The Shift in Ideas About Mental Diseases Over The Years

Abstract

Over the last few centuries, our perception of mental illness has changed considerably, from the view that the ‘insane’ were a deviant group who needed, for the sake of society, to be controlled and hidden, through the age of psychiatry, medicalism and cure whereby medicine became an agent of social control who would normalise the ill ready for return into society, to today, where therapy has become the latest trend and emotional states are used readily as currency in certain social circles. What then, has changed our outlook on the mentally ill so drastically, and is this latest therapeutic development the whole picture? It is my belief that still, centuries on from the days of locking up and hiding the mad, the underlying feature of our mental health care provision is the ‘secure centre’, with the emphasis being put on the idea of ‘risk assessment’ rather than care, and with the term ‘dangerous and severe personality disorder’ being used readily, without psychological or medical definition.

Introduction

Mental illness, in many ways, consumes our everyday lives. According to the National Union of Students, 1 in 4 students will suffer from a mental health problem whilst studying at university , with the figure for non students not being much further behind. As a nation, we have easy access to counselling services face to face, online and through listening services such as The Samaritans, and the local doctor is now often fully versed in topics such as stress, depression and therapy. In fact, so often am I told that I am ‘stressed’ or ‘depressed’ by a doctor looking for a reason for that ever returning cold, that I could quite believe I am in need of an overdue dose of therapy. But is this really the state of our mental health provision today? A more accurate observation is perhaps that there is a thin line between the acceptance of what is seen as somewhat minor, more fashionable personality ‘foibles’ and the much more daunting prospect of a fully formed personality disorder, and should this line be crossed, the barriers of society acceptance shut down, and are very difficult to prise open.

‘The question of how to deal with mental illness and the provision of appropriate care has, throughout history, been the subject of significant inquiry and a source of debate’ , and still is to this day. Are the mentally ill prisoners or patients? Dangerous to the public or dangerous to themselves? All these questions remain unanswered, but the real problem is not how to deal with mental illness as such, but how to define it. Is it what we have come to embrace fondly in society today, or should we in fact still be protected from it? And perhaps more importantly, who should decide?

Lunacy, Madhouses and the ‘Tug of War’

It wasn’t too long ago when the words mentally ill and disorder did not exist. These words, would not have accurately described the attitudes of society in the 18th Century, and would in fact be better replaced with lunacy, mad and insane. The mad, as they were then known, were offered no support or care, often relying on either family care or moving from parish to parish handout and other small offers of charitable relief. Those with a mental illness were not seen as a separate class of people, but ‘were assimilated into the much larger, more amorphous class of the morally disreputable, the poor and the impotent’ . They were often found in local poor houses and work houses, because at that time, there was seen to be no other suitable way of dealing with the insane. However, as the 1700’s wore on, interest in hiding these people grew, and the need for control over certain groups in society became a high priority. ‘The Great Confinement’ began, which started in Paris in 1656 with the creation of the Hopital General, a place to confine what was termed as the ‘socially useless’. Confinement was not however for medical reasons – in fact medicine had very little to do with the insane until far into the 19th Century. In an emerging capitalist society, there was no place for the poor or the mad, and ‘the 18th Century saw a gradual separation of insanity from other points of dependence and deviance’ . In fact it was at this time that the protectionist attitudes began, with confinement being not for treatment, but to protect society from the ‘contagion of madness’ .

Many institutions began to emerge, with a mixture of the privately owned and the publicly funded, however many private madhouses took the opportunity to make increasing amounts of money out of the trade in the mad, especially in light of the fact that charitable relief could only stretch so far. There was no call for treatment – only restraint and control in the forms of shackles and cages, and many private madhouses could charge large sums of money to house the insane as demand began to quickly outstrip supply. There were no laws controlling this growing trend – in fact anyone could set themselves up easily in the ‘lunacy trade’. The majority of those who entered a madhouse were not seen again, almost as if they no longer existed – but this seemed only to add to its benefit. However it soon became apparent that these institutions were only a financial enterprise, and little was provided in the way of care and safety – those few institutions that did were overshadowed by the majority whose treatment of the insane could be termed as ruthless. This started to become a cause for a concern amongst some, and an inquiry was launched in 1763 which exposed the institutions as merely ‘big business’. Despite oppositions from the owners of those madhouses engaged in harsh practice, 11 years later the law began to change, not least with the Madhouses Act 1774.

