Mental healthcare in the balance
The UK Mental Health Bill captures society's shift from rehabilitating the mentally ill towards helping them just to 'survive'.
The UK Mental Health Bill (1) has been widely criticised for its coercive nature and its broad definition of mental disorder.
On 29 July 2002, the Royal College of Psychiatrists announced that it would join with mental health user groups in a September march on Whitehall, claiming the Bill will lead to ‘the forced detention of people who are no harm to anybody except, possibly, themselves’ (2).
Mental health workers and users have good reason to be concerned. The Bill will introduce powers to allow the indefinite detention of those deemed to be suffering from a mental disorder and considered dangerous – even if they have not committed a crime.
The Bill defines a mental disorder as ‘any disability or disorder of mind or brain which results in impairment or disturbance of mental functioning’. Where the current Mental Health Act excludes many problems and illnesses from the category of mental disorder, the new Bill does not. The British Medical Journal warns that this could lead to compulsory treatment for sexual deviancy, alcohol dependence and many personal issues not previously designated as disorders (3).
Some of those who support the new Bill claim they are addressing the ‘safety concerns’ that many have about ‘care in the community’ (4). They cite the killing of Jonathan Zito by schizophrenia sufferer Christopher Clunis, and the murder of Lin and Megan Russell by Michael Stone, who was diagnosed as suffering from a severe personality disorder, as evidence that people with personality disorders are sometimes a threat to the rest of us.
The Zito Trust, set up by Jayne Zito after her husband Jonathan was killed, claims that two people per month are killed by ex-psychiatric patients in Britain (5). But the Trust largely relied on press clippings for its findings – and the impact of mental disorders on violent behaviour is far more complex than that.
Someone may have a psychiatric history and may commit a violent act, but this doesn’t mean that the former necessarily led to the latter. A person may suffer from psychosis and may commit an act of violence, but if the psychosis played no part in the act that is not the same as an actively psychotic person attacking someone. Such causal explanations are too simplistic.
A comprehensive review of the relationship between mental disorder and violence argued that methodological problems have clouded the debate. Published in the Journal of Health and Social Behaviour in 1995, it questioned research that claimed to show an association between mental disorder and violence, pointing out that the patients in the studies were not typical of the majority of the mentally disordered, and there was no comparison group. The review concluded that ‘the contribution to violence of major mental illness, current psychotic symptoms, or threat/control override symptoms is only modest’ (6).
But there is more to the Mental Health Bill than largely unfounded safety concerns. The Bill reveals much about the changing priorities of mental health care, and the shift from rehabilitating the mentally ill towards helping them just to ‘survive’.
The move from the old-style asylum system to care in the community was influenced by many economic, social and medical factors. Over the past 30 years, critics railed against the dehumanising conditions of the asylum system, while psychiatry’s claim to expertise was increasingly challenged by what became known as the ‘anti-psychiatry’ movement. The very concept of mental illness was made problematic.
Such critiques argued that more humane forms of treatment, with more emphasis on a ‘therapeutic understanding’ of the individual, would lead to the rehabilitation of long-stay patients, helping to integrate them back into mainstream society. Re-integration was possible, and rehabilitation was the deal.
In many ways, the new Mental Health Bill represents the end of this rehabilitative ideal.
In the 1950s, there was a much stronger sense that society could not only treat the mentally ill, but also eradicate some forms of mental illness. As one sociologist of mental illness put it: ‘[M]ore advances, more inventions, more wealth, would lead to a situation where fewer and fewer difficulties would have to be borne.’ (7)
The advent of psychotropic drugs and advances in psychological understandings, along with improved housing, employment and resources for the mentally ill, were heralded as the ‘third psychiatric revolution’ – helping to empty out the decaying old asylums. The first psychiatric revolution was represented by the mythical portrait of Philippe Pinel governor of the Bicêtre asylum in France freeing the insane from their chains, and the second by Freud’s belief in psychoanalysis as a ‘talking cure’ (8). The third, many believed, could get many long-stay patients back into society.
