TWO THE MENTALLY ILL

      In my years of chairing a large community and mental health trust in central London, Camden and Islington Community Health Services NHS Trust, I became sadder and sadder at what was happening to people with mental illness who accessed our services, and, still worse, to those who for some reason or other were not accessing the services they wanted or needed. I remember being taken to see the best of our then three main adult inpatient units. One of the (male) consultants said to me that in the first few weeks of being a trainee psychiatrist you cried and cried; if you did not do so, then you would be no use as a psychiatrist.

      In some ways, the issue of mental health is at the heart of this book. For we are not–in the way we structure and think about the services we provide–kind. Kindness is not what we value most, nor does it drive the system. If it did, the services would look quite different and be far more responsive to what users say they want. We would be providing decent housing and trying to provide employment, or at least some kind of daytime activity that makes sense and has meaning; we would be helping with money, with food, with the normal things of life, with talking and engaging with the issues that those with mental illness say bother them. Instead, over centuries now, we have provided a service that is largely based on fear and containment, on a view that those with enduring mental illness are worthless and do not deserve the level of public expenditure that running a series of responsive high quality services would entail.

      This chapter is about those who have mental health problems, how we treat them, and how we regard them.

      It looks at the stigma attached to mental health and at our lack of kindess towards people who are mentally ill.

      It examines how our thinking has grown out of past experience, and tells the history of attitudes towards people with mental illness. It asks whether we are any more enlightened than our ancestors were, and whether our new drugs and other interventions make the lives of those with enduring mental illness any easier.

      It looks at whether we use the mental health system as a form of social control and ask whether the experience of innumerable cases where things have gone very wrong tell us that those who work in mental health do not care for their patients.

      It will also examine the increasingly risk-averse public policy climate and ask if the mental health world can ever be risk free. And it will also ask whether, if the views of service users were taken more seriously, there might not be better outcomes, with people being able to work and live comfortably, secure in the knowledge that if a crisis arises there will be proper care available from a team already known to the individual.

      Finally, it will ask the essential question: if we were seriously concerned to care for, and even cure, those with enduring mental illness, would we ever have invented anything remotely like the present system?

      Psychiatry as Social Control

      We are not alone in our attitudes towards mental health. Many countries, many systems, are the same. How we treat people with enduring mental illness is a blot on the consciences of most of the developed nations, and on quite a few of the developing nations as well. In addition, there has always been the risk of political manipulation: in many countries those who have opposed the ruling system have found themselves confined to the asylum. This was most prevalent in the former Soviet Union, when dissidents were pumped full of drugs and left in the mental wards to rot. Nazi psychiatrists, too, took part in the most appalling destruction of people with mental illness and learning disabilities in the 1930s, long before the extermination of Jews and gypsies. The so-called T-4 programme was devised by psychiatrists alongside Nazi ideologues. The programme was finally ended in 1941, but not before an estimated 80–100,000 people had been killed, including the so called mercy killings of the ‘insane’ and of roughly five thousand ‘deformed’ children.*

      This history of the use of psychiatry as a means of social control led to a critique of psychiatry in the late 1960s and early 1970s led by Thomas Szasz, Professor of Psychiatry at Syracuse University, New York. He argued that mental illness was a man-made myth and suggested that psychiatry as a discipline was a pseudo-science, comparable to alchemy and astrology. Michel Foucault, the profoundly influential French historian of culture and ideas, rather agreed. For him, and for Szasz, psychiatrists became, as Roy Porter puts it, villains, and their discipline akin to a form of magic. Martin Roth and Jerome Kroll argued precisely the opposite–that there had been real progress in the study, diagnosis, and treatment of madness and psychopathologies and that there was a real organic basis to mental illness.

      The truth is that there has been a terrifying and disgraceful history of using psychiatry and its antecedents as a means of social control, whilst at the same time some of the treatments, both pharmacological and psychotherapeutic ‘talking’ remedies, have proved beneficial and effective for some, but not all, sufferers.

      To understand how we view