Those who use mental health services are variably called patients, survivors, service users and more commonly in many countries as ‘consumers’. They are seen to consume mental health services and are meant to have similar powers of choice to any other service in a modern capitalist society. This of course is a false economy. Most often, there is only one service available for inpatient care -especially when there are financial constraints and when you live on city fringes, smaller towns or in rural areas.

Choice is deliberately taken away for those patients who are ‘scheduled’ or ‘sectioned’ -people who are forced into involuntary treatment due to perceived or actual risks of harm to themselves or others. There are many situations where involuntary treatment is still completely justified and the right thing to do when the risks are high and the patient cannot make decisions that help prevent these risks. These people are not consumers -they more closely resemble prison inmates than customers of a company.

Consumerism is a very odd paradigm to try to replicate. Consumerism creates a sense of entitlement and a service orientation towards cutting costs and maximising profits or for public and nonprofit health providers -a budget surplus. Consumerism also creates a culture of transactional services which fosters a management style of transactional leadership which is a toxic leadership style where leaders rely on rewards and punishments to achieve targets that are usually irrelevant to actual health outcomes.

Consumerism in a modern capitalist society also breeds resistance. Feeling like you are a number in a system and that your insurance and/or taxes pay for your psych ward stay leads to a valid sense of resentment for the inefficiency and disrespect that plagues the modern asylum.

The new psych wards take consumerism to the next sinister level. Private hospitals are frequently likened to hotels or even resorts and even many new public psych wards model themselves on hotels. This can still yield a positive experience for patients -an orientation toward delivering a comfortable environment with professional customer service is an enviable goal.

Hospitals are importing some of the worst elements of hotels. We are seeing the dual processes of corporatisation and massification of psych hospitals and psych wards. An alarming proportion of hospitals are now run like businesses but very frequently have managers who lack decent business skills. Nurses become unit managers or further up in the long hierarchy and militaristically enforce their professions values and approaches across the hospital.

In hospitals that do not focus solely on psychiatric care, it is assumed that what works in oncology, ICU or paediatrics should also work in the psych wards. The urgency and rushed nature of the physical health disciplines is often counterintuitive to mental health crises and instead everything just needs to slow down and treatment be trialled then watched carefully in settings that more closely resemble each patient’s daily living.

The reorientation to corporate logics also means prioritising profit or at least surplus in the case of public hospitals or nonprofits. The intense cost-cutting focuses on areas such as meals or group activities for patients rather than the much more expensive excesses of committees and executive remuneration. A decentralised system that empowers clinicians and administrators to make most decisions would save a great deal more money and foster a greater sense that workers are having a positive impact on their patients’ lives.

Cost-cutting may also involve the massification of systems. A cookie-cutter approach to processing patients like factory mass production speeds up the revolving door. This is directly observable through management meetings focused on metrics like ‘average length of stay’ where there is a deliberate and dangerous pressure on discharging patients sooner than they are ready to reduce cost in terms of less number of nights in hospital.

Wards are further massified through the false belief that patients with any kind of disorder or addiction can enter the same group program and still benefit. As someone who has been highly manic in a group therapy of mostly depressed inpatients, I know this is exceptionally problematic. On other occasions when I have experienced psychosis, many of the approaches useful to group therapy members have actually been harmful. It is also almost always unhelpful when groups include both those who have mental illness with those with addictions (and not both coexisting) but private psych wards still do this to be more profitable.

With growing populations and environmental stressors creating higher need for inpatient psychiatric stays, systems attempt to create bigger and more efficient psych hospitals. Corners are cut behind the facade of new and modern buildings. A greater reliance on carers and nonprofit community services allows a shifting of obligations away from these hospitals into more informal settings that do not pose any of the same financial or reputational risks. The long-term financial and health outcomes are much worse though as problems are left unrecognised or inadequately treated outside of hospital leading to future readmissions or serious misadventure in places where the hospital has absolved itself of responsibility for.

Standardising quality of service delivery works for McDonalds in terms of creating consistency. The result of standardising can be consistency -consistently bad. With so many diverse patients with varied symptoms, side effects, stressors and capabilities -there is a need for more tailored approaches to mental health care rather than McDonaldisation. Bigger hospitals try to divide patients into wards based on gender and perceived acuity but end up putting patients wherever they have a bed. This leads to inappropriate approaches applied to whole wards rather than seeing patients as individual human beings with unique challenges and strengths.

The logic of the corporation maximising the long-term profitability it can derive from each consumer does not sit well in healthcare. Attempts to replicate market-based mechanisms are found in programmes like activity-based costing where expenses are assigned to each service occasion with each patient. These methods can quickly become accounting window-dressing used to satisfy funding agencies and appear less wasteful to taxpayers.

The consumer logic of competition should bring about better choice among patients and foster greater empowerment. When we are talking about involuntary treatment and treatment that does not require considerable travel from a patient’s home, there is little or no real competition. The inflexible legislative frameworks, replicated practices within the clinical professions and imitation between health managers all work to create homogeneity among health providers to the point where you are just choosing between different shades of beige.

Differentiating each mental health service is often just a branding exercise -another construction of the facade.

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