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Time to Change

It has been a special but sad experience to attend, in the last couple of weeks, a number of events to mark the end of Time to Change, the phenomenally successful programme which, since 2007, has been working to challenge mental health stigma and discrimination in this country. I had the honour, while I was at Rethink Mental Illness, of being closely involved in the establishment and development of the programme.  There is nothing I have done in my career which is more significant.

In sharing some of my thoughts about Time to Change it is right to start with the numbers.  Between 2007 and 2018 Time to Change achieved a 12.7% improvement in attitudes.  That is equivalent to 5.4 million people with improved attitudes.  That is a phenomenal level of change for a programme of this kind, especially one operating in an area where attitudes were seen as entrenched and constantly reinforced by negative stereotyping in the media.

These numbers are very much borne out in the reality of public discourse where it feels that there has been a sea change in the public willingness to talk about mental health and to accept those who are affected by mental health problems.  The programme has also always been concerned that any improvement in attitudes translates into improved experiences for those affected by mental health problems.  The reported experience of discrimination has always been a key part of the evaluation of the programme which fell by 11.5% over the first phase of the programme between 2007 and 2011 and which have shown further improvements since.

Success was not always guaranteed and there were many who were sceptical of the ability of such a programme to make a meaningful or sustainable difference.  After all attitudes towards mental illness, which had been tracked consistently in this country since the 1990s had either been static or declining.

The programme, however, got some important calls right.  I want to pick three, in particular.

There first was to base the programme on a commitment to partnerships.  Historically the sector had been very fragmented with a tendency to compete rather than collaborate.  The decision of the two largest charities in the sector Mind and Rethink Mental Illness to work together on the programme, rather than pursue separate initiatives, was significant as was the commitment of the rest of the sector to rally behind Time to Change.

Just as significantly there was a risk that the experiences of different types of mental illness might be seen as inimical to each other with a suspicion, for instance, that while it might be possible to shift public attitudes around anxiety and depression it would never be possible to do the same for schizophrenia.

Time to Change took the bigger picture and committed itself to the view that all aspects of mental illness would benefit from a shift in public attitudes.  For the most part that has been borne out.  This was not a case of picking easy middle of the road messaging with the aim of avoiding upset.  The programme made a conscious effort to deal with different narratives of lived experience.  I was particularly proud of the advert “Schizo the movie” which deliberately spoofed the horror film portrayals of mental illness only then to cut through to the everyday experience of someone living with schizophrenia preparing their breakfast.

A commitment to partnership also extended to thinking about the message of Time to Change was taken out into communities, workplaces and schools.  The Time to Change pledge, signed in the end by 1556 organisations employing 4 million people, was indicative of this approach.  Indeed, the world of work has been one of the areas where some of the greatest shifts in attitudes have occurred.  In 2006 a survey of employers by the Shaw Trust indicated that 41% of employers thought there would be nobody in their workplace affected by mental illness.  By 2010 that figure has fallen to 11%.

The second choice related to the commitment to evidence and evaluation.  The programme deliberately took account of the learning drawn from other international anti stigma work such as that in New Zealand and Scotland.  However, the decision to invest substantially in the evaluation of Time to Change was crucial to the sustained funding of the programme and to decisions about its direction and strategy.

The third and most important choice was to put lived experience at the heart of the programme.   The whole model of change for the programme was grounded on the principle of connecting people through the currency of personal stories of mental health problems and on the premise that where people knew others in their circle of families and friends their attitudes towards mental health problems tended to be more positive. 

It still takes some courage to share a personal experience of mental illness but that was so much more the case in 2007.  The bravery of those who first told their stories, both celebrities such as Stephen Fry, Alistair Campbell and Ruby Wax but also many ordinary people was so crucial in building the messaging and impact of Time to Change.  Those who made the first move opened the doors to others and there followed a flood of individuals in many different sectors of life:  sport, politics, business to name a few who stood up to share their own experience. As I know from our own family experience the normalising of conversations about mental health is, in its own right, a powerful therapeutic intervention.

As Time to Change comes to an end I have a number of reflections.

As I said, at the start of this blog, there is an enormous sense of privilege in being involved in such an important initiative and with such a special group of people.  Time to Change should not take all the credit for the change in attitudes towards mental health and the increased political priority and funding which has followed.  Its role, as a standard bearer for change, however has been undeniable.

Next there are lessons which can be drawn from what has been achieved in reducing mental health stigma and discrimination by those campaigning to deliver change in other areas such as poverty and race equality. 

Finally, there is the recognition that, despite what has been achieved, there is still much to do to tackle the stigma and discrimination relating to mental illness.  It is still time to change.

A long year – lessons from the pandemic

Anniversaries are always important times for reflection.

It’s been a year now since pandemic took hold and the decision was taken to start the first lockdown.  It’s almost hard to recall how dramatic those events were and how normal the constraints and reality of the last year have become.

In this country at least the pace of vaccination and the fall in the number of cases points to the possibility of moving out of lockdown and returning to some kind of life beyond the pandemic by the summer.

To mark that anniversary, I wanted to highlight some of the personal and professional lessons have I learnt from the last 12 months.