The Madhouses Act was there to protect the wealthy patients in private madhouses, and to make sure that standards were maintained. There was of course one glaring omission in the legislation – it did not go any way to protecting paupers, even though their numbers far outstripped the wealthy insane. No restriction of practises could be dealt, and no punishment of cruel treatment could be achieved under the act – perhaps this is due on part to the large amounts of money being passed around several institutions, although it can be said that whilst private madhouses outnumbered public ones, the struggle for better treatment of the insane would be a long one.

Despite this, it would be a member of the wealthy insane which began to turn the provision of care for the mentally ill on its head. When King George III became ‘insane’, the focus shifted from restraint to care and even more radically to treatment. Various medical practices emerged, most being along the lines of burning, cutting and other physically painful treatments which would be termed torture today. However, despite its concentration on the physical body as opposed to treatment of the mind, this was an important step forward. Alongside this was what came to be known as ‘moral therapy’, an even more important phase in mental health care development. Kindness, coercion and work therapy, coupled with activities in the arts were thought to act as a diversion from their state of mind , and the overall approach was much more humane than the physical treatment that many ‘patients’ had begun to receive. Many retreats were set up as an alternative to the many institutions that had sprung up at this time, most notably by philanthropists William Tuke, and Bentham. The York Retreat, which was founded in 1792, became the model of moral therapy, and the book ‘Description of the Retreat’ which was based on the retreat and its practices, outlined proper approaches to moral therapy and guidelines in carrying it out. This was very important, and allowed moral therapy to be received by a much wider cross section of society. Its popularity spread, and it soon became apparent that there was no place for medicine in this new treatment – in fact it went along way to affirming the doubts that many were starting to have about the abilities of the medical profession to treat the mentally ill. This doubt was increased further when one contrasted the retreat (with its kind practices and dignity) to the York Asylum which was controlled by physicians and relied on medical treatment which was neither effective nor humane.

With the popularity and faith in moral treatment rising, and with its organisation in the hands of the humanitarians, the medical profession appeared redundant. ‘Since moral treatment began to work, the medical profession had to find a way to accommodate it.’ The medical profession therefore, began to take the practice of moral therapy on board, and due to their status in society and better organisation, it became known to be part of their general expertise, leaving the lay persons who had created it far behind. Legally, the treatment of the insane lay in the medical professions’ hands.

With the Victorian age came the birth of the Asylum, which replaced the now redundant Madhouse. These institutions were purpose built, in that they took into consideration architecture and design to help with treatment. However, the positivism first associated with the asylum turned to great concern with large overcrowding in public institutions, which made moral therapy and its related curative treatments almost impossible to carry out, turning them to the same fate suffered by the Madhouses. Institutionalisation became a grave concern at this time, as many believed one could not live in the community again after entering an asylum. Harsh treatment and bad conditions crept in, and by the end of the 19th Century the insane were in no better position than at the end of the 18th.

However, although sympathy over conditions was afforded to the insane, and distress at the thought of sane, upstanding members of society being locked up for financial reasons, this was not enough to combat the real concern of the time – protection of the public and social order. So, with the introduction of the Lunacy Act 1890 came legal intervention. Medical control was no longer supported by society, as no positive results had materialised, which put control of the insane firmly in the hands of the law. The detention process, certification and treatment were all regulated, to the point where there really was no role for medicine in mental illness anymore.

However as always, it was not long before attitudes changed and the position began to switch. Yet again no suitable results were seen from legal control, so society turned to medicine once more for the answer. Medicine was beginning to prosper – a new system of care for the mentally ill came into force and preventative medicine became popular. The profession of the psychiatrist was born. World War I cemented this respect as their role in society increased, and the idea of certification started to meet with dislike, as stigmatism became a worry. Society didn’t want war heroes, who were coming home with illnesses such as ‘shell shock’, to be labelled as insane. The Mental Treatment Act of 1930 went further than anticipated, giving treatment without certification under the Provisional Treatment Order, and voluntary admission. Altogether treatment was more relaxed, but more importantly treatment happened. Another shift in social outlook meant a change in care provision.

