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UK politics

World Mental Health Day: reasons to be cheerful

There are lots of reasons to be anxious at the moment: the recession, ISIS, ebola, the rise of far right parties across Europe. But there’s one big reason to be cheerful, and to be proud of UK public policy: mental health.

The UK is leading the way globally in recognizing mental health as a major policy priority. It led the way back in 2007 in making talking therapies available on a mass scale through the NHS, for free. The Improving Access for Psychological Therapies programme is not perfect at all – waiting times are too long, the types of therapy on offer are too narrow – but it’s still so much more than any other country is doing.

And gradually, UK politicians are waking up to the fact that mental illness should be taken just as seriously as physical illness, and that just as much money should be put into it. Mental illness accounts for 28% of the disease burden in this country, but only receives 11% of the NHS budget. That needs to change.

If you look at mental health through the prism of well-being economics, the moral imperative to do more for the mentally ill becomes even more powerful. The impact of mental illness on personal well-being is actually more profound than for many physical illnesses – yet we do far less to tackle problems like depression or anxiety than we do for physical illnesses. We suffer in silence, and hide our mental pain in a way that would be considered perverse if it was physical illness.

I’d highlight three areas where mental health policy is improving at the moment, and three areas where improvement is desperately needed.

Firstly, companies are beginning to take mental well-being seriously – but it’s only just beginning. Human resources departments tend to do one half-day session on ‘resilience’ once a year for their staff, and these sessions could be on anything – they’re not always evidence-based. A lot more could be done, but the momentum is in the right direction.

Secondly, I think British male culture is beginning to change in its attitude to mental illness. Men are slightly less likely to get mental illness than women, but they’re worse at dealing with it, less likely to seek help, and more likely to kill themselves. The reason to be cheerful here is the way male sports are beginning to lead the way in taking mental health seriously – in rugby, football, cycling, tennis, cricket, boxing and other bastions of macho culture, things are changing and sportsmen are becoming ambassadors for a more emotionally intelligent male culture.

Thirdly, community education about mental health is improving – although again, only very gradually. Public Health England recently emphasized how important adult education is to preventing mental illness, but I don’t get a sense that Clinical Commissioning Groups in local authorities really know how to do community education in this area. However, I’m optimistic we will work this out – informal adult education is, in some ways, flourishing in this country, despite the austerity assault on libraries, through groups like the Reader Organization. We need to work out how to link this up better with the NHS.

Three areas where a lot more needs to be done:

Firstly, the understanding and treatment of psychosis, and particularly schizophrenia, still seems woeful to me. This isn’t anyone’s fault necessarily – it’s a very hard condition to treat. All we can do is try and put more money into research, both of new drugs and particularly of talking therapy approaches. We need to be better at treating people when they first have a psychotic episode, because the trauma of being sectioned can really impact their long-term chances. And we need to work out how to help people with psychosis get back into work and community life – at the moment, they are often very marginalized and isolated. They’re the forgotten people of our society, the unpeople.

Secondly, child psychotherapy services could be a lot better. Again, more investment here could save a lot of money further down the road. Teenagers are too often sectioned in adult facilities a long way from their families. And, at the less extreme end of the spectrum, this government still doesn’t know how to teach emotional intelligence in schools. The last ten years have seen education policy in this area go backwards, not forwards. We’ve become more obsessed with winning the ‘global race’ in exams rather than taking care of our young people.

Third, mental health in prisons seems to me an area that could be radically improved. The example of Wormwood Scrubs, where prisoners are locked up in cells on their own for most of the day because of staff shortages, is a particularly dire example. Again, the prison population are unpeople, invisible, off the policy radar.

Finally, I’d suggest the historic neglect of mental health policy is a consequence of materialism. Our ruling philosophy for the last 200 years has, to some extent, ignored the mind, ignored consciousness. The physical is what is real, therefore physical illnesses are given much more attention and money. That’s beginning to change. We’re waking up to the mind, to consciousness, and how it can make life a heaven or a hell.

And as we wake up to consciousness again, we’re also returning to spiritual traditions where there is much wisdom about consciousness and how to heal and transform it. I’m not being hippy here. The two best and most evidence-based approaches for emotional disorders are CBT and mindfulness-CBT, which emerged directly from the ancient philosophies of Stoicism and Buddhism, respectively. We’re also discovering that spiritual experiences through psychedelics can be profoundly healing for mental illness. There’s a paradigm shift happening. This is a reason to be cheerful.

I think the next stage of this paradigm shift could be to connect  taking care of our selves with taking care of our planet. Rediscovering a good relationship with our inner nature is profoundly connected, I suggest, to rediscovering a good relationship with nature as a whole.

At the moment, mental health policy is still quite atomized, individualized and Cartesian. But people are slowly beginning to understand how healthy it is for us to spend time in nature, to rediscover a sense of connection and relationship to nature and to other animals. Stoicism, the source of CBT, made this connection between taking care of one’s inner nature and discovering a connection to Nature as a whole.  We’re beginning to make that connection once again.

