The travel writer Tim Salmon’s son, Jeremy, developed schizophrenia in the late 1980s. This book is Salmon’s record and examination of the ‘strange voyage’ that has followed. It’s a critical, challenging book, but very well written, and never bland.
Schizophrenia turns Salmon’s previously able son into a difficult, paranoid and sometimes violent young man. He behaves in ‘ways that were strange and inexplicable beyond anything I had ever known, beyond anything I had the language to account for’. Every aspect of his son’s life is affected, his paranoia making friendships hard and intimate relations more difficult still. Salmon offers a personal carer’s view on the situation that has developed; the fear and despair he feels as a parent, the hopes, regularly dashed, that his son may eventually lead a more ‘normal’ life.
As the title suggests, a great deal of the book is devoted to examining Salmon’s pragmatic frustrations with the NHS and one is left with an impression that he wishes to inform but also to vent. He is not always diplomatic in this regard, and this may explain why this book has not reached a particularly wide audience. It’s not difficult to sympathize: the constant changes of NHS staff make relationships of trust with professionals hard to form; it takes three years – and a barrage of letters – for a care planning meeting to be held; Jeremy’s hostels are toxic and lonely. Of one NHS employee he writes:
“He replied that he was going on a course and would no longer be involved in Jeremy’s care. He had arrived on the scene in January of February, heard my concerns but kept me at arm’s length out of respect for client autonomy, unable without my son’s consent to disclose the time of meetings I had been attending for years, encouraged my son to go on a course which lead to my having to go to Toulouse to rescue him and now, in July, after a mere six months of involvement he was going off on a course and washing his hands of the whole business. Par, one might say, for the course!”
Salmon is generous towards psychiatrists – whom he regards as ‘scientists, trained to look at evidence, identify facts and call them by their proper name’ – but sharp stones are aimed at managerial staff whom he considers to be often of low intellectual quality. Salmon’s provocative stance is that their increased involvement in patient care has been associated with a shift of emphasis away from effectively treating and supporting those with mental disorder towards an unhelpful focus on ‘issues around mental health’ – ‘accommodating ethnic diversity, obsessive concerns about confidentiality and patients’ rights’. He finds the accompanying terminology distasteful:
The current jargon – empowering, accessing, service-users, delivering services, service-providers, advocacy, client – implies at number of assumptions that in my view are inimical to the cause of the mentally ill. First it implies a relation between the sick person and his healer that resembles that between the purchaser of a pound of peas and the shopkeeper more than that between what we used to call the patient and the doctor. Second it seems to imply a sort of hostile intent on the part of the healer: that treatment whether clinical or otherwise is a sort of coercive intervention from which the ‘client’ needs protecting. Third it implies that the sick person is a rational being capable of taking informed decisions about his own condition and treatment.
Also an anathema is the repositioning of mental health charities towards addressing all mental health problems, serious or not, and their focus on ‘stigma, fear and prejudice’ at the expense of practical help. He considers talk of empowerment inappropriate for people with schizophrenia who ‘are not going to move on’ and who need ‘stability, security’ above all else. The recovery model is dismissed as a fudge as, with this approach, ‘put crudely, you do not need to be well to be called well.’
Salmon’s ultimate conclusion is bleak:
He is difficult my son, it goes without saying, but what use is a system that in thirteen years has not been able to tackle any of his central needs, even the straightforward practical ones like benefits and prescriptions?
As well as offering a personal narrative on the effects of mental illness Schizophrenia: who cares is an uncompromising view of the shortcomings of mental health care in the UK today. Although such a statement of doubt is valuable in itself, I would have welcomed a more fully developed argument on why the current narrative of recovery and empowerment has taken root. The current ‘issues around mental health’ approach can be seen as a reaction to historical concerns regarding institutionalization of patients, exclusion of ethnic minorities, and abuse of human rights. Whilst Salmon may believe that we’ve overshot with our concerns in this regard I doubt he would be in favour of a wholesale return to past practice. Given his day job it is curious that he is not more sympathetic to the vulnerability of ethnic minorities and a general weakness of this book is Salmon’s generalizations which do not peer beyond his own cultural viewpoint or experiences – some people with schizophrenia can hope for a much better outcome than his son for instance.
What’s in a name? Patient, survivor, client – Tim Salmon letter to The Psychiatrist 2010
All in the mind – Tim Salmon features 15 June 2010