sit through it.
The effect is that people with complex conditions where their ability to make any decisions is impaired, intermittent, or informed by poor insight, are frequently left to their own devices, filling the 167 hours as they see fit before their keyworker checks in on them once a week, unless something “serious” warrants further investigation. Miss that appointment because your client is asleep (a common side effect of medication and a lack of routine), out (because they visit their friends), or just doesn’t want to see you, and those 167 hours stretch into weeks.
Even if your client is willing to engage with you in that one hour, there is little you can do but set some goals for them to do in the rest of the week. I cannot make anyone remember to take their medication every day. I cannot force anyone who doesn’t think their meds make them feel better, to take them every day. The threat of being hospitalised has a motivational effect on some, but for many others, lacking routine, life goals, or a reason to get up in the morning besides “chilling”, as many of them describe it to me, hospitalisation presents little to no disruption to their lives.
For some, being in hospital is a break from the hustle. There are people to talk to with shared life experiences, there is a timetable of activities, your food is provided, your clothes are washed, and a nice nurse will come to you morning and evening and watch you take your medication. You do not have control of your life and, for many people living isolated battles with their minds, a hospital is a safe place where they don’t have to deal with things like TV licenses, food shopping, and what to fill the long, long hours within an evening.
Asylums have an extraordinarily bad rep but the institutions we once built to house people with mental health problems were intended as a solution to a problem – some people are so severely mentally ill they cannot be cared for in the community. Bethlem, the original asylum, was not locked. Residents could freely move around the building and the local area unless they were deemed a risk to themselves or others.
The incredible cost of this system – and the principle that developed that no-one, no matter how persistently ill, could be regarded as incurably insane – meant that all of the people who had known safety and security within those hospitals, were moved out into the community to participate in a ladder of recovery. The effect has been devastating.
It is a well-known if rarely aired truism among older community mental health workers that the closure of long-term psychiatric hospitals and then the day hospitals for people with intractable mental illness was one of the worst things that ever happened to many of the people who needed them. It is not kind to keep trying to sign someone up for a music class to “engage them in the community” when they can’t sustain the most basic blocks of Maslow’s Hierarchy.
The possibility that someone who has lived with barely treated psychosis for twenty years may not ever be a functioning member of their community is heresy. The idea that someone with a history of abuse and abandonment may never be able to live by themselves without the lifelong support of an institution, is not permitted. Someone in the thrall of a decade-long addiction amid a cloud of acquisitive crime that is steadily destroying them isn’t considered to be in crisis at all.
The consequence is that it is residents of social housing who are required to tolerate people who are miserable, short-sighted, and antisocial, with no help whatsoever from those in authority. “They’ve got mental health problems” is considered an explanation that takes no questions.
As Henry Hill noted in a recent article for the Daily Telegraph, this is also an extraordinarily expensive system, with the costs of emergency callouts, hospitalisations, this supported accommodation, that arrest, these key workers, distributed across multiple budget lines meaning that the costs of caring for these people who are unhappy and unwell are hidden away so no-one ever has to take responsibility for the fact that the system is failing them.
The financial cost may be hidden, but every so often with cases like Valdo Calocane, we are reminded that it can also be measured in human lives.
Hygenia Legere works in NHS mental health services in London. Hygenia Legere is a pseudonym.
Valdo Calocane was an unwell man. He had been involuntarily detained in hospital four times, believed that MI5 was spying on him, which caused him immense distress. He had an existing warrant out for his arrest when he stabbed three people to death in Nottingham last summer. “Mental health services should deal with it” is the most thought anyone seemingly gives to this social problem.
The reality, however, is that community mental health services are limited in what they can do for people like Calocane living with serious mental illness. The Mental Health Act requires us to assume capacity for any decision-making unless demonstrated otherwise through an assessment per decision that is impossible to perform if the client is not willing or able to sit through it.
The effect is that people with complex conditions where their ability to make any decisions is impaired, intermittent, or informed by poor insight, are frequently left to their own devices, filling the 167 hours as they see fit before their keyworker checks in on them once a week, unless something “serious” warrants further investigation. Miss that appointment because your client is asleep (a common side effect of medication and a lack of routine), out (because they visit their friends), or just doesn’t want to see you, and those 167 hours stretch into weeks.
Even if your client is willing to engage with you in that one hour, there is little you can do but set some goals for them to do in the rest of the week. I cannot make anyone remember to take their medication every day. I cannot force anyone who doesn’t think their meds make them feel better, to take them every day. The threat of being hospitalised has a motivational effect on some, but for many others, lacking routine, life goals, or a reason to get up in the morning besides “chilling”, as many of them describe it to me, hospitalisation presents little to no disruption to their lives.
For some, being in hospital is a break from the hustle. There are people to talk to with shared life experiences, there is a timetable of activities, your food is provided, your clothes are washed, and a nice nurse will come to you morning and evening and watch you take your medication. You do not have control of your life and, for many people living isolated battles with their minds, a hospital is a safe place where they don’t have to deal with things like TV licenses, food shopping, and what to fill the long, long hours within an evening.
Asylums have an extraordinarily bad rep but the institutions we once built to house people with mental health problems were intended as a solution to a problem – some people are so severely mentally ill they cannot be cared for in the community. Bethlem, the original asylum, was not locked. Residents could freely move around the building and the local area unless they were deemed a risk to themselves or others.
The incredible cost of this system – and the principle that developed that no-one, no matter how persistently ill, could be regarded as incurably insane – meant that all of the people who had known safety and security within those hospitals, were moved out into the community to participate in a ladder of recovery. The effect has been devastating.
It is a well-known if rarely aired truism among older community mental health workers that the closure of long-term psychiatric hospitals and then the day hospitals for people with intractable mental illness was one of the worst things that ever happened to many of the people who needed them. It is not kind to keep trying to sign someone up for a music class to “engage them in the community” when they can’t sustain the most basic blocks of Maslow’s Hierarchy.
The possibility that someone who has lived with barely treated psychosis for twenty years may not ever be a functioning member of their community is heresy. The idea that someone with a history of abuse and abandonment may never be able to live by themselves without the lifelong support of an institution, is not permitted. Someone in the thrall of a decade-long addiction amid a cloud of acquisitive crime that is steadily destroying them isn’t considered to be in crisis at all.
The consequence is that it is residents of social housing who are required to tolerate people who are miserable, short-sighted, and antisocial, with no help whatsoever from those in authority. “They’ve got mental health problems” is considered an explanation that takes no questions.
As Henry Hill noted in a recent article for the Daily Telegraph, this is also an extraordinarily expensive system, with the costs of emergency callouts, hospitalisations, this supported accommodation, that arrest, these key workers, distributed across multiple budget lines meaning that the costs of caring for these people who are unhappy and unwell are hidden away so no-one ever has to take responsibility for the fact that the system is failing them.
The financial cost may be hidden, but every so often with cases like Valdo Calocane, we are reminded that it can also be measured in human lives.