All services and projects require money if they are to survive. As already discussed in a previous post, the source of this funding will exert an overarching influence on the practices of the initiative in question. Irrespective of whether we are referring to service-delivery teams, charities, service-user projects or statutory health providers, the assumptions, values and priorities of the commissioners will ultimately shape the output that is delivered. Once in receipt of a recurrent funding stream, the beneficiary is obliged to justify its expenditure to the paymaster’s bureaucrats and, if those supplying the money harbour traditional views about mental health, neutralisation of innovative ideas will inevitably occur.
So what is the optimal way to fund pioneering mental-health projects that strive to provide alternatives to the dominant biomedical paradigm? If we want these radical approaches to thrive, without being diluted or assimilated, and ultimately rendered mainstream, from where should their money derive?
I don’t profess to know all the answers to these questions. Instead I will share a few potential sources of funding (together with my initial thoughts) and, hopefully, stimulate a debate around what I believe to be a central issue for those committed to providing alternatives to Western psychiatry.
The funding streams – and subsequent discussion – described below are set within the existing context of the United Kingdom. Nonetheless, I believe the relative pros and cons of each option will broadly relate to other countries.
1. Comprehensive state funding
The provision of services exclusively on the basis of need and free at the point of delivery is, understandably, an appealing option for many people. In this model, efforts to improve mental health are funded centrally by the government of the day, the money being raised through general taxation.
There are two nation-wide, state-funded organisations that can potentially act as lead suppliers of mental health provision.
a) National Health Service
In the United Kingdom, the lead responsibility for mental health currently resides with our National Health Service (NHS). The NHS is a wonderful institution, striving to deliver free health care to anyone in need and irrespective of the ability to pay. In dedicating a proportion of its resources to mental health, it usefully conveys the message that addressing human distress and suffering is as important an endeavour as helping those presenting with broken bones and cardiac arrests.
However, the deeply entrenched medical culture within the NHS, with its ‘illness like any other’ approach to human suffering, renders it fundamentally unsuited to a lead role in responding to mental health problems. Most psychiatrists in the NHS cling to the myth that a brain aberration is the main cause of distress in their service users and, as these medical specialists retain the lion share of power within the system, the inevitable consequences are excess drugging, pessimistic messages about the likelihood of recovery, the encouragement of passivity and more stigma. Furthermore, innovative projects aimed at promoting more psychosocial approaches are often met with resistance or are allowed to atrophy due to lack of funding.
Risk aversion is a further important disadvantage associated with a large bureaucratic organisation like the NHS leading on mental health provision. Fear of censure and litigation, together with the government’s unrealistic expectations around risk reduction, result in defensive practices that often stymie the recovery journeys of service users.
b) Local Authority – Social Care System
Although also bureaucratic and risk averse, the local authority social care system may offer key advantages over the NHS in acting as a lead provider of mental health services. Unencumbered by a medical culture, a community-based social-care led service could appropriately focus on countering environmental adversity and promoting wellbeing. In addition, the local authority context would be more nurturing for projects promoting a psychosocial approach to human suffering.
The local authority environment would also be well placed to put greater emphasis on prevention of mental health problems by population-level interventions to reduce many of the determinants of emotional distress, such as: domestic violence; poverty; inequality; high levels of crime; homelessness; work-related stress and alcohol/drug misuse.
2. Private, profit-generating organisations
The overarching goal of a private company in the Western world is to make a profit for its shareholders. As such, much of the activities of private organisations will be dedicated to maximising their incomes and minimising their spending. Thus, any investment in a mental health project will only be forthcoming if there is a clear expectation that a financial gain will be realised.
The ubiquitous influence of the pharmaceutical industry on psychiatric practices has been well documented (Sidley, 2015) and has included disease-mongering, promotion of excessive drug prescribing, dishonesty around research data, and the blatant bribing of stakeholders. Such partisan, self-serving practices are not restricted to drug companies; a brief search of the Internet will reveal an array of commercial psychological-therapy providers making outlandish ‘miracle-cure’ claims for their own brand of intervention.
In their defence, private companies would argue that they only make a profit if the product they are offering – or service in which they are investing – is valued by those in receipt of mental health support. There are, however, two fundamental weaknesses to this argument. Firstly, the private sector has a history of effectively convincing people that they have a ‘disorder’ that requires their product, even when no such problem exists. Secondly, the requirement that anyone using the funded service must pay (directly or through private health insurance) for their mental health support inevitably means that those with little money – the group in greatest need of help – will be denied access to the service.
3. Charitable donations, fundraising & voluntary contributions
Organisations that are financed via charitable donations and their own fundraising activities are arguably in a better position to maintain consistency with their explicit ethos and values, protected from the neutralising pressures associated with state funding and the profit imperatives of private companies.
A prominent example of a charitable organisation successfully retaining its distinctive philosophy is the UK’s hospice movement, with its focus on enhancing the quality of life of people with terminal illnesses. National charities – such as Marie Curie Cancer Care and the Sue Ryder Foundation – and other voluntary donations account for much of the hospice funding, a key factor in preventing the dilution of the hospice-movement ethos.
With regards to mental health, the Hearing Voices Network (HVN) is a thriving 3rd-sector organisation offering its members the opportunity to make sense of their voice-hearing in a supportive environment, immune from the traditional psychiatry pressures to automatically view such experiences as symptoms of illness. To support this work, the funding for the HVN derives from a combination of individual donations, local community grants and fundraising activities.
National charity status is not, however, a total guarantee against dilution and neutralisation. The MIND organisation was for many years recognised as an authoritative mouthpiece for the psychiatric service-user movement, but has recently been criticised for its use of stigmatising, illness-like-any-other language and its apparent collusion with simplistic government ‘return to work’ initiatives targeting people with mental health problems. This ideological drift could be related to the fact that, in 2015/16, 29% of MIND’s income derived from ‘grants’, a proportion of which is likely to have come from the government Department of Work and Pensions.
4. Mutual aid cooperatives
The most radical – and potentially most effective – way of protecting innovative mental health schemes could be through the development of mutual aid cooperatives, organised and run entirely by survivors of the psychiatric system.
Such a model recognises that potent contributors to human suffering and overwhelm derive from factors that are inherent within Western societies, such as disempowerment, poverty, discrimination, victimisation and homelessness. By creating a mini society of mutual cooperation, immune to both the toxic influences of the wider world and the self-serving intentions of the psychiatric industry, it is hoped that participants can reciprocally satisfy each other’s needs in an egalitarian, non-competitive environment.
In some respects this sort of initiative strives to replicate what happens in the corners of the world where Western psychiatry has yet to infiltrate, and where prevalence of mental health problems is significantly lower than in developed countries. A wide ranging debate about the potential of mutual aid cooperatives was recently instigated by Richard Cronshey on the ‘Drop the Disorder?!’ Facebook group.
The primary aim of this post is to stimulate further debate about the relative merits of different sources of funding in sustaining innovative developments in mental health. I suspect the above is not an exhaustive list of options and I would, therefore, be keen to hear about alternative forms of finance that could allow pioneering projects to flourish without diluting their raison d’etre. Please share your ideas in the comments section.
Sidley, G. (2015). Tales from the Madhouse: An insider critique of psychiatric services. PCCS Books (p148 – 152).
Photo courtesy of Stuart Miles at FreeDigitalPhotos.net