 It would not be an understatement to say that it has been a challenging time for most of us.  The worst of it, from a personal perspective, was the loss of my mother, last June. The issue was not so much the fact of her death in itself, she was 92 and had dementia.  Rather it was the impact the pandemic and the lockdown restrictions had on the quality of her last months of life and the constraints it placed on our ability as a family to be with her at the end and to mark her passing with the normal rituals of grief. Many families have been through the same or worse.

In other respects, I have been lucky.  I and the rest of my family have kept well.  I have continued in employment and have been able to adapt pretty easily to working largely from home.  While it has not been an easy year for my children, they are grown up and have not had to experience the major disruption to education and life chances that others have had to cope with. 

So, what are the wider lessons from what we have been through.

The first is to acknowledge the positives of how we have collectively coped and adapted.  I have seen that very clearly in the NHS where I work.  Staff have moved mountains to continue to care for patients, despite unprecedented levels of need and major practical and emotional stresses, and in some cases heightened levels of personal risk, in doing so. The same is true of many public services, in the fullest sense of the word, which have kept the essentials of life going through the last year.

That is not to ignore the mistakes which have been made. I, for one, favour some kind of public inquiry into the pandemic, not because I want to find scapegoats but because it is crucial that we learn the lessons of what has happened.  One thing that is clear is that, as a country, we were not adequately prepared for the pandemic and it would be negligent to assume that this kind of threat will not happen again, even if we emerge relatively soon from the acute phase of this crisis.

So, beyond the general experience what have been the more specific lessons.  I want to pick out three.  There are, of course, many more.

The first is inequalities.  The pandemic has highlighted very graphically the extent and impact of inequalities in Britain.  Mortality from Covid 19 has been much higher in minority ethnic communities and, for all sorts of systemic factors, the burden of the pandemic has fallen heavily on poorer socio-economic groups.  The pandemic has highlighted the economic fragility of many individuals and families dependent on benefits or low paid and insecure employment.  While the short-term measures taken by the Government to alleviate the economic consequences of lockdown have been significant and welcome there is real risk that the longer-term economic consequences of the pandemic will be felt disproportionately by lower income families and that inequalities are, as a result, further increased.  We ignore this at our peril.

My second lesson is around the importance of local places and communities.  In the last 12 months I have spent more time in the place I live than any time since the 1970s.  On the whole it has been a positive experience which has made me much more appreciative of my immediate surroundings.  I hope the world after the pandemic will have more of a local focus and that the move to blended models of work will allow us to eliminate the need for many unnecessary journeys. 

However, there will also be challenges.  It is hard to know exactly how radical the changes will be in our patterns of living and what the consequences will be for the physical infrastructure of our cities and towns.  Many urban places owe their origins to being focal points for trade and exchange and this could be under a profound threat if the shift from the high street to online commerce accelerates further.  There is again a real threat that such changes will further exacerbate inequality and impact disproportionately on communities that have already been hollowed out as a result of deindustrialisation.

My third point relates to the media and the quality of public discourse.  The pandemic appears to have worsened a trend towards an ever more polarised and intolerant level of public debate.  The voracious appetite of the media to fill a 24-hour news cycle and the impact of social media has fed on and fostered a collective sense of anxiety.  We need to reflect on what we can do to correct this and to create a space where facts and the nuance of legitimate difference between points of view are given greater prominence.

Like wars, the pandemic has been a collective period of trauma.  How we deal with the aftermath of that experience will have much to say on what its long terms consequences for our society will be.  Good things can come out of bad experiences.  The First World War gave women the vote, the Second World War gave us the NHS and the modern Welfare State.  What is it that we most want to create as the legacy to the pandemic and what is our collective will to create it?  That is the big question for the next 12 months.

The Dig

Like many others I enjoyed the portrayal of the discovery of the Sutton Hoo burial in the Netflix film “The Dig”. Sutton Hoo remains one of the most spectacular archaeological discoveries in this country and its circumstances need little elaboration to make excellent drama.

When I was at University, I was involved quite a lot in archaeology.  Watching “The Dig” reminded me of some of what was very special about excavation and the world of archaeology.  This blog shares some of those reflections.

Archaeology is an interesting discipline: one third craft, one third science, one third poetry. 

The aspect of craft is epitomised by someone like Basil Brown, the self-taught local archaeologist in “The Dig” whose knowledge of landscapes, and above all soils, and mastery of the  technical skills of excavation are more than a match for his academic (and social) superiors.  I was lucky enough to work alongside real craftsmen on some of the excavations I attended.  Those were the days when the archaeological workforce was often a mixture of students, like me, and unemployed people on Manpower Services Commission schemes.  One individual, in particular, stands out in my memory, the neatness of whose digging and the clarity of the features he exposed was outstanding.

Science is also central. Archaeology is many ways a magpie discipline using wider developments to help address its own questions and there have been big developments since the time I was involved in excavations. 

The secret to archaeological interpretation is stratigraphy and the ability to distinguish different layers of activity on a site and to date them by linking them to an independently verifiable point in time.  The introduction of radiocarbon dating at the end of the 1940s was the major breakthrough in this respect and over time the sophistication of this techniques and other approaches to the scientific dating of artefacts have increased enormously.