Further thoughts on philosophy in prisons (from a rank amateur)

freiheit-3Yesterday I finished a pilot course in practical philosophy at Low Moss prison. It’s an eight-session course that introduces people to the ideas and life-philosophies of various ancient philosophers, including Socrates, the Stoics, Plato, Rumi, the Buddha, Jesus and Lao Tzu. I’ve been running it in partnership with New College Lanarkshire, which runs the learning courses in west Scottish prisons.

The emphasis is on how we might be able to use their ideas today. Participants are also encouraged to criticize the ideas, and choose which ones work for them. Pick n’ mix? Certainly, but that way they hopefully don’t feel they are being forced down one particular path. The pluralism of the approach, I believe, makes it more likely that a group of cynical and anti-authoritarian people still take onboard some good ideas.

We had zero drop-out in the course – nine started it, and eight finished (one prisoner was transferred to another prison) – which is not bad, considering this was 12 hours of quite intense learning and discussion. This may have been because Nikki Cameron, the formidable teacher who runs Low Moss’ philosophy club, made sure everyone attended!

I often felt quite naive, stumbling into elephant traps that an experienced prison-teacher would see coming a mile off. In a session on Aristotle and the art of citizenship, for example, I asked the group how they would improve the prison system. Bad idea! It fed immediately into prisoners’ deeply-held conviction that they are the pitiable victims of an incurably corrupt system. In fact, it was probably a bad idea to broach the whole topic of citizenship – the group were so utterly disenfranchized from politics (with the exception of one who had been an active member of the BNP).

In another session, we discussed forgiveness. It’s such an important topic – can we forgive people who have wronged us, do we deserve to be forgiven for our wrongs? But it rapidly veered into a discussion on the merits and methods of revenge. No one wanted to support an ethic of forgiveness – it might seem weak. A more experienced teacher would have been aware of that in advance, and more prepared to challenge the conventional revenge ethic.

Philosophy in prisons can touch raw nerves and open wounds – prisoners will bring up issues of race, religious sectarianism, or simply complain about the prison ad infinitum. It’s easy for an outsider like me to bounce in, bounce out and claim quick results – the truth is that people inside have deep levels of anger, hurt, despondency, self-denial and self-absorption. You only have to look at the rate of recidivism and the number of inmate suicides to see what teachers are up against.

It might be argued that the idea of raising consciousness through prison philosophy is a bad idea from the start, for both the prisoners and the prison. Instead, perhaps we should sedate rather than awaken prisoners’ minds, via large-scale meds programmes (prisons spend millions on meds like methadone each year).

But within the group there did appear to be cognitive shifts – probably not through my brief course, but mainly through the philosophy group that Nikki Cameron has been running twice a week for a year. One participant, a former BNP member, discovered a love of Rumi’s poetry, wants to find out more about Taoism, and told Nikki he wants to study social sciences when he leaves prison. This is a guy who refuses to take part in any ‘behaviour modification’ courses to reduce his sentence. Of course, that’s only anecdotal evidence, but Kirstine Szfiris is doing more qualitative analysis and has so far found positive results.

Nikki Cameron  (left) and Ruth Fracchini (right) of the Low Moss learning centre, with two visiting Holocaust survivors
Nikki Cameron (left) and Ruth Facchini (right) of the Low Moss learning centre, with two visiting Holocaust survivors who spoke at the prison this month

Philosophy and desistance theory

I asked the group what their ‘philosophy of life’ was at the beginning of the course, and then at the end, they wrote down their life-philosophy on a card, which they read out and could then put up on their wall. It’s the idea of having them publicly commit to their ethics, which perhaps makes them more likely to try and live by them – a ‘testimonial’ method which churches and 12-step programmes use to good effect.

Their espoused value systems were usually admirable – ‘using education to learn from past mistakes and move towards a better future’ was how one participant summed up his life-philosophy. The problem was sticking to them, or using bad ways to try and meet them. For example, many of their value systems involve loving and protecting their family, but the means they have used to reach that end have been highly counterproductive, ending with them separated from their family for years.

After they read out their ‘life-philosophies’, we presented them with a certificate of completion – I told them ‘you are now a philosopher’ and shook their hand, and the group applauded each other. Yeah, cheesy I know. But still, a good idea (of Nikki’s).

Desistance theory, a hot topic in Scottish prisons, thanks to the work of Fergus McNeill and others

It fits with a theory in criminology called ‘desistance theory’, which suggests that people stop re-offending partly through an internal choice. They choose not to. They choose to live differently, which partly means recovering a sense of personal autonomy and control, and rejecting the identity of being a criminal or bad person to choose a different identity or narrative.

Practical philosophy fits very well into desistance theory, as both Nikki Cameron and Kirstine Szfiris have been researching. It emphasizes the Stoic idea that while we don’t control many things in our environment, we do have some choice over own thoughts, beliefs and actions. We don’t control the past or the future, we can control the present. We don’t control what’s happened to us, we can control how we respond to it. It’s worth repeating, over and over, just as Epictetus repeated this idea to his students in lecture after lecture.

