The history of my profession – specifically the mental health aspect, rather than the social work aspect, is not a glorious one. And there was a programme last night which highlighted a lot of what went wrong -
BBC Four: "Mental: A History of the Madhouse"
[should be available to watch again for UK users in that link until 25 May.
Warning: contains some disturbing scenes of experimental/harmful surgical procedures.]
Starting out in the early twentieth century rather than at the beginnings of asylum in "Bedlam" times, it told of the large Victorian institutions which were both the sanctuaries and sole carers, but also the prisons and occasionally torture chambers of those deemed "unfit for society".
It moved from the "Poor Law" age, where asylums were places of incarceration, through the new NHS age in the late forties where they became misguided capitals of psychiatrist power, into the sixties and seventies where they became unfashionable to the eighties and nineties when the last major institutions closed down.¹
In harrowing testimony and archive footage, it told of the injustices of the systems; of people forcibly admitted for "actions against society" [one person in Ipswich I got to know in the early nineties had been admitted and kept for decades for the shame of being a single parent as late as the fifties]; of the institutional abuses carried out in the name of keeping order; of the sheer horror of some of the misguided experimental attempts at providing a surgical "cure" for mental illness; and finally of the system's decline because of its huge running costs, its dismantling, and the ramifications of the mass closures.
For those of us who have a direct interest in the mental health system – and that's just about everybody, unless you're an undiagnosed sociopath – this piece of history is a harrowing watch, but also one with hope; the issues are still red-hot live, but we're not dealing with the same level of abuse, of degradation, of needless suffering as we used to. It's a stage in our acceptance of the past, and hopefully our path to the future.
I urge you, so long as you're not in a place where it'd be bad for you to watch such things, to have a look. It's not only horrible – there are also good stories – but it's also so revealing about the cultural thinking, not only about mental health but about society in general, that was going on at those times.
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There's a couple of aspects I particularly want to mention -
The first, and still germane to our times, is the idea of power without responsibility. The major example of this was where the old institutions were perfect examples of where a government said "here, you deal with this problem, I don't care how, just do it so we don't have to see it". In essence, they were perfect Stanford Experiment models even decades before the experiment actually happened – and the results, sadly, were as predictable even then as they are now in our modern versions of the "total prison".
Below the major abuses, though, was a more subtle expression of power, that of utter primacy of the professionals. The psychiatrists which ran the place did so, I'm sure, through the highest motives originally, but became as institutionalized as the patients; they had come to believe in their own moral superiority.
The credos and dogma they spouted came from rational language, ostensibly miles from the Victorian Xian paternalism of their forefathers, but in reality was as good at shielding itself from the negative effects of its actions as any circular-logic theology.
To take one example; for some time, the dogma was that insulin shock therapy is a good thing; therefore insulin therapy is what we do; and if the patient doesn't respond that's the patient's problem, not the therapy's or the psychiatrist's. It took several decades for the realization that this therapy was actually severely harmful to filter down through to the ivory-towered psychiatrists.
Those days have long gone. Or have they? Consider these days, where "treatment" for anxiety-stress-depression is governed not by the dogmas of Xianity or medical paternalism, but by the constrictions of NICE. They've deemed that the best – by which they mean the most cost-effective as well as backed by the most scientific evidence – treatments are the cheapest SSRI drugs, and cognitive behavioural therapy if need be.² GPs which prescribe more costly treatments will either have to justify doing so or get a right bollocking off their health authority.
It's not quite like before when actively harmful treatments were meted out³; but, like before, we see a situation where mental health problems are treated as if they were physical ones; the "best" treatments must always be applied because the dogma is that the stress-anxiety-depression is separate and distinct from all other issues; so there's no need to take other factors into account when deciding which treatment will work "best". Just dish out the Prozac, put the patient on the [months-long] waiting list for CBT, and shout NEXT!
This doesn't sit well with "patient experience" which always points to a more "holistic" view of their difficulties – each individual having their own particular complex set of problems, therefore needing a particular complex set of solutions – but there's no way a holistic approach is going to get properly funded in the current environment.