Similarly geophysical surveys have opened up the ability to explore sites without invasive excavation which by necessity destroys the evidence it is investigating.  While much archaeology these days is done in advance of development there is sometimes a question about whether it is the right thing to open up a site or whether it is better to wait until the development of techniques allow less invasive exploration. 

Finally, there is the poetry.  Archaeology is inevitably partial in what it can tell us about the past.  There is an enormous space for interpretation which still requires imagination and creativity. From my experience much of that task is carried out in the pub.  I have very fond memories of evenings listening, over a few beers, to lively debates about the meaning of what the finds on the site we were excavating meant in terms of the activities of our ancestors.  There was a particular frisson to discussions around features described as “ritual”.  In part it was an archaeological catch all term for things for which there was no practical explanation for what has been found, but it was also a lovely reminder of how our species has always been interested in more than the utilitarian aspects of life.

I have three other observations about archaeology and how it has helped shape, for me, a wider view of life.

The first relates to the issue of migration.  One of the constant challenges for archaeological interpretation, in particular in the absence of historical records, is whether changes in material culture are the product of the movement of people or just of ideas and objects.  With the growing precision of DNA analysis this debate has become more sophisticated.  Whatever the events in any given period the archaeological record highlights the ubiquitous nature of movement and exchange as the catalyst for human development and challenges the simplistic concepts of national identity.

The second is the democratic impact of archaeology.  While the eye may be captured by high status discoveries such as Sutton Hoo, most archaeological discoveries relate to ordinary activities and ordinary people, people who, in most periods, would have left no other record of their lives.  Archaeological discoveries have broadened our understanding of periods with no or only limited historical records and of people and activities that would otherwise have remained invisible to us.  Those discoveries have helped us to rebalance our understanding of certain periods and corrected some of the inevitable  biases of historical accounts.

The final observation is how much archaeology has to do with death.  Burials and burial rituals, such of those of the ship at Sutton Hoo, form a major part of the archaeological record.  They cast a light on the most significant event for any of us and the beliefs which different generations and communities have had about the meaning of death, what might come beyond and the ongoing presence of our ancestors in the world.  Those windows into the beliefs of those who have gone before about death and mortality can help us in how we interpret that most inevitable reality of our own lives.

The highlight of my archaeological career was when I was given the chance to excavate the central burial in a Bronze Age round barrow at a site just outside Radley near Oxford.  The burial contained an intact beaker pot, one of the most iconic objects from any period of history, and the skeleton of a young child.  It was a very profound moment to have the privilege of contemplating, at the remove of several thousand years, another life, cut short all too early but nonetheless special. It is memory which will live with me all of my life.

The Matter of Wales

Few writers understand the issues of identity better than the late Jan Morris and nowhere more so than in her descriptions of Wales and Welshness.  In this she demonstrates a lovely ability to think of Wales from both “inside”, proud of her own Welsh identity, but also from “outside” in an observant and detached way bringing out the essence of this place and its people. Inspired by that example I thought I would have an attempt, for this St David’s Day blog, of offering my own reflections about the character of Wales.

Like Jan Morris my Welsh identity has an element of inside and outside.  Like her I have a Welsh father and an English mother.  I have never lived in Wales, but I have visited Wales virtually every year of my life (2020 for obvious reasons being one of the few exceptions).  I have routinely mixed with Welsh family and friends and have, as an adult, learnt the language which every previous generation of my Welsh family has been able to speak.  And yet I can also approach Wales with the eye of other identities.

There are many aspects of Wales it would be possible to comment on but for this blog I want to pick out four.

The first is size.  By any standards Wales is a small country.  Yet within a small country there is a remarkable diversity of places, landscapes, people and identities.  The geography of the country reinforces this with mountains often protecting the separateness of different communities. It is a long-held truth that it is easier to get from South to North Wales via England than directly through Wales, but that sense of very local identity goes much deeper.  It is a special quality which contributes to the distinctive beauty of the country although it has perhaps not always helped our attempts at self-government.

The second, perhaps related, point is around the sense of community.  This is a palpable part of Welsh identity and Welsh politics.  It is not surprising that the two politicians who played the greatest part in establishing a universal system of health care in the United Kingdom, David Lloyd-George and Aneurin Bevan were Welsh.  My father was always proud that, despite the wider material poverty he experienced growing up in the Rhondda in the 1930s, that his community had organised a system of access to healthcare, funded by contributions from other working men years before the establishment of the NHS.  It is, for the most part, a country with a concern for the poor, disabled and disadvantaged. 

The third is a love of music and poetry.  Whether in eisteddfodau or on the rugby field Wales is indeed “Gwlad beirdd a chantorion”, “a country of poets and musicians”.   At the same time, culture, has, for the most part, a more democratic feel in Wales than in some other places and it is a country which is happy to see those who excel in poetry and music as some of its greatest lights.  

My final point is around a sense of the past.  It is not difficult to feel close to the past in Wales and I always have a strong sense of the ghosts of previous ages and people when I travel round the country.  More than other countries the history of Wales is, in part defined, by a strong sense of clinging onto to a place and identity which could so easily be washed away by the tides of the modern world.  Dafydd Iwan’s alternative Welsh National Anthem “Yma o hyd” epitomises this with its rousing chorus “er gwaetha pawb a phopeth ry’ni yma o hyd” “despite everyone and everything we’re still here”.  Nothing characterises this more than the battle to maintain the Welsh language which, as the defining achievement of Welsh nationalism, has succeeded in defying the gravity of history.  

