"Mental: a History of the Madhouse"

As a part of a series of documentaries detailing changes in views about mental illness in the last 60 years, BBC4 screened Mental: A History of the Madhouse last night, and it did an admirable job of exploring the spectrum of shades of grey involved in the issue without black-and-white judgement.

For example, there was Maggie, who volunteered for "experimental" brain surgery in the 1960s and who feels that, after 5 years of debilitation that followed the surgery - in which a section of her brain was burned out to stop the fits of violence that would require increasing lengths of hospitalisation - she recovered in spite of and not because of the operation. She has been given awards for campaigning for community causes...but one is left wondering if this would have been possible without the operation.

I thought of this towards the end of the documentary, when we saw the dark side of the opposite of the asylum model of care. Following a series of murders by people who had been released into the community as beds were closed (so the chance of their being readmitted stadily diminished), the most famous of which was the 1992 murder of Jonathan Zito by Christopher Clunis at Finsbury Park, a psychiatrist briefs a police shift that one of his patients is having increasingly violent urges, and then a dozen riot officers break into his house because both psychiatrist and police have decided that "overwhelming force" is required.

There have, of course, been huge leaps since the days of the asylums, when staff violence towards patients was recalled by a former psychiatric nurse as having been justified, when he was a student, by his charge nurse on the grounds that "if you live among shit you become shit". Although thankfully I missed this period, I felt ashamed to have been a psychiatric nurse.

In 1959, Patricia Hornsby-Smith (in Harold MacMillan's Conservative government) reported on the crippling price of keeping more people in psychiatric institutions than there had ever been, reporting on the "appalling legacy" of the buildings and how maintaining them would take up an increasing portion of the NHS budget; but she also spoke on how an appreciation of mental illness being like "any other disability" was a prerequisite on action that would need to be taken on both pragmatic and humanitarian grounds.

Hornsby-Smith's speech was the prologue that Enoch Powell's 1961 Water-Tower Speech was written to follow:

it is the duty of a Minister of Health and the duty of the National Association for Mental Health, to...choose and to favour wherever they have the choice, the course of more drastic and fundamental change: for we may be pretty sure that even so the progress of medical thought and method will still be well on ahead of our practice.

Powell was, of course right (and it was good to see the BBC admit that the man was more than a controversial 15-minute speech): as the documentary showed, "hope came from the laboratories [in the form of] a new generation of psychiatric drugs". However, Largactil (chlorpromazine) created new problems to replace the ones it solved in the form of simultaneous agitation and sedation, and Parkinson's Disease-like symptoms. Had the resarchers looked further into its genesis, they might have found that it was derived from a dye produced in Victorian England, but wasn't much use. So it was fed to cows to see the effect, which was that the cows calmed down. And died shortly afterwards.

However, the growing voice possessed by mentally ill people and their advocates - who included many mental health workers - drove the phamaceutical search for medications that had maximum effect on symptoms with minimum unwanted effects. The quest still continues.

But how did we get from this sense of optomism to a mentally ill man's flat being raided by a dozen riot police? As beds decrease, I worry that the stigma that infested the ageing Victorian structures hasn't disappeared but has rather been absorbed into society, which has become itself an über-asylum wherein, asserts London Mayor Boris Johnson in an exegesis of Eleanor Rigby, too many people "pretty much stay at home and watch TV" with their loneliness acting as a straitjacket - a garment never used once in the history of the crumbling Victorian asylum where I trained.

As politicians struggle to describe how they are going to deal with the deficit, it's obvious that there are going to have to be cuts. But this should not blind us to the fact that cuts started some time ago. Fulbourn hospital, the psychiatric hospital serving Cambridge and surrounding areas, lost two rehabilitation units and two acute psychiatric wards in 2007. This could have been ameliorated by better services in the community, but Vocational Services, providing occupational therapy, and Cambridge Clubhouse a range of less structured opportunities of rehabilitation after psychiatric treatment, are long gone. The Clubhouse was replaced by a mental health resource centre that aimed to make ex-patients in the community into trainers, but access is now only by telephone.

I'm not setting out my stall for my territory, having switched from a psychiatric nurse to a psychiatric patient some years ago. I'm merely arguing for common sense: in the absence of dedicated resources people requiring mental health treatment are, at the more severe end, going to keep ricocheting between inpatient wards, police cells and prison and, at the less severe, take up more of the general resources that are available, eg GP appointments, A&E beds, etc.

And the human cost is intertwined with the financial one, something that Patricia Hornsby-Smith and Enoch Powell would have recognised. I met a fellow Clubhouse veteran recently; unable to maintain employment without input but "not ill enough" to warrant a community psychiatric nurse, she spends her time subsisting on benefits - mostly, as Boris Johnson says, at home watching TV. Investing in resources that would help people like my friend both to work and to pay more taxes would, in my opinion, be a win/win situation.

Related posts:

Good taste back on the Horizon: How Mad are You?

Blurred Boundaries, Fine Lines - How Mad are You?