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The other aspect of this history I want to mention comes with the closure of the asylums, and the introduction of "Care In The Community".
Nowadays it seems ironic, even perhaps absurd, to think that the first great champion of closing the institutions and freeing the patients within was the grand Conservative politician, then destined for high things but later derailed by being a paranoid racist twat, Enoch Powell.
Nor does it seem quite right that the government which finally bit the bullet and fully implemented the policy was a Thatcherite one at its mid-eighties height.
Were they right to do so? Unquestionably. Anyone who suffers from "asylum nostalgia" has never been near one.
Should they get the credit for doing so? Absolutely, but with this proviso. Powell and Thatcher's instincts were libertarian; they had very little concern for the treatment or "freedom" of any of the asylum inmates – they just wanted the big drain the institutions made on the public finances halted and staunched.
When the inmates were released, few went into situations where they had any proper support or rehabilitation into the "community".
Some thrived – and Powell and Thatcher deserve the credit for allowing them to do so. Some struggled – with housing, money, community stigmatization, and all the other easily predictable problems. Some went straight from asylum to prison and have stayed in and out ever since. Some fell into the "charity sector" – Salvation Army hostels became their new institutions, with no abuse but lots of enforced bible-thumping. And quite a few didn't survive.
The late eighties and the early nineties were marked by a long series of scandals in which patients released with little or no support committed murders and violent crimes; the killing of Jonathan Zito caused the most outcry.
[Another I remember was when a patient in a psychotic state managed to climb into a lion's cage at London Zoo. The joke at the time was that afterwards he received the best tip-top care and round-the-clock therapy - whilst the patient was shoved back on the street with a bottle of pills.]
It took the ousting of the Conservative government in 1997 for reforms to be made which strengthened the obligation for authorities to provide support for vulnerable sufferers in the "community". The libertarian ideal of patients completely free outside of asylums was tempered by new laws such as "medication orders" which forced people to take their pills, and eventually a new Mental Health act. The arguments about the balance between personal freedom and community "safety" are still raging. The problems with "community care" are ongoing, and very rarely spoken of by those in power in public [in case the bill for it frightens the outraged-taxpayer middle Englander].
I take all the above as evidence that although libertarian instincts are in a lot of ways okay, in practice they lead to some pretty shitty outcomes if you've not got the money and personal power to cushion yourself.4
Of course I wouldn't say that the outcomes were worse than the history which preceded them – I can imagine little worse than lifelong incarceration without appeal – but must we really have suffered from the lesser of two evils? Was it necessary to go through the laissez-faire approach of those who were mentally ill and unable to cope with life outside sleeping rough on the streets, frightening or attacking people, and, even still today, filling our prisons – in order to get rid of the old institutions?
To those who are powerless, to those who are in need, giving these people a set of theoretical "freedoms" and "choices" works great for a few, but works very badly for an equal set of few, who'll impact extremely heavily on the rest of society. The lie of Thatcherite libertarianism [and its even scarier American cousin] was – and very much still is – to pretend that others will pick up the pieces, that somehow it'll evolve into its own balanced solution – ultimately, that those negatively impacted can be safely brushed under the carpet where the so-called "hardworking, decent families" beloved of populist politicians won't have to notice them.
By wanting psychiatric patients to "hide away" and not bother anybody, the Thatcherites in the end were guilty of the same crime as the Victorian paternalists.
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1 The programme said they all disappeared – not quite true; Broadmoor, Ashworth, Rampton and Carstairs "high-security hospitals" are still with us.
2 If available, but that's a whole other can of worms.
3 although some, eg Ben Goldacre, maintain that SSRIs have little therapeutic value for a lot of side-effects. My unscientific observation is that they have a lot of value for long-term sufferers, and very little for those who have just temporarily fallen off their metaphorical horse.
4 This sense of "nice theory, pity it won't actually work" is not the only thing libertarianism shares with Marxism; also comparable is the way their followers are unshakeable believers, resolute arguers and utterly annoying as frog.
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