So where does Wales find itself in 2021, after 20 years of devolution and with the wider changes in the UK following Brexit.  I start by declaring my support, at present, for the maintaining the Union which I still believe is in the interests of all parts of the United Kingdom.  However, it is not something which can be taken for granted and there is no doubt that there is growing and genuine support in Wales for the idea of independence, reinforced by a strong sense that both Scotland and Northern Ireland are, post Brexit, on an inevitable course to leaving the Union and with a UK Government, for its own reasons, playing the card of English nationalism.

I have, by contrast, always been a strong supporter of devolution.  It has been a positive development in the last year for the distinctive actions of the Welsh Government to become more visible at a UK level.  For me the case for independence has to be made in Wales, through deeds and not just words and with a clear vision of what would be different about a separate Welsh state including how it would protect the economic interests of the country.  The desire for independence must never be just a function of the resentment of London based politicians and media.  

The real challenge for Wales and Welshness is how it can define itself confidently and proactively and not just in terms of its relationship with England.  In the past this has manifested itself in the establishment of distinctive Welsh ideas and institutions, of Welsh leaders such as Lloyd George and Bevan who can also be leaders of a wider nation and of cultural figures such as Dylan and RS Thomas who can hold their own on a wider stage. 

Wales can and should hold its head high in the modern world.

Mae hen wlad fy nhadau yn annwyl i mi.

What if there is life on Mars?

It has been difficult to avoid a sense of excitement about the landing of the Perseverance rover on the surface of Mars, particularly so when you’re part of that generation which grew up with the Apollo moon landings.  There is something totally compelling about the continuing story of mankind pushing the boundaries of knowledge of worlds beyond our own and the technical wizardry of landing and operating the rover at a distance of 130 million miles.  And then, this time, there is also the genuine possibility of finding evidence of other forms of life as the rover explores a part of the Red Planet which demonstrates historic characteristics which might have been capable, in the past, of supporting it.

In our imagination there are few more potent questions than that of the possibility of finding life beyond our planet.  In part this is a feature of man’s enduring curiosity, but it also points to a much deeper existential concern.  In particular as the presence of religion fades in our societies and our knowledge of the vastness of the universe increases the question of whether intelligent life has developed elsewhere or whether we exist in a peculiar isolation becomes ever more intriguing.

If Perseverance finds evidence of life it is likely to be extinct, a product of more benign times on Mars which may have been conducive to the development of life.  Nonetheless such a discovery would be immensely profound demonstrating clearly that the existence of life is not a singularity and that there might well be intelligent life elsewhere.

I am not sure this will be a question which will be answered in my lifetime, but the pursuit of an answer is profoundly fascinating.  However, at the same time, it is also worth asking what might it be like meeting another sentient form of life be like and what do other experiences in our history have to say about that?

The precedents are not that encouraging.  Whether it’s the extinction of neanderthals, the arrival of europeans in the Americas or more contemporary expressions of intolerance, our species can display a disturbing inability to co-exist peacefully with others and, just as frighteningly, an ability to justify our actions in doing so.  If we can not readily accept those of our own species with different skin colours, who speak different languages or practice different customs why do we think it will work out well if we were to meet aliens (itself a totally loaded word) from other worlds?

Science fiction, which I have always found quite a profound artistic medium, has provided some compelling insights into what that moment of meeting another intelligent species might be like. For instance, the iconic 1951 film The day the Earth stood still, while it uses the presence of extra-terrestrial visitors to communicate a wider message about the danger of nuclear weapons, creates a very powerful sense of the incomprehension and paranoia which might accompany an encounter with another form of intelligent life.  Even my favourite science fiction series, Dr Who is not short of examples of how ambiguous mankind might be in their dealings with those from outer space.  On many occasions it takes the Doctor with his greater intergalactic wisdom to counsel the Brigadier and other human characters from thinking that blowing them to smithereens is the only effective form of communication with aliens.

As our exploration of worlds beyond our own again gathers pace it will be important to reappraise our purpose and motivation in doing so.  Is this a matter solely of scientific exploration or will be quickly drawn into another phase of colonialism and exploitation, the legacy of which, on our planet, is so contentious?  We might be able to do both and if we are exploiting genuinely empty worlds it may not matter.  However, Columbus was seen initially as explorer and the principle of terra nullius (no one’s land) was used in a cavalier manner to justify great swathes of western colonialism.  If we ever meet another species will we again be drawn to exploit their resources, labour and freedom as we have done in our own world?

For me this also points to another aspect of the modern world.  We live in age of enormous technological development where, in so many fields, what we can do as a species has been transformed out of all recognition.  However, I am not sure that our moral science or systems of governance have kept up at the same pace.  Scientists, like the rest of us, can have clay feet and how we arbitrate what the consequences of scientific and technological discoveries has become increasingly difficult, especially in an increasingly interconnected and fast-moving world.  As a distinctively social species, Aristotle’s “political animals”, the systems of morality and collective decision making we put in place to govern our affairs are of crucial importance and justify just as much attention as scientific discovery and technological innovation.