The Mental Health Act 1959 took the era of medicine even further, and gave even more credibility to the psychiatrists. More emphasis was put on combating stigmatism by more access to voluntary admission and legal intervention diminished significantly, although Mental Health Review Tribunals were created to regulate compulsory admission. This was a positive step in care provision, as it began to realise the needs and rights of the patient – however despite this constructive influence of the law in this way, control was still firmly in the hands of the psychiatrists. Nonetheless it was a positive time for medicine, and patients had options which were unknown to them previously. There appeared to be a sensible balance between appropriate care and patient rights, epitomised by the strong emphasis on voluntary admission, and public protection appeared to be no longer a great cause for concern.

In spite of this, the tug of war between legalism and medicalism was not yet over, ‘confidence was short lived and by the mid-1960’s disillusionment and criticisms had again begun to resurface’

The Mental Health Act 1983

The Mental Health Act 1983 is the one of the most recent pieces of mental health care legislation, and currently regulates the majority of care provision. It reflects yet another change in social perception of mental health, especially with regards to the role of medicine and the law in the whole matter. This act largely characterizes the age of rights, and the new concern over patient protection and medical intervention. Positions adjusted, and patients began to be seen as holding rights, despite their mental state. An increasing interest in rights, with movements such as feminism gave weight to this, as did increasing awareness of the European Convention of Human Rights. If you add to this growing pressure from MIND, who gathered support throughout the 1970’s for patient protection and a legal framework within care provision, a legalist revival was beginning to take shape.

Not long after the 1959 Act came into force, the recent psychiatric ‘boom’ started to go into anti-climax. No new headway with regards to treatment were made, and the 1960’s/70’s were a time for consolidation – the lack of activity wasn’t popular, and the once optimistic view of psychiatric ability began to ebb. Furthermore, public protection was left in the hands of the medical profession with little legal support, and this caused alarm amongst many in society. Finally, much of the success of the 1959 Act relied upon community care, something which was proving to be far too much of a financial burden to be able to bear, leaving care under resourced and under managed. This prompted much investigation and with the emergence of the new Mental Health Act 1983.

Its aims were very clear – to regain legal control over mental health provision and care. There was a desire for a greater control of the professional’s power over the patient, and for more safeguards to be in place for the protection of the patient and more importantly society at large. This would come in the form of a legal framework, setting out policy on accountability, detention and treatment, and revising the roles of those in the profession, to ensure appropriate care was administered and received.

Patient Classification

Patient rights were extremely important, and this encompassed such issues as appropriateness of care, and the level of rights a patient should be afforded dependant on his/her mental state. The MHA 1983 s(1) defines the term ‘mental disorder’ as four separate categories; ‘mental illness’, ‘arrested or incomplete development of the mind’, ‘psychopathic disorder’ and ‘any other disorder or disability of mind’. This is very broad, and many different types of illnesses can be made to fit the definition, although under s1(3) exclusions are made with regards to drugs, sexual behaviour and immoral conduct. What is perhaps important to note, are the distinctions made between different forms of mental disorder – this now means that depending on what you suffer, and how seriously you suffer it, rights will be afforded accordingly. However these terms do not attract a medical definition, rather a legal one or more accurately ‘what an ordinary person would consider’ these terms to mean.

Detention

· s2 – authorises compulsory detention for assessment for up to 28 days. This does not exclude treatment.

· s3 – compulsory detention for up to 6 months for treatment. Must reapply at the end of each 6 month period.

· s4 – compulsory detention of up to 72 hours for emergency assessment and treatment.

These provisions provide a clear legal framework within which the medical profession must work. The reasoning behind this is that by adhering to strict guidelines on detention, no patient is kept unnecessarily or unfairly, and in order to be detained for a 6 month period, treatment has to be administered meaning that there is a better likelihood that a patient will now receive proper care.

Treatment

· s57 – serious treatments must have consent (for example Psychosurgery)

· s58 – less serious and reversible treatment (for example drugs) must at first have consent, if this is not forthcoming then a second medical opinion must be obtained.

