Psychiatrist in dissent – part 2

In part two of Psychiatrist in dissent Sean O’Shea discusses some of the changes in mental health services associated with the NHS Community Care reforms in the eighties/nineties, considers the politics of diagnosis and assesses the legacy of rebel psychiatrist the late R D Laing (1927 – 1989).

Most of us are now likely to die in hospital.
Do we as citizens want to live in one?

During the seventies I frequented the Load of Hay pub in Haverstock Hill, London where Laing held impromptu seminars for those interested in engaging with him. Laing after two or three whiskeys was eloquent, after a few more the pace slowed a little but he still managed to make more sense than many of his colleagues when entirely sober.

After the pub closed one evening I wandered up the road with him. He asked, “Do I know you?” I said, “No, you don’t, but I know you through listening to you these past months and through reading your books which I have found challenging and thought provoking.” “I’m glad I made a connection with you,” he replied. With that he raised the collar of his raincoat and disappeared into the night.

His celebrity status was in decline and because of his “wild ideas” and sometimes troubled personal life he had become an object of derision in the media particularly the tabloids, and was forsaken by some of his erstwhile friends in the profession.

In wider society chill winds were blowing. Counter-culturalist dissent was being met by a right-wing back lash and Thatcher was elected in 1979 on the promise that she would bring the nation to heel and restore order.

Community care  

In the mental health field the old, expensive Victorian hospitals were to be replaced by more cost-effective locality-based services. Society didn’t exist but henceforth people with mental health problems would be cared for in the community.  Social services were to be the lead agency in this initiative but were not furnished with the resources to deliver it (Health and Social Care in the Community, Means and Smith, 1998).

Paradoxically the closure of the large mental hospitals contributed to the demise of the therapeutic communities. There were still some local council sponsored halfway houses run on therapeutic community lines and voluntary sector organisations such as the Richmond Fellowship continued their commitment to psychosocial rehabilitation. But as a way of supporting people with mental health problems the therapeutic community approach was gradually abandoned in favour of allegedly more cost-effective individualised “treatments.”

As the old hospitals closed there was a rapid rise in the prison population prompting some to argue that the Community Care reforms involved little more than a transfer of people with mental health problems from the hospital to the prison system. The prison population in England and Wales soared from just under 45,000 in 1990 to 88,179 in 2012, and it was estimated that over 50% of these were people with mental health problems (UK National Statistics and NICE)

Those fortunate were allocated supported housing in their local neighbourhoods. Others ended up in hard-to-let flats on derelict inner city housing estates. Others still were dispatched with one-way tickets to the seaside. Their destinations were often coastal towns with high IMD (Index of Multiple Deprivation) scores, and with which they had no personal connection. And finally there were those who drifted into homelessness and vagrancy.

Community psychiatric nurses were deployed to deliver long-acting or “depot” injections to people with mental health problems in their own homes. Community Treatment Orders (CTOs) were introduced which required “community patients” to take the medication prescribed for them notwithstanding their sometimes disabling side effects. If a patient failed to comply they could be involuntarily re-admitted to hospital where they could be kept for up to 72 hours for assessment. Service users and some professionals expressed objection to CTOs focussing on their restriction of patients’ personal liberty (Mental Health Alliance, 2007). Laing too would have been opposed to such a policy and it is to a consideration of his legacy that I will now turn.

Legacy

 – dreams of freedom

Those who study, explore and write about the darker, conflict-ridden dimensions of individual and group experience run the risk of finding themselves out on a limb, and may encounter ambivalent and sometimes quite hostile reactions from the public at large as well as their professional peer group. So it was with Laing who seemed to have been loved and hated in almost equal degree.

For some he embodied the hopes, struggles and aspirations of a generation. He also embodied the failure of that generation to radically transform society and turn their multi-faceted counter-culturalist vision into a reality.

Yet he did not invent a new form of therapy or a new religion, nor did he spell out a plan for institutional/political transformation. Those who expected this of him were to be disappointed and some could not forgive him for refusing the role of political revolutionary or spiritual saviour/shaman – nor was he forgiven for his personal failings.