I don’t expect to meet a man from outer space but the possibility of doing so and the establishment of clear purpose in our ventures to other worlds requires moral as well as scientific exploration.  While we are doing so, we could also ask ourselves the question of why, when we can land a rover on a planet 130 million miles away, we cannot tackle problems closer to home, for instance ensuring that every child has enough to eat?

Let us not forget

On the whole I have focused my interest in the history of the great conflicts of the 20th century on the First World War.  Exposed, as a young person, to the haunting imagery of the war poets and to first-hand accounts from relatives who took part in the conflict, the Great War has always represented for me the definition of the tragedy and, in part, futility of war.

This year during Lockdown I decided to refresh my knowledge of the Second World War, aided by Anthony Beevor’s brilliant and epic histories and, latterly, discovering the mesmerising accounts of the Russian wartime correspondent Vasily Grossman.

I have always had a reasonable knowledge of the key events of World War 2 but I rapidly realised, through what I have read this year, that there was something missing in my perspective of the conflict. 

I don’t think I am alone in this country in that respect.  In all my lifetime we have made a particular point of celebrating Britain’s contribution to the defeat of Nazi Germany as our “finest hour”. Significant while Britain’s role was, especially in the early years of the War, this picture fails to take account of the real scale of the conflict, the unbelievable horrors committed during its course and the phenomenal loss of life in other parts of the world, in particular in the USSR and China.

This was the bloodiest conflict in the history of human history, claiming at least 60 million lives across the World, including 20 million in the USSR (nearly 14% of the population).  While, with hindsight, the defeat of Nazi Germany (and Imperial Japan) can seem inevitable given the, eventually, enormous superiority of men and armaments put together by the Allies.   However, at the time, it must have seemed far less certain and many cases of individual sacrifice were required before victory was secured.

The Second World War also witnessed some of the most frightening and brutal examples of human violence and cruelty ever perpetrated.  Although the worst examples undoubtedly rest with the Nazi, and Japanese, regimes, few combatant nations passed through the war without something that might trouble the national conscience. This includes the mass pillage and rape carried out by victorious Russian troops in Germany or, in our case, the systematic area bombing of German cities.  In some cases, there was some justification, for instance in relation to the decision of Harry Truman to drop nuclear weapons on Japan but in other cases they were products of the brutality of total war.

At the same time, the Second World War witnessed phenomenal acts of bravery and personal sacrifice.  Vasily Grossman made his reputation through his coverage of the Soviet defence of Stalingrad.  In what must count as the fiercest battle in history, Grossman highlights examples of the desperate courage of Russian defenders which, perhaps, more than anything other one event, represented the turning point in the fortunes of the War.  Such courage is also displayed in respect of actions to defend Jews and other groups singled out by the Nazis.  When Grossman revisits his hometown of Berdichev in the Ukraine and discovers that 30,000 Jewish inhabitants, including his own mother, have been massacred he also reflects that those Jews who have survived have done so through the help of local Russians and Ukrainians who risked their own lives to offer protection.

No part of Vasily Grossman’s narrative is more moving than that which he wrote in the wake of witnessing the discovery of Treblinka, one of the first of the concentration camps to be “liberated”.  I have, perhaps, been guilty, at times, of thinking of the Holocaust in too detached a way.  There was something in reading Grossman’s account which brought out the raw and physically repulsive nature of what he witnessed as the absolute paradigm of human evil. There is no way we must ever let its memory fade.

The Second World War was different from the First.  In the First it is difficult, at times, to determine what were the ends which sent so many of Europe’s young men to their deaths.  In the Second, the ends are clear and there was an unassailable morale argument that, once the nature of Hitler’s horrific regime had emerged, action was required to stop it.  There was a moral challenge, however, at times through in respect of whether those ends justified all the means required to topple the Nazis.  A challenge brought to the fore by the need to collaborate with the evil of Stalin and his regime.

For the West at least, the aftermath of the Second World War has been much better than had been the case in 1918. Whereas the settlement of the First World War sowed the seeds of a further, more calamitous conflict, within a generation, Europe has managed, since 1945, to enjoy, with the exception of the wars in the former Yugoslavia, a period of unbroken peace.  One of the most significant figures during the War and its immediate aftermath was the American, George Marshall, Chief of Staff of the US Army and “organizer of victory” and, as US Secretary of State in Truman’s Government after the War, author of the eponymous Marshall Plan which did so much to contribute to European peace and prosperity.

Reading in more depth about the Second World War has reminded me of why the events of the last decade, and the echoes they have brought of the economic and political woes which led to the rise of Hitler and the horrors of that conflict have been so concerning. 

On this Remembrance Day it is right that we remember the enormity of the sacrifices which have been made in previous conflicts but also to remember what they were for and to do what we need to do, in our generation, to ensure that the World never has to witness again what it had to see in the dark years of the early 1940s.

We could just be happy

One of the most special parts of the day I spent, a couple of weeks ago, celebrating the centenary of the Tavistock Clinic was a session we had talking about involvement in the Trust.  A number of our service users who have been actively involved in the work of Trust attended the session and make some brilliant observations about their experiences. 

Something about the dynamics of it being a centenary event made it very different from other sessions of that kind with a much stronger sense of equality than usually exists between those who provide services and those who use them.

