Buy from Waterstones Amazon

I am forming a theory that, rather like a stew left in the fridge, the longer one leaves a book on a shelf, the better it becomes.  For instance I left Jonathan Coe’s ‘The Rotter’s Club’ on my shelf for four years before reading it and it turned out to be brilliant.  By contrast I acquired its sequel ‘The Closed Circle’ and read it without leaving it to languish at all, and it turned out to be most disappointing.

When clearing out an office at one of my placements eighteen months ago I requisitioned Jeremy Laurance’s book ‘Pure Madness’ and it’s been kicking around my flat ever since.  Subtitled ‘how fear drives the mental health system’ it’s a really interesting examination of the problems with the UK’s mental health system, and how these problems have come about.  Laurance is the health editor of the Independent newspaper and took nine months off to write the book.  A noble effort, considering that he can’t have been expecting to sell many copies. 

Throughout the book Laurance’s journalistic skills shine through, as the book is both informative and interesting, a not inconsiderable achievement given its potentially dry subject.  In large the book deals with current culture in the mental health field where the predominant concern is risk management rather than patient care and where the care of patients appears to lurch from crisis to crisis, with limited resources available for long term work.  Laurance also discusses that dissatisfaction that many people who use the service feel towards the care that they are offered. 

In chapter 11 ‘The new meaning of community care’ Laurance sets out the problems as he sees them:

‘In reality, over the past decade, mental heath services have been driven by public and political pressure to adopt the risk avoidance agenda.  Facing a chronic shortage of resources, community care has never been realised in its full scope and the services have been narrowly focused on securing the safety of the public rather than meeting the needs of the individuals.  The result is a service which:

Provides help in a crisis for people with mental health problems but offers little in the way of prevention to stop the crisis occurring, or support after it is over

Is medically driven and focused on drugs with little choice of other kinds of treatment

Relies on containment and compulsion with a 50% increase in the sectioning rather in the past ten years and increasing use of medication. 

Is strongly disliked by users and…

Has been heavily influenced by carers’ organisations

Is being driven to be more coercive and controlling by Government proposals for legistation which highlight dangerousness.’

How did this all start?  In terms of the risk model, Laurance identifies a turning point at which the debate about mental health treatment changed.  This turning point was the fatal attack by Martin Clunis, a man with a diagnosis of schizophrenia, on Jonathan Zito, a unfortunate bystander knifed at random.  Following this tragic incident, Laurance contends that, in terms of the care of those with mental health problems, concern for the welfare of the (non-violent) many was replaced by the fear of the risk posed by the few.  The result was an ‘inquiry culture’ and press frenzy.  Whist ignoring society’s most prominent cause of violence – that of people intoxicated by alcohol, suffering no mental illness – papers continually printed stories of unprovoked attacks of on strangers by ‘nutters on the loose’.

Clunis lived in the community, but fifty years earlier he would most likely have been in an asylum.  These places were more about containment than treatment and lead to the institutionalization of many people.  During the 1960s social and economic pressures, as well as the advent of anti-psychotic medication lead to their gradual closure.  At first this went smoothly – there were many people in hospital that shouldn’t have been there in the first place – but discharging patients with more severe problems proved more difficult and often the appropriate care for them in the community was lacking.  The money saved by closing asylums was diverted into physical medicine rather than being invested in mental health provision. 

In 1998 Frank Dobson, Health Secretary, stood up in front of the House of Commons and declared that ‘community care has failed’.  This view is disputed by Professors Graham Thornicroft and David Goldberg.  They contend that community care has only been half implemented and so this cannot be said to have happened.  The reduction of the number of psychiatric beds was achieved by closing the vast majority of long stay psychiatric beds but the number of acute beds has remained stable.  However no provision was made for the possibility of short term admissions for the previous long stay patients who are having a crisis.  The result is immense pressure on acute psychiatric wards, with occupancy rates often exceeding 100%. 

Community care is popular with patients, but standards are low with psychiatric wards being unpleasant places and community care without the resources for long term work and geared towards dealing with crises.  But the argument that community care has lead to increased risks to the public cannot be sustained; Laurance says that figures show that there has been no increase in killings by people with mental health problems in the forty years that mental hospitals have been emptying. 

The new president of the Royal College of Psychiatrists Dinesh Bhugra, was recently very critical of UK mental health provision.  Thornicroft would agree and is quoted in the book as saying: ‘There are ways in which the mental health services we have got used to wouldn’t be accepted in other forms of care’.  Laurance illustrates this schism whilst talking of suicides ‘imagine if cervical cancer patients, screened and treated on the NHS, were still dying at a rate of 300 a year with shortcomings in the service blamed for the deaths of a further 900?’

Very valuably, Laurance lends much of his book to providing reports as the feelings and wishes of people with mental health problems who use the service.  There is much dissent. 
‘the biggest change in the last decade has been the growing protests from people with mental health problems who use the service.  There is enormous dissatisfaction with the treatment offered with the emphasis on risk reduction and containment and the narrow focus on medication.  They dislike the heavy doses of antipsychotic and sedative drugs with their unpleasant side effects and a growing number reject the biomedical approach which defines their problems as illnesses to be medicated rather than as social or psychological difficulties to be resolved with other kinds of help’

With this in mind, we hear of Bradford consultant psychiatrists Phil Thomas and Pat Bracken who published a well known paper in 2001 entitled ‘Postpsychiatry: a new direction for mental health’.  Their attitudes are popular with user groups and Laurance finds them ‘prepared to take greater risks than many of their colleagues to protect the autonomy of people with mental health problems and are less in thrall to the ‘safety at all cost’ culture that dominates the profession’. 

This reminds me of Rufus May, who works in Bradford, and this site’s postings about his television programme ‘The doctor who hears voices’.  One of my major criticisms was that May did not manage the suicide risk of his patient adequately.  I still think that May took a big chance in the way he approached ‘Ruth’s’ treatment, but I can recognise here in my approach the effects of the culture in which I have been immersed. Like a creature of my training I was horrified at what I saw as May’s risky approach, whilst May took an approach that valued the autonomy of his patient over all else.  Rufus May features in the book, in a chapter in which Laurance details the ‘life stories’ of several people with mental health problems.  What stands out in all the stories are the difficulties people face in receiving the care that they might wish, but also the broad nature of the problems with which mental health services must deal. 

In conclusion Laurance reports that the Government has reacted to the problems of patient care and public safety with two opposing agendas: firstly they have identified mental health as one of its three health priorities, making new money available.  But they have also proposed more coercive laws to deliver a safer service.  Psychiatry has always had within it an element of social control, but the question is to how far these powers should extend. 
Laurance finishes:

‘The argument of this book is that the most effective way to increase satisfaction and at the same time improve public safety is to devise services that genuinely engage mentally ill people and meet their desire for greater involvement in their care so that they are encouraged to lead stable risk free lives.’ 

If you enjoyed this post you can buy me a coffee!

This entry was posted on Monday, July 21st, 2008 at 11:12 am and is filed under Books Films Television. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.