Laing was a wounded healer. He could be kind, intuitive and supportive. He could also, by some accounts, be hurtful, inconsiderate and apparently negligent of his responsibilities to those closest to him. However, it is important to separate the man from his ideas and work.

His views on how dysfunctional families may precipitate mental distress in one or more of its members were given a sympathetic hearing by his professional colleagues, and judging from sales figures for Sanity, Madness and the Family, resonated with members of the public as well. Indeed many of his books became bestsellers, and contributed to an improved understanding and awareness of mental health issues amongst a mass audience.

 – medication and politics of diagnosis

Laing was often criticised for being anti-medication. However he did not deny that medication can provide relief from troubling symptoms and did not object to it providing it was taken voluntarily and with informed consent. He remained opposed to electroshock and involuntary psychiatric treatment.

He was concerned about the politics of medication as well as the politics of diagnosis i.e. the issue of who decides who needs what drugs, to what purpose and under what conditions. The same questions apply to imputed “mental disorders”.

What thoughts, feelings, experiences and behaviour are to be defined as a disorder or a “mental health problem,” in whose interests and under what conditions? How might one distinguish between a disorder and a non-disorder? Even the writers of the DSMV (Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association) conceded the difficulty of drawing a fixed line within a continuum of behaviour from ordered to disordered.

The practice of incarceration of political dissidents in mental hospitals and their involuntary treatment with neuroleptics is a case in point and well documented. Usually however it is faraway places e.g. Russia, China, and Cuba which are cited as the main culprits in the political abuse of psychiatry. However, there are concerns closer to home (Psychiatric diagnosis as a political device, Joanna Moncrieff, UCH, Social Theory & Health Vol.8, 2010)

For example an often used psychiatric diagnosis particularly in the USA is ‘oppositional defiant disorder’ (ODD); its symptoms include anger, defiance of authority and going against social norms. Psychologist Bruce Levine writes that this label is particularly applied to young people who ‘actively defy or refuse to comply with adult requests or rules’ and ‘often argue with adults.’ (Psychiatry’s Oppression of Young Anarchists—and the Underground Resistance, Mad in America, June 2013)

If political dissent can be a sign of madness what of so called ‘spiritual awakenings’ or ’emergencies’? The DSM has another category i.e. ‘religious problem or syndrome’ to cover such states.

Laing’s ideas about psychosis as potentially transformative as well as his interest in human potential and the mystical dimension of psychedelics were regarded by many as going beyond the pale, and few of his professional peers were to follow him in his academic and personal explorations of this psychoscape.

However he was not a lone voice. Seminars were held in the sixties at the Esalen institute Big Sur, California – a non-profit alternative educational facility focusing on human potential – which undertook research in transpersonal psychology and challenged orthodox thinking about psychotic experience. Teachers and seminar leaders at Esalen included such luminaries as Aldous Huxley (The Doors of Perception), Timothy Leary (The Politics of Ecstasy) Carlos Castaneda (The Teachings of Don Juan: A Yaqui Way of Knowledge) and Laing himself.

The Esalen institute is now a world renowned retreat, research and educational centre which continues to pursue its goal of reconciling ‘scientific and mystical perspectives into a more encompassing vision of human possibility’, and takes a critical stance towards the indiscriminate pathologizing or problematizing of non-ordinary states of consciousness (www.esalen.org)

Wing of madness

Daniel Burston, author of The Wing of Madness: The Life and Work of RD Laing (1998) writes, “The general view of Laing’s theories within psychiatry is that they are the product of a wild, utopian, romantic imagination – or interesting as museum artefact but of no contemporary relevance.”

I beg to differ. Laing’s criticism of mainstream psychiatry is as valid today as it ever was – possibly more so. Forgotten or derided as he may be by his professional peers he is remembered by many who have suffered from mental distress as a person who at least understood their plight.

While mainstream psychiatry was often dismissive of the anti-psychiatry critique it was not entirely unaffected by it. The medical model gave way to an allegedly more humane and liberal model of mental illness, the biopsychosocial model. This, in theory at least, acknowledged that psychological, social and cultural factors, as well as biology, are relevant variables in the aetiology of mental disorder.