At the end of the session the question was posed about what our aspirations were for the next hundred years of the Tavistock’s work and indeed for mental health and mental health services, more generally.  One of our service users, Julie, struck me particularly with her answer “Perhaps, by then, we could just be happy.” 

Julie was particularly concerned by the impact of stigma on those who are struggling with mental health problems and how this significantly intensified the distress which people experienced.  The remark however opened, for me, a wider question of how, in both mental health services and in life more generally we deliberately create an environment which gravitates against wellbeing and encourages mental distress.

I wanted to draw out a couple of points.

One of the words I have heard most often from people who use services is that of judgement.  How, whether in their experience of services or in their wider lives, the sense of being judged has added to their distress and, by converse, how opportunities they have had to engage in non-judgemental therapeutic relationships or other activities have been central to their recovery. 

Linked to this is the issue of expectations.  Positive expectations can, at times, be a very positive thing, giving people the confidence to move forward and achieve things in their lives which they thought were beyond them.  It can be a very double-edged sword and many people in distress struggled with the weight of unrealistic or even malicious expectations. Amongst these, unattainable expectations of perfect happiness can, ironically, be some of the things which lead to the greatest unhappiness.

A second theme relates to stereotyping.  This is central to the experience of stigma for people with mental health problems where a negative stereotype of mental illness, in general, or of particular conditions can reinforce distress or inhibit recovery.  Stereotypes affect many other aspects of life whether in relation to race, class, gender or other characteristics. Negative assumptions about individuals made consciously or unconsciously in this respect are both hurtful and can limit an individual’s experience or ambition.

A third area is the cultivation of anxiety. As I have written in other blogs, anxiety is an important human characteristic which in the right doses helps us to anticipate future problems.  However, in excess, or out of control, it can be very destructive.  It is clear to me that we live in an age of anxiety, often fuelled by the behaviour of our media and their constant search for headlines, and now given a new twist by social media.  During the last months of the pandemic the dominance of sensation and scaremongering over rationale debate and reassurance has been, from a psychological perspective, one of the most damaging features of what has been happening to us. Such an atmosphere is especially challenging for those who already are struggling with anxiety.

All of this highlights for me the need to put a focus on wellbeing and happiness, however difficult they are to define as concepts, at the centre of public discourse as well as how we think about services.  A couple of years ago there was a period of interest, championed by thinkers such as Richard Layard, on elevating wellbeing as a determinant of public policy, above or at least equivalent to other priorities such as growth in GDP, or in the case of healthcare the simple preservation of life.

Such a narrative appears to have lost its way, as if we can only think of happiness in times of wellbeing and prosperity.  Yet it is times of adversity we most need a focus on wellbeing in ways which support our resilience.  There are occasional echoes of this in the current debates about the pandemic but too often this aspect is crowded out.  Nothing epitomises this more for me than the issue of the rules around visiting older people in care homes. As was borne out by the experience of my mother who died earlier in the summer, the presence of loved ones at the end of life is of particular importance.   

There is also an individual dimension to this.  The choices and priorities we make in our own lives and the insights we gain into to our characters which best help us maintain our psychological equilibrium in the face of adversity, are crucially important.  The focus which the ancients gave to understanding “the good life” and the moral attitudes and response which support it, is depressingly absent in modern life.

Life can be very uneven and unfair and there is no magic wand we can wave to guarantee happiness but as an attitude of mind it is the right approach.  We live only once, and it seems wrong not to do what we can to try to be happy ourselves and undertake the actions which promote the happiness of others.  

Looking back, looking forward – marking the centenary of the Tavistock

27th September marks the 100th anniversary of when the first patient, a child, was seen at the Tavistock Clinic.  While inevitably more muted, due to Covid 19, than originally planned, it remains a good time to reflect on a 100 years of a unique tradition in mental health and its relevance for the next century.

In some ways, it is hard to imagine the world in 1920.  It was a challenging time as the country emerged from the collective trauma of the First World War and the devastating impact of the Spanish Flu pandemic.  It was a period before the NHS and at time when mental health care equated with long stay hospitals.

It was against this background that a group of clinicians led by Hugh Crichton-Miller set up the Tavistock Clinic.  Informed by experience of using Freud’s theory of neurosis in the treatment of shell-shocked soldiers, the aim was to provide systematic major psychotherapy for people unable to pay private fees.

Much has happened in the last 100 years which has made the Tavistock synonymous with a distinctive tradition in thinking about and responding to mental distress, bringing together a range of different traditions such as psychoanalytic, psychodynamic and systemic thinking and increasingly marrying those with innovative interventions. Tavistock figures like John Bowlby, Isabel Menzies-Lyth, Wilfred Bion, Enid and Michael Balint and many others have made a profound contribution to both practice and social policy, in this country and internationally.

While a centenary is, in part, about looking back and celebrating the achievements and heroes of the past it is also a time to make the case for the relevance of our approach and areas of interest to the addressing of contemporary problems.

I want to highlight four areas. 

The first is the importance of early years and attachment.  Standing back from the day to day challenges of running children and young people’s mental health services, the importance of the first thousand days and the significance of difficulties in forming secure attachment, especially for those young people experiencing the greatest distress, is a clear priority for me in how we need to think about our response to the growing scale of mental distress in young people.

