Pure Madness: how fear drives the mental health system, by Jeremy Laurance

A chilling tour of Britain's psychiatric frontline

By Richard Bentall
Tuesday 28 January 2003 01:00

Looking at the history of psychiatry over the last century, it is difficult to believe that the profession has much to be proud of. The therapeutic outcomes achieved for severely mentally ill patients by modern services have hardly improved on those at the end of the 19th century. It is true that large asylums have been closed, and most patients now live in the community, but their lives are often blighted by isolation, unemployment and poverty.

Jeremy Laurance has walked the frontlines of psychiatric care in Britain today, and Pure Madness is an unsettling read. As Laurance notes, people who use mental health services are "angry, distressed and loathe the way they are treated, the drugs that are pumped into them and the attitudes their diagnosis engenders in the rest of society".

Attempting to find out why services fail to meet their needs, he focuses on the way that fear of the mentally ill has driven policy over the past 20 years. Selectively reported by the mass media, a series of appalling tragedies (the murder of Jonathan Zito by Christopher Clunis, the slaying of the Russell family by Michael Stone) has created the widespread impression that large numbers of mad axemen are roaming the community. Yet mentally ill patients are not a dangerous group (certainly less dangerous than drunken drivers).

A major target of Laurance's criticism is the coercive mental health legislation now proposed by New Labour. This will require currently well patients to return to hospital if they refuse to take their drugs, and allow psychiatrists to detain indefinitely people with awkward personalities who are deemed to present a risk to others (a power most psychiatrists do not want). It would be better to create services that patients want to use, Laurance argues.

The book also gives some grounds for optimism. Good practices are described, such as a mental health service in Bradford that involves former patients in decision-making, is sensitive to patients' cultural circumstances, and uses drugs only as a last resort. Above all, Laurance sees hope in the rising clamour for consumer control.

The numerous, vivid vignettes of interaction between clinicians and patients are a major strength of this book. We follow psychiatrists and social workers on a tour of acute psychiatric wards, hostels and squalid inner-city flats where discharged patients have taken up residence. We meet patients who exacerbate their own symptoms by taking street drugs, but also success stories such as Rufus May, once a schizophrenia patient and now a practising clinical psychologist.

If I have one criticism, it is that the relaxed style makes it difficult to trace the research literature that has informed the conclusions. I would also have liked more discussion of how the theories embraced by modern psychiatry – the idea that schizophrenia is just a brain disease – have contributed to the exclusive reliance on drugs. Nonetheless, this book should be required reading for politicians, pundits and anyone whose idea of modern psychiatric care is a psychoanalyst perched at the end of a sumptuously-upholstered couch.

The reviewer's book 'Madness Explained' will be published by Allen Lane this summer

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