Pure Madness

How Fear Drives the Mental Health System

Jeremy Laurance

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134201075
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Public alarm for random attacks by mentally ill people is at an all-time high. The brutal killing of Jill Dando, the TV personality, and the assault on George Harrison, the former Beatle, are among the cases which have undermined confidence in the mental health service. Community care is widely seen as a failed policy that has left too many people walking the streets, posing a risk to themselves and a threat to others. The Government has responded with a programme of change billed as the biggest reform in forty years, but will it achieve the 'safe, sound, supportive' service as promised?For Pure Madness, Jeremy Laurance travelled across the country observing the care provided to mentally ill people in Britain today. Based on interviews, visits and case histories, his book reveals a service driven by fear.

Chapter 1

The state we're in

Psychiatric treatment can often do no more than apply a sticking plaster to society's ills. Anyone who spends a few months examining the mental health system as I have cannot fail to be struck by that. People with an inherited vulnerability are driven mad by their impoverished, pressured and distressing circumstances, powerful anti-psychotic drugs bring them round and then they are returned to face the same desperate problems.

In one ward round I attended in Hackney, east London, I met a mother treated as a drudge by her family who started hearing voices, felt persecuted by her relatives and threatened one of them with a meat cleaver. Her family denied she was mentally ill (‘She just needs drugs to help her sleep, doctor’) because they wanted her back to cook and clean for them.

There was the African refugee who saw his father murdered and his home torched, who lost contact with his wife and children and did not know whether they were dead or alive and who was living in one room in a hostel with his mother. Uprooted, isolated, bereaved, he was, unsurprisingly, suicidal.

There was the arsonist who compounded his schizophrenia by smoking cannabis and crack and suffered from paranoid feelings and heard voices. (‘The thing is, the weed helps me to relax and talk to people, doc.’) He had set fire to the kitchen of his house the previous week.

Each one had to be assessed clinically, on the nature of their illness, and socially, on their chances of coping in the community once they were discharged. Dr Trevor Turner, clinical director of the community psychiatric service at Homerton Hospital, said: ‘How do we deal with the mother's family and their beliefs about her illness, how do we deal with the African refugee's one room existence in the hostel, how do we stop the arsonist from taking his community care grant and snorting it up his nose? Treating the illness is straightforward, treating the social problems that lie behind it is immensely more difficult.’

In the eyes of many people, professionals and patients, the treatment is part of the problem. Admission to hospital is disabling – there is the stigma, the wards are often crowded, unpleasant and dirty, there are many highly disturbed patients and there is often violence. The health department's Standing Nursing and Midwifery Committee reported that ‘users, carers and professionals agree that inpatient units are becoming increasingly custodial in their atmosphere’ (Addressing Acute Concerns, June 1999).

The experience may be damaging rather than healing and at the end of it the patient is discharged back to where he or she came from – to face the same problems that led to admission in the first place. One woman with a long psychiatric history was told by a friend: ‘Open your eyes. Your first admission to the loony bin immediately damaged your life chances by 70 per cent.’ A medical record becomes like a criminal record with this difference: the psychiatric patient can never clear his or her name.

A senior civil servant, a former manager of mental health services, told me: ‘Most psychiatric wards are frightening places. They are noisy, people out of control, young and old, abusers beside the abused, not enough staff to cope. I would feel safer on a high security ward in Broadmoor than on most inner city wards. If your first experience of the mental system is of compulsion and being over-medicated – drugged up to the eyeballs – you are never going to use the services again.’

He added: ‘I used to go and see families where there had been a suicide and they would say to me it was admission to hospital that killed their son or daughter. Patients see all the psychotic, disturbed people on the ward and they think “I will end up like that” – and they kill themselves. Medicalising mental illness is no help – patients are put in an environment that is alien to them, increases their distress and leaves them more disturbed.’

His point is illustrated by the suicide of Teresa O'Shaughnessy, who killed herself on Monday 27 March 2000. A devout Christian, described as deeply spiritual, she died, lonely and frightened, in a derelict building where she had taken refuge while medical staff and her family searched in vain for her.

Diagnosed with manic depression she had been sectioned twice in the early 1980s – experiences which left her deeply traumatised, according to Jan Wallcraft, a mental health researcher, who had known Teresa for twenty years. Although her mental condition had deteriorated sharply in her final days and she had been persuaded to seek treatment, it was her fear of what the doctors might do to her which led to her last fatal act.

Teresa had religious visions and relied on guidance from higher spiritual beings with whom she had intense encounters. She accepted medication and was sustained for many years by a long-term relationship but when the relationship broke up in 1999 she started to deteriorate.

On the day she died, the occupational therapist at a day centre she attended became so concerned about her state of mind that she persuaded Teresa to go with her to the local hospital. However, once there, Teresa became frightened that she would be sectioned.