From John Bowlby, the father of attachment theory, onwards the Tavistock has seen such issues as of central importance.  Today, as well as putting such concepts at heart of clinical practice we must advocate for the importance of a greater focus on early intervention and support for those groups, such as looked after children, where issues with attachment are bound, in many cases, to be more difficult.

Linked to these issues has been the Tavistock’s long-standing focus on the whole family and on the intrinsic challenges of parenting.  There is no more difficult task in life than that of being a parent and, in my view, we are immensely neglectful, as a society,  of an honest debate about the measures which would support what Donald Winnicott describes so honestly as “good enough parenting”.  Family work should be at the heart of good care for children and young people.

The second theme relates to the uncertain boundary between physical and mental health.   Interest in this goes a long way back into the history of the institution but has recently seen expression in the primary care services the Tavistock has run in Hackney and Camden.  In a mechanistic health system, we can easily over focus on the physical symptoms of illness and distress without having the curiosity to explore the underlying causes.  As colleagues in primary care often recognise, much of the distress they see in their surgeries has no real clinical name and medically unexplained symptoms are a major draw on NHS resources.  We have created the same dilemmas at the end of life where the relentless desire to extend life is prioritised over the psychological acceptance of death and the provision of good palliative care.

My third area relates to the Portman Clinic and its work with forensic patients.  Founded in 1931, it joined with the Tavistock in the 1980s.  Over the years it has demonstrated the ability to work effectively in the community with patients who have been troubled by problems of criminality, violence, problematic sexual behaviours, or anti-social personality disorder and who often may have acted on their fantasies.

The work of the Portman has always highlighted for me the importance of a criminal justice system which addresses not just the consequences but also the causes of crime and can hold together a view of individuals as both perpetrators and victims.  The work is very special, the insights crucial and is indicative of the values of other initiatives which the Tavistock has led, such as Family Drugs and Alcohol Courts, to deliver more compassionate models of justice.

The final topic I want to focus on is the contribution which the Tavistock family has made to understanding the unconscious dynamics of the workplace and of groups more widely.  This has great contemporary relevance as we think about staff mental health in the wake of the pandemic with its focus on thinking systemically about what is going on in the workplace and not just focusing on individual distress.

The Tavistock has also been committed, since its earliest days, to a mission of teaching and education, based on a model of clinician educators. Over the years, many students have appreciated the impact of teachers whose teaching is grounded in the reality of clinical practice.

At its best the Tavistock has been an organisation which has been prepared to engage with some of the most difficult issues of the day, as has been the case, in recent years, in working through the public controversies surrounding what is the most appropriate care for gender diverse young people.

These are uncertain times.  However, the issues which have driven a century of clinical work and thought leadership at the Tavistock remain as valid in 2020 as they were in 1920.  Working with others we must continue to make the case for their relevance.

Reimagining our cities

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The physical environment in which we spend our lives is central to human wellbeing.  While it is always changing, at times, those changes can be more profound and significant.  The aftermath of the pandemic may be one of those moments.

The imposition of lockdown measures across the world has led to major changes in how millions (if not billions) of people have lived their lives.  People have stayed at home, both to work and study, long distance travel has ground to a halt and many activities have become virtual through the use of technology.

Lockdowns have been loosened but it is not clear that all of us will revert to how we have done things in the past. The potential for many more people to work effectively from home, with reduced need to travel and a reduced need for office space to accommodate them could have a massive effect on our lives and the shape of cities.  According to Simon Jenkins writing in the Guardian on Thursday only 34% of British office workers have gone back to work.  While some of this reflects the impact of a slower relaxing of lockdown in the UK than other parts of Europe, it is possible that there may be a substantial fall in the requirement for office space.  The same article suggests a 25% reduction.

With the decline in the traditional office will also come other changes in the shape of cities, in particular our bigger cities.  Office workers support a large tranche of the retail and hospitality sectors which, without their custom, would struggle to be sustainable.

Office work, again particularly in our bigger cities, also sustains a substantial part of our public transport infrastructure. While no one would make a particular virtue out of commuting there is a very significant relationship between the shape and structure of our cities and a public transport infrastructure created to get commuters to work.

There are benefits of change.  Virtual working can connect us with colleagues at distance but without the need for travel and working from home gives us the space to invest more in terms of time, money and involvement in the places in which we live.  For those with children and caring responsibilities more flexible working can make it easier to balance responsibilities (although this hasn’t always been the case in the last couple of months with the disruption to schools and other forms of childcare).

How this plays out will vary between individuals and between places.  It will be a particular challenge for bigger cities, whose wealth is especially dependent on office work.

A decline in the need for office space could open opportunities for the development of housing, including affordable housing (as has happened to the office I started my career in).  As well as addressing housing pressures repopulating the central districts of cities might have wider benefits in terms of revitalising the life and identity of these areas.  It will need proactive planning and investment in social infrastructure and green spaces to support this in a way which creates genuinely mixed and successful communities.

Similarly, if we no longer come to city centres to work, we need think about other reasons to do so.  The current threat posed by the pandemic to our cultural institutions is of significant concern and we need to take proactive action to address this if we are to avoid another source of lifeblood being sucked out of city centres.