However, in practice genetic factors and neurochemical imbalances in the brain continue to be regarded as primary. This attitude is reinforced by medical training which emphasises somatic pathology and encourages reliance on drugs as the first-line treatment for mental health problems – as well as physical illness.

The role of doctors as primarily dispensers of medication with a prescription pad at the ready persists. And these medical norms are reinforced by heavy marketing and sponsorship by the pharmaceutical companies.

People not psychiatry – the impact of cuts

Laing believed that many so-called mental disorders were an understandable response to an often insane world, and that psychiatrists and other mental health professionals had a duty to get to know and communicate empathically with patients rather than just diagnose them and prescribe/administer medication.

However getting to know a person takes time and, in the case of those labelled schizophrenic, Laing argued that a particular quality of listening and attention was also required if one was to decipher the intelligibility of their utterances. Psychotherapy also requires emotional investment and commitment from the therapist as well as the patient. It is not a quick fix.

In a climate of fiscal restraint and preoccupation with cost effectiveness there is just about enough time to categorize a person’s symptoms in accordance with the latest version of the DSM, prescribe the recommended psychotropic drug, set a review date – and, if you’re lucky, make a referral for some talking therapy.

Laing argued for the humanisation of psychiatry and for treating people as persons not objects or cases to be processed. However, a quarter of a century after his death  the mental health service is in still in crisis, is grossly underfunded and is more target-centred than person-centred.

As far as psychotherapy goes the national NHS programme ‘Improving Access to Psychological Therapies (IAPT)’ aims to increase the availability of talking therapies for people with mental health problems. However, while this is a valued addition to available resources the therapies are time-limited, waiting lists are long and – because funding so far has been restricted to primary care services – it excludes those defined as having long-term or enduring mental health difficulties.

The voluntary sector has played a key role in the provision of mental health services including supported housing, social care and advocacy However, recent cuts and policy changes are strongly impacting this area. It is anticipated that the sector will lose around £911 million a year in public funding by 2015-16 (National Council for Voluntary Organisations, 2011)  Furthermore mental health is not top of the priority list for grant making bodies and charitable trusts. Voluntary agencies are still in the throes of adjusting to a business culture and competitive tendering. This ethos is fracturing a sector which has traditionally taken pride in collaborative relationships.

The combination of increasing demand and decreasing resources, now affecting both public and private mental health services, increases the likelihood that some of the most emotionally and psychologically vulnerable in society will  disappear off the institutional radar and fade back into the wilderness from whence they came.

Addendum-DSM

 The Diagnostic and Statistical Manual of Mental Disorders (DSM) colloquially referred to as the psychiatrist’s bible is, along with the ICD-10 (International Statistical Classification of Diseases) the standard manual used by mental health professionals to categorize, diagnose and treat mental disorder.

It is a dismal tome that has substantially increased in size since the first edition was published in 1952. Laing used to carry a battered copy around with him which he read at random to illustrate to his audiences how easy it was to be numbered amongst the mentally disordered.

The manual was initially 130 pages in length and listed 106 alleged mental disorders. Homosexuality was included on the list and wasn’t removed until 1974 after persistent pressure from the gay community. Since then the criteria have expanded and the most recent DSMV published last year is 947 pages in length and lists more than 300 mental disorders. So in the last half century madness has clearly been on the increase! Observing the exponential increase in diagnostic categories one critic commented that if this tendency to turn human behaviour, thoughts and feelings into pathological symptoms continues, the majority of the population will soon be regarded as having a diagnosable mental disorder. And one of the prime beneficiaries of this trend is likely to be the pharmaceutical companies.

Most of us are now likely to die in hospital (www.demos.co.uk/publications/dyingforchange)‎ Do we as citizens want to live in one?

• If you are interested in finding out more about the DSM and are curious whether you may be on the list check out the following link:  www.allpsych.com/disorders/dsm
• Another useful website is www.criticalpsychiatry.co.uk‎
• Part 1 of Psychiatrist in dissent can be found here

SOS, April 2014

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