Jan Wallcraft, now of the Sainsbury Centre for Mental Health, wrote in a tribute posted on the internet:

I know how nervous and sensitive she was about her encounters with the medical profession; how concerned with what they would think of her, what they would do, whether they would try to impose treatment that she didn't want ... Perhaps she feared a return to the nightmare days of the early 1980s after all the hard work she had put into rebuilding her life and learning to trust her visions.

Teresa ran out of the hospital, with some of the staff after her. She eluded them and managed to buy paracetamol, electric flex and two knives. She hid herself in a derelict building, while the staff and eventually her family searched for her. She took all the medication, some of the paracetamol, tried to slash her wrists and then hung herself using the electric flex. She wasn't found until two days later when a passer-by saw her and reported it to the police.

Ms Wallcraft believes it was the threat of coercion that drove Teresa to take her own life.

She needed care and protection, perhaps, but was never willing to accept coercion. Above all she wanted people to understand and respect her experiences and visions. These were sometimes terrifying to her but at the same time she had gained much wisdom from them ... She needed a helper who would respect her for the person she really was, rather than seeing her as a helpless victim of delusions who needed to be artificially numbed into forgetfulness.

The complaint that the mental health services are too coercive, too narrowly focused on medication and do not offer the kind of support that people want is widespread among people with mental problems. They see a service focused on containment, with little regard for people's individual experiences, few resources devoted to talking therapies and an emphasis on crisis management rather than preventive care.

Psychiatrists, on the other hand, argue that coercion is used only as a last resort when there is no other way of protecting an individual from themselves – and has saved far more lives than it has cost.

However, the mental health system is becoming more coercive. The number of people forcibly admitted to psychiatric hospitals has risen by half in a decade. The total stood at 26,700 in 2000–01, up from 18,000 in 1990–91. These are people whose liberty has been removed even though the vast majority have committed no crime. Unlike prisoners, they have been forced to accept treatment, including drugs and ECT, which in any other circumstance would amount to an assault. This is the clearest measure of a system driven by fear – fear of what these people may do to themselves or others.

In addition to these formal admissions to hospital, a further 20,500 patients were formally detained under the Mental Health Act 1983 after admission to hospital as voluntary patients. That figure, too, is sharply up on the number ten years ago. So the total number detained in hospital stood at 50,000, around 20,000 more than a decade earlier.

In keeping with these trends, the number of beds in secure units has more than doubled, from less than 1,000 in 1991–92 to 2,000 in 1997–98.

Why the increases? Dr Roger Freeman, chairman of the parliamentary committee of the Royal College of Psychiatrists, has a simple answer: ‘It probably reflects less permissive attitudes in society rather than any changes in mental health problems.’

The same view was put by researchers from the Department of Psychological Medicine at Guy's, King's and St Thomas’ School of Medicine in a study charting the rise in compulsory admissions which suggested the increase in drug and alcohol abuse by psychiatric patients and the fall in hospital beds were also factors. They wrote: ‘The public's fear of violence by mentally ill patients and pressures to keep patients in hospital until it is “safe” to discharge them put further strain on the availability of beds’ (S. Wall et al., British Medical Journal, 5 June 1999).

The Mental Health Act Commission, the independent body that monitors mental health services, suggested one reason for the increase in detentions following voluntary admission might be that patients ‘have to be coerced to stay’ – a grim comment on the dreadful state of most inpatient wards (Ninth Biennial Report, December 2001).

Lucy Johnstone, clinical psychologist at the University of the West of England, described returning to work in an NHS psychiatric ward after a ten year absence:

It is, I believe, good policy to keep people out of psychiatric hospital where possible, and only admit those in acute need; but if you have entire wards consisting only of such people, with too few staff, beds and resources and too little support, training and supervision, then you have a recipe for disaster. Entire shifts consist of crisis management, with no time for staff support or debriefing or doing anything remotely therapeutic with the patients. Scarcely has one person been retrieved from the bridge than another slashes her wrists in the bathroom, while a third is breaking windows in the office ... Hospitals seem more and more like warehouses for the sedation of the utterly victimised and powerless.

(Clinical Psychology, 7, 2001)

Many senior psychiatrists express the same view (see Chapter 6) condemning the state of their own inpatient wards as scandalous. In light of the shortage of resources, it is not surprising that they rely on medication to control mental illness. To take on the social dimension would open a Pandora's box of problems they have neither the scope nor the resources to tackle. Obviously drugs are important – but many people with mental health problems are angered by the simplistic reductionist approach that says as soon as you have passed a certain clinical threshold then you have a diagnostic label – ‘schizophrenia’, for example – and a prescription.

