OpenMind 97, May/June 1999
Falling through the net... or deliberately jumping?
By Rachel Perkins
We frequently read criticisms of mental health services that allow people to ‘fall through the net.’ The image is of a set of services with holes between them into which ‘poor unfortunates’ accidentally descend. In response to these ‘falls’, service solutions like ‘discharge under supervision’ and ‘assertive outreach’ are portrayed as ways of preventing such supposed mishaps.
Twenty years’ acquaintance with the mental health system and its recipients indicates to me that this conceptualization is very misplaced. I would suggest that a great many of those who are supposed to have accidentally 'fallen through the net' have in fact very actively and purposefully jumped through any hole they could find to escape the attentions of a system to which they are singularly averse. To my mind, this is yet another example of the prevailing perspective that people with mental health problems are the passive recipients of services offered. People who have to be forced to accept what experts think they need... for their own good, of course. As Patricia Deegan says, “people do not ‘get cured’ and ‘get rehabilitated’ in the way that television sets ‘get repaired’ or cars ‘get tuned up.’” (1)
But does it matter whether we see people as passive recipients or active agents? Well, yes, it does. If we think of people unwittingly falling through holes in nets then the obvious questions revolve around how to block the holes. And solutions to ‘the problem’ invariably take paternalistic and controlling forms. If, on the other hand, we see people as actively escaping a system they find objectionable, then a different set of questions spring to mind. What is it about the services they decide to escape from? How could practices be changed to provide them with what they want? Might not the very idea of being ensnared in a net be unacceptable? Of course, this latter analysis is more difficult and searching for service providers to take on. It raises the possibility that we may actually be doing something wrong, despite all our expertise. The people who escape our attentions change from being poor hapless souls, who must be protected from accidentally failing to receive the help they need, to active citizens with important and valid opinions and wishes that must be addressed. Attention shifts from exploring ways of making sure people get what the experts think is good for them, to exploring ways in which these experts are failing to address needs and concerns as defined by the recipients of their ministrations.
I have often felt like giving users of services the advice ‘if you want something, ask for the opposite.’ So, for instance, if you want the attentions of a professional, refuse to see them... then you stand a fair chance of being ‘assertively outreached.’ If you don't want to be seen, then persistently telephone and demand a visit... and then you can be ignored as ‘attention seeking.’ This way the services can remain ‘in charge’ and dictate what you do.
Beliefs run deep that the expressed opinions of mad people should be discounted as manifestations of madness. Numerous Inquiry reports precipitated by murders committed by people with mental health problems show that, at some point, the person asked for help... and was sent away... only later to be compulsorily detained. Could it not be the case that the best way of ‘increasing public confidence’ in mental health services is actually listening to what mad people say they want - and heeding our requests? Might this not be a better way of increasing the confidence that both the mad and the sane public have in the services available?
(1) Deegan, P. (1988) ‘Recovery: The lived experience of rehabilitation.’ Psychosocial Rehabilitation Journal 11, 11-19.