Casting a cold but hopeful eye.

Complex systems, rooted in age-old beliefs, and buttressed by powerful interest groups, are notoriously difficult to change. And yet, in a span of only two or three decades, from the early 1960s through the 1980s, the system for “caring” for people with serious mental illness appeared to have been virtually demolished. In the US, the resident population of state mental hospitals plunged from over 500,000 in the 1950s to about one-tenth that figure 50 years later. This transformation, which continues in the US to this day, as in other parts of the world, was the result of a “perfect storm” of independent forces working at a broad range of societal levels. At the highest levels: a) a civil rights movement swept American society, fueled by international conflicts with the totalitarian fascism and communism; b) visionary policy experts, hoping to transform the lives of people with serious mental illness, sought institutional reform; and c) government budgeters, facing increased wages for hospital workers, sought to shave stretched budgets by reducing costly hospital care. At intermediate levels, mental health system managers responsible for designing regional care systems, local facility directors, and clinical managers within such facilities sought to create new programs, train new kinds of professionals, and restructure care so that it would support fuller lives closer to communities where people reside. Finally, clinicians, working directly with clients (and at the same time, trying to preserve their jobs), and clients and their families tried to pilot their way to a new kind of interaction that would allow a freer more dignified life. Thornicroft et al draw on years of practice transforming and being transformed by public mental health systems to sketch their experiences at the intermediate level of this long chain. They center their presentation around “ten key challenges”. The word “challenge” has achieved a remarkable ambiguity in common English parlance, reflecting alternatively an opportunity for triumphant victory and a euphemism for unavoidable failure, with many shades in between. True to both meanings, Thornicroft et al describe the rich possibilities that emerge when people learn from each other, observe how each other adapts to new circumstances, bond in mutual support, and even party in celebration to create “learning communities”. On the darker side, they depict challenges posed by staff anxieties about change and loss of familiar job routines, rigid opposition from threatened interests, reluctant neighbors, and heartless budget cutters at upper levels of government. Their meditation reads as if its authors have briefly come up for air during a battering struggle, to tell us that the road is very rough in places but that mutual support and mutual learning sometimes present unexpected opportunities for success and succor. For all of us, it depicts the bittersweet balance of a social movement between notable progress in the face of great obstacles, and failure to accomplish its overarching goal of allowing people with serious mental illness to experience the same range of opportunities as other members of their communities. The focus on experience is wisely differentiated from that on ethics and on evidence, drawing attention to the murky middle ground of tactics, strategies and policies intended to move things forward through small negotiations, successful persuasions and studied alliances. These “moves” may inspire hope, but typically achieve only partial success. Charles Lindbloom 1 famously described the implementation of public policy as “muddling through”, and Grob and Goldman 2 applaud the quiet successes of small incremental changes. It is remarkable and dispiriting that the very persistence of the field of community mental health is in part attributable to the fact that the huge strides that have been made in basic brain science in recent years have not yielded useful knowledge about the causes of serious mental illness, much less led to its cure. Medical scientific progress has been slow and benefits from the perspective of the clinician or consumer are close to nil. And so the task remains to muddle through, doing the best we can in times which promise no swift biomedical breakthrough. Nevertheless, from year to year, decade to decade, systems seem to get stronger, clinicians are more expert at working in the free setting of the community. Peer support, recovery and other innovations have emerged from clients themselves, and along with practical interventions such as supported employment or assertive community treatment, continue, one can hope, to make things a little bit better. By focusing on these challenges, Thornicroft et al offer a realistic but hopeful vision of what is to be done in the grey world of community mental health. Their counsel echoes that of W.B. Yeats: “Cast a cold eye, on life, on death, Horseman, pass by!”.