In the UK, we tend to be horrified at the lack of state mental health provision in the US:
My biggest hang-up isn’t even the orange nightmare you’ve somehow let into the White House—it’s the fact you seem totally fine with just letting people… die (Adam Kay, 2019)
In contrast, we celebrate Scandinavian socially just welfare systems. Our media frequently invoke a Nordic utopia manifest in Nordic countries’ regular appearance at the very top of World Happiness Report rankings. This blog considers state mental health care in the Nordic region in light of recent Scandinavian studies, challenging the idealised notion of Scandinavian egalitarian welfare.
Nordic countries are broadly similar to the UK and other West European neoliberal states regarding welfare and public health provision. There have been similar sorts of reforms to mental health care over recent decades, including an overall shift from institutional psychiatric care towards community-based care.
In Denmark, the overarching field is still referred to as ‘Psychiatry’, whereas other Nordic countries such as Norway more commonly refer to the area of ‘mental health’. Nevertheless, all these countries have seen political attempts to shift from a medically styled ‘psychiatry’ to a more humanistic and social-psychological orientation in mental health care systems. As a result, mental health work now commonly includes health promotion, user perspectives and a focus on resources, resilience, recovery and active participation from users and relatives.
While this shift may partly reflect a response to early post-structural critiques of bio-medical psychiatry, it has generated new forms of critique in the UK. Notably, in Our Psychiatric Future, Rose argues that the UK mental health field now comprises numerous antagonistic elements: ‘many psychiatries’. These are various ideologically ambiguous movements continuously struggling for power, including the pharmaceutical industry, bio-medicine, government actors, NGOs, professional and user movements. Specifically, within the user movement space, several political, professional, ideological and user-oriented ideas of mental health work are said to be openly competing to acquire legitimacy and define good practice.
An early driver within the international user movement was the recovery movement that gained traction in the eighties. In the UK Harper and Speed argue that political and professional agents have partly co-opted the user-driven and socially-oriented recovery movement despite its original emancipatory heritage. This makes psychiatric survivors responsible for their wellbeing while maintaining traditional forms of medical authority.
The observance of ‘many psychiatries’ and the co-option of recovery with aspects of user involvement have recently been described in a range of Scandinavian studies. But these are not mere theoretical critiques and commentaries. Extensive Nordic empirical research points to the possibility that these trends may be doing more wide-ranging forms of harm than the traditional form of Psychiatry they replace. Specifically, so-called humanising shifts in the field actively blur the boundaries between private individuals and the neoliberal state. Moreover, these subtle reforms to psychiatric systems paradoxically reinforce the shadowy presence of psychiatric medical authority and increase its use of coercion in the name of risk management and societal burden by ‘responsibilising’ users and relatives and demarcating more clearly those deemed most dangerous.
The presence of multiple (competing) definitions of recovery in Nordic psychiatric settings negatively impacts the way psychiatric inpatients are cared for rather than emancipating them. Moreover, users of psychiatric services in Scandinavia and their family members are increasingly being made responsible for enacting subtle forms of coercion badged as prevention, monitoring, treatment and control. This inconspicuous shift is passed under the guise of personal recovery or user and carer involvement which sounds like it should democratise, not coerce.
Herein lies potential harm. Despite increased political and clinical will towards reduced coercion, recovery mentors, shared decision making and so on, policies such as ‘carer involvement’ enable more subtle forms of oppression by co-opting patients, peers, family members, neighbours and so on into the medical state apparatus’ workforce while increasing the burden on patients and relatives.
Other new forms of psychiatric duress have also evolved in Scandinavia over the twentieth century. For example, as concepts of ‘self-determination’ in psychiatry grew, more intrusive forms of coercion developed to regulate those deemed most dangerous, resulting in less explicit coercion for the many but more coercion for the few.
The practice of ‘user-controlled admissions’ in Scandinavia applies the empowerment discourse, reinforcing the idea of a ‘new psychiatry’. In effect, the policy places users in ‘liminal’ (in-between) subject positions, where they are simultaneously expected to be responsible and self-governing despite having historically been made dependent on ‘old psychiatry’. Along with new forms of subtle coercion, this suggests an emerging legitimisation of the idea that state institutions can take over, compell and deprive individuals of their rights and authority if they are not adequately autonomous or not taking responsibility properly.
Should the recovery movement be abandoned then, given it appears to lead to unintended harm? Or is the idea of re-orientation towards emancipation and rights needed more than ever in Nordic countries and beyond?
Probably the latter. But recent Nordic critical psychiatry work raises questions about professional integrity in endorsing various pseudo-humanising practices and ideological reforms, which ultimately cause harm. The United Nations (UN) recommends that Nordic countries and other western industrialised countries must revolutionise mental health care; psychiatry must be humanised, democratised and fully oriented towards personal recovery, sustainability, equality and human rights. Yet Nordic critical psychiatry research suggests that orienting systems towards personal recovery does not humanise or democratise, but tends to do the opposite. Albeit with a neoliberal spin, the traditional psychiatric notion of good practice continues to govern the organisation, structure and function of services.
Some Nordic scholars are optimistic about the role of critique in the reform of the mental health field. These suggest that while debates about psychiatric practice can be fraught with tension, and that dialogue often collapses, there may be ways to enable discussions to occur more constructively to enrich psychiatric practice. Other Nordic scholars retain a more pessimistic outlook on this utopian ideal of an ‘enriching’ dialogue between incommensurable views on good mental health care.
More broadly, critical social science observations of Nordic mental health care are generally pessimistic about the increasingly covert forms of psychiatric compulsion masked by the language of reform and enabled by the shifting boundaries between state and individual. While constructive dialogue between alternative positions can enrich most fields in marginal ways, it seems a more radical rethink of how to democratise mental health care in the Nordic region is now required– as is probably also the case in the UK and other Western democracies beguiled by ‘recovery’.
About the authors: Susan McPherson is a regular contributor to the Cost of Living. Jeppe Oute is Associate Professor in Mental Health Care at the Department of Health, Social and Welfare Studies at the University of South Eastern Norway and works in the field of recovery and critical mental health.M