There are also opportunities to continue a process to make our city centres cycle and pedestrian friendly.  Part of this relates to creating the required infrastructure which improves safety for cyclists and pedestrians but there is also the desirability of rolling back some of the monstrous infrastructure brought into cities such as Birmingham in the 60s and 70s to improve access by car.

Aesthetics as well as practicalities matter.  So much of the modern architecture of our city centres (office blocks stand out as a particularly egregious example) is brutal and utilitarian in character.   If we want to maintain the vibrancy and attractiveness of our city centres, we need to be prepared as a society to invest in things of beauty, as our Victorian and Georgian predecessors did.  A dual focus on preserving our heritage and investing in new buildings which combine aesthetic quality and environmental friendliness is required.

There is a question on who should take the lead in championing a new generation of urban renewal.  As ever organic development led by the market has its place but we will also need strong leadership from local and national Government with the willingness for the public purse to bear the costs of public buildings and public infrastructure which improve the beauty of the cities in which we live and add to the wellbeing of citizens.

During my time as I student I worked on archaeological excavations at two major Romano-British cities.  In their time Silchester (in Berkshire) and Wroxeter (in Shropshire) had been thriving urban centres.  Today they both sit forgotten in the midst of countryside.  They were powerful reminders of both the importance of urban development in our history but also of the fleetingness of human institutions.

The changes fostered by the pandemic can be forces for good but, in their wake, we will need to come together to rethink and reimagine the urban spaces in which the majority of us spend our lives.

 

Forgotten Lives

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Last month marked the hundredth anniversary of the death of my great aunt who died of tuberculosis at the age of 25.  More starkly, as recorded on her death certificate, she died in the Lunatic Asylum at Hatton, just outside Warwick.

Ever since I have worked in the field of mental health, I have thought a lot about my great aunt.  I had heard something of her story when I was young when I spent a lot of time with grandmother but never really learnt what had happened to her and why she was admitted to a mental hospital.  As was so often the case in that generation mental illness was not a subject of conversation and was probably, if not explicitly described as such, a source of shame to my grandmother’s family.

Dorothy Leary is not the only person with mental illness whose story has never, properly, been told.  Indeed, throughout history, the voices of people affected by mental illness have been neglected and, for the most part, have been absent from the historical record.  As for many other groups a lack of voice obscures injustice and reinforces disadvantage across generations.

As a student, I studied the ancient world.  The written records, which form the basis of the history of, say, the Roman Empire, concentrate on the lives and interests of a small minority, perhaps, at the most, 100,000 out of a total population of 50-60 million.  Inevitably, as a result, we have a narrow and limited view of what happened.  While I remain very respectful of the universal relevance of much of the classical canon it is a shame that we know so little about the lives of so many inhabitants of the ancient world.

This limited view of the Roman world was challenged in a brilliant book I read a couple of years ago, “Invisible Romans” by Robert Knapp.  It pulled together a much bigger range of sources, both literary, epigraphic and archaeological to shine a light on the lives of the forgotten lives of the past.  Much of what emerges is an unsurprising account of economic and social oppression but there are moments too of dignity and examples of individuals, whether poor, women or slaves who succeeded, despite the odds against them, in making their way in the world.

For me individual stories are an essential ingredient of social change.  The biggest factor, in recent years, in changing attitudes towards mental illness has been the bravery of so many people affected by mental illness to share their stories publicly in ways which have challenged existing attitudes and stereotypes.  In particular they have helped break down the myths that people with mental health problems are somehow different from the rest of us and that mental illness, terrible though it can be, excludes people from work, relationships and other aspects of life which we take for granted.

Lived experience is crucial in the case of other issues.  Just as the lives of poor people were excluded from the historical record of the ancient world their real stories can also be absent from the narratives we tell about our own age.  It easier, even for those who believe in tackling poverty, to ignore the complex and multi-layered experience of disadvantage which is the day to day reality of many people who are caught at the bottom of society.  This is, again, beginning to change and excellent accounts such as “Poverty Safari” by Darren McGarvey tell these stories in a powerful manner which compels attention.

This exclusion of voices is important for another reason.  In failing to listen and understand the reality of lives of disadvantage, those in positions of privilege can easily exclude those they are seeking to help from any meaningful role in the design and ownership of solutions.  As a result, those solutions are far less likely to have any real impact on the lives they are seeking to improve.

Much of this has played out too in the debate around Black Lives Matter.  For me one of the most telling consequences of what has happened in the last months has been a much greater awareness of the breadth of conscious and unconscious bias that colleagues from black and minority ethnic backgrounds have faced on a ongoing basis throughout their careers.  Much of what they have described, seeing people cross the cross the street when they approach, being regularly mistaken for an administrator or junior colleagues because the assumption has to be that a white person is in charge is pretty shocking but can all too easily be invisible to white eyes unless looked out for.  This has increased for me the sense of urgency about what needs to change and highlighted the role which those with lived experience need to play in shaping what happens next.

So back to my great aunt.  Whatever the circumstances were about her admission to a mental hospital and her death I wish had asked the question when my grandmother and others who knew were still around.  To have learnt about that forgotten life in my own family would have helpfully enabled me to realise, at a much earlier stage, the significance of mental illness and the importance of how we think it as an issue in society.