Today, such optimism is notable by its absence in the mental health debate. Some of the psychotropic ‘wonder drugs’ of the 1950s and 60s had limited success and were found to cause severe side-effects – and risk-taking has been replaced by risk minimisation. Today’s attitude to mental ill-health is characterised more by anxiety and caution, rather than a belief in progress and trying out new treatments.
This pessimism is not confined to legislators and policymakers. Ironically, many of those who criticise mainstream psychiatry also have a diminished view of our ability successfully to treat and transform the mentally ill. So while psychiatry continues to search for a cure for madness, many of its critics claim that such a pursuit is ‘immoral’. Liz Sayce, former head of mental health charity MIND, says ‘the aim is not to eliminate madness…. The ethics of such an enterprise would be questionable’ (9).
According to some, therapeutic treatment of the mentally ill should be marked by ‘an acceptance of individual limitations’ (10). Underlying such sentiments is a loss of faith in progress – not just medical progress, but individual and social progress. Mental distress is seen as being insurmountable, something we should just accept (or maybe even celebrate), rather than trying to defeat. This negative view is best captured by the number of individuals and groups who now identify themselves as ‘survivors’ of the mental health system.
According to one source, a survivor is ‘a person with a current or past experience of psychiatric hospital, recipients of ECT, tranquillisers, and other medication, users of counselling and therapy services, survivors of child abuse’ (11). Given the proliferation of therapy and counselling into many more parts of our everyday lives, it would appear that almost any one of us could be classed a ‘survivor’.
Of course, many ‘survivor’ groups have established useful alternatives to the under-funded and often patronising traditional forms of mental healthcare – and many have written useful critiques of policy and practice. So it is important to distinguish between individual ‘survivors’ who have something to tell us and the survivor phenomenon, where some organisations and campaigners tell us that ‘we’re all survivors now’.
In essence, the ‘survivor’ shares many traits with sociologist Erving Goffman’s degraded patient. In his classic study Asylums (12), Goffman detailed how on entering an institution the individual went through a ‘degradation ceremony’ – where they were stripped of their own clothing and given uniform hospital clothing, and encouraged by staff to disown their previous life and adapt to their new environment. In short, they were stripped of their previous identity and became ‘the patient’.
This idea of a fixed identity has been rejected by many ex-patients, who challenge the assumption that ‘once a schizophrenic, always a schizophrenic’.
The rejection of notions of fixed identity showed that people believed they could move on and transcend their difficulties. ‘Surviving’, by contrast, is about claiming recognition for past or present distress, and can be even more imprisoning than the old fixed patient identity. For ‘survivors’, recognition must be ongoing, as to ‘get better’ would mean losing their identity.
In the course of their struggle with social and/or medical aid the patient may get better and take control of their lives. But the ‘survivor’ is forever imprisoned in the past, their identity fixed and requiring constant validation.
Ken McLaughlin is senior lecturer in applied community studies at Manchester Metropolitan University.
spiked-issue: Mental health
(1) Mental health section
of the Department of Health website
(2) Psychiatrists to join protest over bill, Guardian, 29 July 2002
(3) ‘Detaining dangerous people with mental disorders’, British Medical
Journal, 325:2-3, 6 July 2002
(4) See A mad approach to mental
illness, by Ken McLaughlin
(5) ZT Monitor: the journal of the Zito Trust, Issue 2, October 1997
(6) See ‘The Social Context of Mental Illness and Violence’, V Hiday, Journal of Health and Social Behaviour, 1995, vol 36
(7) The Mentally Ill in Contemporary Society: A Sociological
Introduction, A Miles, Martin Robertson, Oxford, 1981, p193
(8) See Social Order/Mental Disorder, A Scull, Routledge, London,
(9) From Psychiatric Patient to Citizen, Liz Sayce, Palgrave, 2000,
(10) Quoted in From Psychiatric Patient to Citizen, Liz Sayce,
Palgrave, 2000, p132
(11) Quoted in From Psychiatric Patient to Citizen, Liz Sayce,
Palgrave, 2000, p9
(12) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, Penguin, 1961
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