And it re-labels the participants from ‘offenders’ to ‘philosophers’. It recognizes their dignity as free-thinking agents. It also recognizes the dignity of their experience in negotiating adversity, and connects that to millennia-old wisdom traditions and their strategies for coping with adversity. It gives a positive value to their experience of adversity, rather than only seeing it as a negative. As one participant put it, ‘prison makes you become a Stoic, out of necessity’. Nikki said to them yesterday, ‘you’ve all had to practice more philosophy than most academic philosophers’, which is absolutely true in my opinion.

One of the questions in desistance theory is ‘why do people stop committing crimes?’ Age might be a part of it – their value system changes with their hormones (in that sense, it’s less of a choice than a chemical transformation). Time also plays a role – they just get sick of being in prison. Relationships play a key role – someone takes an interest in them, sees the good in them, and they want to live up to that. I see this clearly with Nikki’s relationship to the group. One inmate came up and apologized to her for expressing a vengeful opinion in the class. He said sorry to her ‘because you’re my pal’. The importance of personal relationship is worth bearing in mind in any attempt to ‘roll out’ some mass solution to the prison system. There is no such thing as ‘intimacy on a mass scale’ as one think-tank put it.

Reforming probation services

One of the key issues with desistance, of course, is what happens when the person is discharged? What happens when they leave the prison with £46, no house, no job, and often very little probation follow-up? The Ministry of Justice spends around £40K a year on each prisoner inside, but much less on follow-up. The re-offending rate is very high, particularly for short-term inmates (as much as 70%).

The Justice Ministry is, in fact, about to embark on a huge privatization of the National Probation Service, transferring about 75% of its tasks to private-sector companies. Forget the ban on buying books for inmates – the reform of the probation service is a far, far bigger story.

The historical roots of the probation service go back to missionaries like these chaps from 1906

Minister Chris Grayling says he wants to see more voluntary organizations involved, as part of a ‘compassionate Conservative’ approach. He seems keen to take probation back to its historical roots in charitable Christian volunteers. But the 21 ‘community probation companies’ who have been contracted to start work are mainly the usual suspects of multinational contractors – Sodexo, Capita, G4S, A4E. There is a risk that compassionate Conservatives seek Big Society but end up with Big Business.

Will these private contractors ‘join up’ with voluntary organizations so that people coming out of prison find jobs and supportive communities? Maybe, but there is not a clear alignment of interests or scale. Charities tend to be small, local and value-driven, while the community probation companies tend to be large bureaucracies and profit-driven.

Joining up with probation companies

Well, I’m so new to this area I really shouldn’t pretend to understand these issues! I’ll just highlight them, and end on this point – how do we join up desistance approaches inside prisons with desistance approaches outside? How do you help a person to extend the new story they have embraced into the wider world?

Christian or Muslim groups can do that – my friend Tom Seidler, an ex-offender, runs a charity called Transformed, which meets people at the gates and tries to embed them in churches. A Muslim group called Mosaic also works to try and help the 12% of the population in prisons that are Muslim (some London prisons are over 30% Muslim now, which is shocking considering only 4% of the British population are Muslim).

What about for the non-religious? Can you provide a strong community for prison graduates, other than the BNP?

As the arts and philosophy in prisons approach evolves, it would be great to build links with both voluntary organisations and community probation companies, particularly ones such as Co:here, a new probation company set up as a mutual, which is committed to the desistance / self-help model of rehabilitation.  Could ex-offenders become co-partners in these organizations, or is that meaningless jargon??

In the mental health recovery movement, for example, one of the steps to recovery is coming to see oneself not just as a victim of mental illness, but as an expert on recovery. I wonder if that’s possible in prisons too, where people could come to see themselves as experts on rehabilitation and resilience, with stories to tell that can help others?

And could the staff at prisons and in probation companies also be given time to go on courses in practical philosophy, so that some of these ideas filter out and become a shared culture? Could inmates and staff become co-philosophers?

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In related news:

Here is an article on desistance and prison arts courses, looking at the experience in west Scottish prisons like Low Moss.

Here is a piece I wrote comparing the ‘wisdom’ approach to the ‘critical thinking’ approach in practical philosophy, and here’s an initial article I did on doing a philosophy talk in HMP Dumfries.

Here is a useful PowerPoint from the philosopher Gregory Sadler, drawing on his experience teaching philosophy in prisons, and connecting it to a Kohlbergian model of wisdom development.

Here is an article on well-being in prisons, looking at the reform of the Singapore Prison Service.

Andrew Chignell, a Cornell philosopher, taught a course on the philosophy of hope in a New York prison, as he describes here.

Here’s the Prison University Project website, which provides philosophy courses in San Quentin prison.

Here is a blog by Alan Smith, who taught philosophy in prisons for 14 years.

Here is an article by Eric Anthametten, who teaches an introduction to philosophy course in Texas prisons.

This is an organization called Inside-Out, which links up academia to prisons.

Aislinn O’Donnell teaches philosophy in an Irish prison. She was part of an EU-funded project to explore how to build self-esteem among inmates using the arts.

Here is a short film about meditation in prisons. A documentary has been made about philosophy in prisons in Germany, called Inner Freedom, but it’s not online alas.

Finally, this is a website about a project at Roehampton Uni promoting Prison Reading Groups, which you can donate to if you want.

See you next week,

Jules