Reflections are good for you. In a world of instant experience and shifting memories it is wise for everyone to spend time looking back and musing. This is even more important when events tumble over themselves and create rapid change. Such is the case with the community management of people with mentally illness, and especially those with intellectual disability. Nick Bouras covers the 40-year period from 1974 – ‘a golden age full of optimism’ – to the present age of CRS (continuously restructuring services) (my acronym) – when he notes ‘it is surprising that (they) do not take into account the implementation evidence of previous policies before introducing new ones’.
What Nick Bouras has provided in this informative book is a road map of developments primarily in intellectual disability over this long period, as well as speculations about the future. But it is like a large-scale map of great detail covering happenings in southeast London and west Kent, with only the occasional foray into Buckinghamshire, the USA and Greece. And what detail indeed! He starts with his initial training in Greece, followed by his first post at St John's Hospital, Stone, in the Chilterns, ‘surrounded by green valleys and blossoming trees’ and with Dr David Watt as medical director, ‘a gentle, caring and fatherly figure’. So, the golden age continued as he consolidates his position, first as a pioneer at the Lewisham Mental Advice Centre, then later as he plunges as a consultant into the field of intellectual disability, mentioning every major figure in the field as he goes, but giving his most glowing tribute to the late Jim Watson. Not surprisingly, in so doing, he edges ever closer to the Mecca of UK psychiatry, the Maudsley Hospital, where the last part of his book finishes.
Many of the reflections are those of personal interactions, and here Nick Bouras is a psychiatric Boswell exposing the bon mots of his colleagues, seemingly innocently, but with insights into their personalities. So we hear that Professor Steven Hirsch, after listening to an exposition by the Bouras team criticises them for ‘wrongly using the word “evaluation”’, Bouras himself tackles Jim Mansell by describing him as belonging to a ‘group of psychologists’ that expresses ‘profound habitual residual scepticism about mental illness and psychiatry’, and takes him to task for creating a policy entitled ‘Valuing People’ as ‘a well-intended policy of “good wishes” making arbitrary recommendations and setting time limits not based on any evidence’. He also observes that the Rolls-Royce of Elaine Murphy ‘took up a lot of parking space’ at an overcrowded Guy's Hospital, and describes the way in which he was examined for his MD thesis, commenting that the examiner began his final assessment in ‘a cruel way’ by listing the options open to examiners, starting with ‘fail’, but then finishing by telling Dr Bouras he had passed. He also describes a paper his group sent to Psychological Medicine, which was accepted, ‘provided we responded to some additional comments by the editor, Michael Shepherd, that none of us were able to understand’. These comments will be read with wry amusement by those who know the individuals concerned.
But these snippets are not the main purpose of the book, which is to reflect on what has happened in community psychiatry, especially in the field of intellectual disability, over the past 40 years. He does not come to a firm conclusion, but my reading of the book is that MEROPE, one of the many acronyms developed in Nick Bouras' career, is a suitable summary. MEROPE is a star in the Perseides that shines dimly because, according to Greek legend, she had married Sisyphus, a mortal man. The current intellectual disability star is also shining a little dimly, and is also like Sisyphus, condemned in perpetuity to roll a boulder out of hell only to let it slip and roll down again just as it reaches the top. But the efforts must continue. When Bouras told his American colleagues some years ago about his plans to move intellectual disability rapidly to community care, ‘they all unanimously responded, don't’. Our response must be a unanimous ‘please do, but give us the resources to do so, not just fine words’.
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