Anne Cooke of the British Psychological Society said: ‘It is as if the only issue is what brain chemicals are involved and how they can be tweaked with drugs. That is the public rhetoric of psychiatry and it is how a lot of it is conducted. Patients complain the only treatment on offer is drugs.’

The Mental Health Act Commission echoed this view: ‘While we recognise the value of pharmacological treatment for serious mental disorder, such impressions appear to be profoundly anti-therapeutic for patients and raise concerns about the reality of multi-disciplinary working.’ (Ninth Biennial Report, December 2001)

Official figures show a sharp rise in the prescription of anti-psychotic and antimanic drugs in the community, up from 3.5 million prescription items in 1991 to 5.9 million in 2000, a 66 per cent increase in a decade. Partly this reflects the growing numbers of mentally ill people treated in the community, but there has also been a real increase in prescribing. The cost of the drugs has risen almost sevenfold over the same period, from £15 million in 1991 to £100 million in 2000, as the newer atypical antipsychotics have been increasingly prescribed. In 2000, atypicals, which are said to have fewer side effects, accounted for 1.1 million of the 4.9 million prescriptions issued for antipsychotics, 23 per cent of the total (Prescription Statistics, Department of Health, 2000).

Many psychiatrists take a wider view and would like to attend to other things in patients’ lives than medication but they are constrained in reality. The imperative that drives the service is risk avoidance and damage limitation – to lives lived on the edge. What inner city psychiatrists worry about is having to stand up in court to explain their management of a case. When that happens they know they will have to defend themselves in terms of the prevailing view of appropriate treatment – that is, drugs. Some have found the strain and disappointment of medicating society's problems too much – and have left the profession. Up to 14 per cent of consultant psychiatrist posts were vacant in some parts of the country at the start of 2002.

Drugs do work for many people by calming them down and alleviating or removing symptoms – but they have side effects and they can be dangerous. The overwhelming demand from patients is for more talking treatments but they are rarely available. The National Service Framework for mental health noted the increasing evidence for the effectiveness of psychological therapies in schizophrenia. Yet guidelines on the use of the therapies issued by the health department in February 2001 specifically excluded psychotic disorders from its scope. Tartly noting this ambivalence, the Mental Health Act Commission recommended that services should set standards for ‘recreational, educational and therapeutic activities’ which should be closely monitored. But this still leaves out of account all the other things that affect life – jobs, relationships, housing, money, friends.

Margaret Clayton, chairwoman of the Mental Health Act Commission, highlighted in her foreword to the Ninth Biennial Report (December 2001) the ‘huge variations’ in the quality of provision for detained patients. ‘A high proportion of these patients would not need to be detained if satisfactory health and social care were available in the community,’ she wrote. Almost exactly the same points were made in the Eighth Biennial Report and in those that preceded it.

People with mental problems need a seamless service with all levels of support but what they get is a patchy service with good support at certain levels and nothing at all at other levels. A researcher who studied the home treatment service in Manchester found people liked it when they got it but complained they only got it when they had a crisis. There was nothing to prevent the crisis occurring.

In a similar way, inpatient treatment was welcomed by some as a sanctuary, a place of safety where recovery could take place. But when they were discharged again there was nothing – no support, no help other than an outpatient appointment in four weeks’ time. Most suicides occur on the day after discharge from hospital, according to the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Safety First, Department of Health, March 2001). The Government has set a target of reducing suicides by a fifth by 2010 and from March 2002, all patients with a history of severe mental illness must be seen in person, by a professional, within seven days of discharge.

I heard stories about the difficulty of getting help again and again on my travels round the country. People with mental health problems wanted to get hold of the services they needed, when they needed them. Flexibility and accessibility were the keys. But the response of the professionals was uniform – the service had to be rationed, in practice, to those who posed some kind of threat. ‘There is a sea of distress out there,’ a manager in Norfolk told me. ‘If we have open access we will be overwhelmed.’ A psychiatrist said: ‘I will do my best for the 5 per cent most severely affected – not for the most vociferous or articulate or best at demanding services.’

‘You can be as mad as a meat-axe,’ said the psychiatrist, ‘but if you can live independently – cook, clean and look after yourself – and you don't frighten the neighbours then no one is going to take the slightest notice of you.’

Doing the community visits in Hackney, east London, the truth of this observation becomes obvious. It is the threat to public order that drives the service – and secondarily the threat to the safety of those who are ill. I...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• 1 The state we’re in
• 2 How we got here
• 3 Mad axemen and the growth of coercion
• 4 A new law for the twenty-first century
• 5 The clamour for consumer control
• 6 Taking care to the community
• 7 Taking care to the home
• 8 Taking care to the streets
• 9 Life stories
• 10 Carers: the missing link
• 11 The new meaning of community care
• Index