Jeremy Laurance: Fear is the worst way of managing mental health

I cannot think of another speciality that generates such hostility from patients as mental health
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One striking feature of the mental health system is the deep loathing most people have for the services that are supposed to help them. They hate the way they are treated, the drugs that are pumped into them and the attitudes their diagnosis engenders in the rest of society.

One striking feature of the mental health system is the deep loathing most people have for the services that are supposed to help them. They hate the way they are treated, the drugs that are pumped into them and the attitudes their diagnosis engenders in the rest of society.

This should not surprise us. People with mental problems are discriminated against at work and locked up even when they have committed no crime. Comedians joke about them, headline writers demonise them and now the Government is poised to erode their liberty yet further with a mental health Bill condemned on all sides for its coercive intent.

A psychiatric diagnosis acts as a bar to relationships, employment and key services such as insurance and mortgages. Unlike a physical diagnosis, it is often for life. Since the diagnosis is made primarily on the basis of a judgement about a person's conduct, there is the risk of it invalidating their whole identity and sense of self.

A diagnosis can become true just because it has been made. Once labelled "schizophrenic", a patient cannot object to or resist treatment – that would be evidence of their mental disorder. Branded as a mental patient, he or she is no longer a credible witness, even about his or her own mind.

It is against this background that the "user movement" has grown over the last 20 years, pressing for a greater say in services. During the past 18 months I have travelled round the country observing the mental health services for a book I have been writing.

Everyone I spoke to, from inner-city social workers to the mental health tsar, Professor Louis Appleby, agreed that the growth of the users movement was the single most significant development of the past two decades. Yet in their eagerness to jump on the populist bandwagon of protecting the public from psychopathic murderers – the mad axemen of popular myth – ministers have failed to ask why so many people with mental problems reject the services on offer.

There is enormous dissatisfaction with the emphasis on risk reduction and the narrow focus on medication. People with mental problems dislike the powerful drugs with their side-effects, and a growing number reject the bio-medical approach that defines their problems as illnesses to be medicated rather than as social and psychological difficulties to be resolved with other kinds of help. They want a range of options from crisis houses to support groups to help with new strategies for living.

I joined several meetings of the Critical Mental Health Forum, a group that assembles once a month in a deep basement room of the YMCA off Tottenham Court Road, in central London.

About 30 people turn up on an average night, mostly in their 20s and 30s but several over 50 – some with jobs, some without, most with current or recent experience of mental illness. They sit in a rough circle on squashy cushions and share stories, advice and opinions. One issue that generated the most animated debate was that of control and compulsion.

The overwhelming view of the meeting was that compulsion may be acceptable in extreme cases, but there has to be more on offer than the "chemical shackles" of medication. One woman said she would prefer to be tied up in a straitjacket than forcibly injected. "At least you take the straitjacket off when the crisis is over." Another woman said she had instructed her boyfriend to chain her to the radiator in their flat rather than admit her to hospital. "I don't want to be pumped full of drugs which is all they do," she said. The services they wanted were not there – and they did not want the services that were there.

For many of those present, the problem lay with the biological model of mental illness on which psychiatrists rely. There was much criticism of the pharmaceutical companies in promoting drugs that, it was said, have no specific effects but offer different ways of sedating people, to make them easier to control. Drugs, it was said, may be useful at times of crisis but they will not provide a long-term solution. They rejected medical labels as a way of construing their distress and saw their problems overwhelmingly in social and psychological terms.

Several complained they were too often caught in a catch-22. If the mental-health services said they needed the drugs and they refused them, that proved they were mentally ill and needed sectioning. Equally, if they took the drugs, that proved they were mentally ill. They were insane to take them and insane not to. Once the psychiatric establishment had its claws into you, there was no escape.

The strength of the opposition to the mental-health services from the people who use them is remarkable. I cannot think of another speciality that generates such hostility, partly, it must be assumed, because of the element of social control that is a part of a psychiatrist's duty. Although there is much criticism of doctors in general – targeted at "arrogant" attitudes and poor quality of care – there is no similarly combative anti-movement in any other area of medicine. (One possible exception is cancer care, where there are groups aggressively promoting alternative approaches based on remedies such as coffee enemas and wheatgrass juice).

But this opposition is something that government ministers refuse to acknowledge. Instead, they have adopted a bullying approach, threatening patients with forced treatment if they do not take their medication and incarceration if they are judged to be a danger to others. The flaw in the draft mental health Bill, highlighted by an unprecedented coalition of the Church, medical and legal professions, voluntary groups and patient organisations, who have united in condemnation of it, is that the people at risk will be driven away from the very services that can keep them, and us, safe.

The Mental Health Act Commission observed in its last report that "where there has been a public inquiry into [cases of homicide] the failure has often been more in the non-use of existing services than the absence of legislative provision".

To brand mentally ill people as dangerous is the worst kind of stigmatisation. Figures show there has been virtually no increase in killings by people with a mental illness in the 40 years during which the mental hospitals have been emptying. Over the same period the overall murder rate has soared. Yet ministers continue to stress the risks posed by the few as the justification for their authoritarian approach.

There are grounds for hope. The Government has an ambitious programme to expand community care with new home-treatment teams aimed at providing more flexible services. There is substantial new investment, and with good organisation, fewer people should fall through the net.

But that depends critically on how the new services are perceived by the people for whom they are designed. If they appear too coercive, geared to getting medication into people and little else, they will fail to engage them. If ministers persist with a heavy-handed emphasis on protecting the public, the gains from the new strategy will be lost – and the risks, both to people with mental problems and to the public, will increase.

The author's 'Pure Madness – how fear drives the mental health system' is published this week by Routledge (£9.99)

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