· s62 – the above safeguards do not apply in an emergency (necessary to save the patients life or alleviate suffering or to prevent further deterioration)

Consent in this context must be given freely and the patient must understand fully the nature of the treatment. This again shows the efforts of the MHA 1983 to afford more rights and protection to patients undergoing care and treatment.

Voluntary Admission

Under the MHA 1983 there is an even greater emphasis put on voluntary care, and this can be found in s131(1). It provides for patients seeking treatment on an informal basis, or staying in hospital informally after detention has ceased. This is perhaps one of the most important provisions in the act because ‘it recognises that an individual may seek hospital care for psychiatric difficulties in the same way as one would for a physical disorder’ This in turn should help to combat the ‘social stigma’ that has long been associated with mental health, an intention of all of the mental health legislation throughout the 20th Century.

As much headway as the MHA 1983 made, it was not, and is not without its problems. There is still serious overcrowding in hospitals and institutions, with the NHS struggling to provide the sort of care and treatment that the campaigners of the 1970’s envisaged. There is little money or resources, meaning the long term care of seriously ill patients is lacking. Voluntary patients are increasing rapidly, as was desired, and yet the legislation makes no provision for their protection – this is only provided for patients who are detained.

The Mental Health Act 1983 has failed to get the balance right, and this is perhaps its main flaw, and the flaw with all other mental health legislation which preceded it. What is required is equal weight placed upon patient rights, their welfare and the rights of society at large, and yet what we have is an unsatisfactory mix of all 3, with different things applying at different times. Stigma and labelling still exist, and are much worse today, and society has shifted again from patient care to third party protection – society is now more concerned with their own welfare, and yet the act does nothing to reflect this. Is it perhaps time in the 21st Century to move on again?

Care in the Community

In December 1992 Ben Silcock, a schizophrenic, climbed into the lion’s enclosure at London Zoo, in order to ‘talk to the animals’, and whilst doing so was mauled and killed. He was discharged into the community and was left alone to deal with his illness and society around him. In the same year Jonathon Zito was stabbed to death by Christopher Clunis, another schizophrenic left without care. In the wake of the MHA 1983, much was made of community care, and in the early nineties actual policies began to take shape. Yet the above cases are just some of the examples of where community care went wrong.

Community care was supposed to be an enlightenment in mental health care provision – it would not only take the heat from the institutions and hospitals, but it would allow a patient to live in society with family and friends and maintain dignity and independence. However the reality was much different. The burden of providing proper facilities and patient cooperation was a harder task than first anticipated – and it was seriously under funded, leading to the cases above. At the time MIND estimated that it would cost £300m to bring the community services up to scratch, but the government’s answer was the Community Treatment Order, a debated policy throughout the 1980’s and early 1990’s.

The Community Treatment Order would permit medical treatment for disorder outside of the hospital setting, and therefore overcome the problems of those patients in the community who couldn’t or wouldn’t continue their medication or treatment – it would be compulsory, therefore avoiding the sorts of incidents so often associated with the mentally ill who lived in society. It had many advantages – cost, less labelling of patients and the ability for patients to still live among their families safely. However, organisations such as MIND were far from supportive, believing the orders to be a serious breach of civil liberties – how far were patients actually free to live in the community? These treatment orders in one form or another were discussed and investigated for some time, before an appropriate solution could be found. The Department of Health came up with a ten point plan for caring for the mentally ill in the community in 1993, and in 1994 the NHS Management Executive introduced a supervision register of patients discharged into the community. These were a preliminary for the legislation that was to come in 1995, with the Mental Health (Patients in the Community Act).

This act introduced after care supervision, and was designed to gain more control over those patients released into the community. However, with many still concerned for civil liberties, and increased coercion, even when patients are supposed to be relatively free in the community, this act was limited in what it could achieve. After the tragedies of 1992, mental health provision, and especially that which occurred in the community was put under intense media scrutiny, and it became apparent that the services were lacking. However what followed wasn’t what those in the psychiatric profession or those in campaigning organisations had hoped for. Instead of proper community care, patients were served with orders and forced medication. What about the other advantages of community care such as patient independence and care in the family? It appears that there is neither the money nor the inclination to hold these in much regard, meaning a shift from community care to community enforcement. Yet how can anyone hope for community treatment to succeed with a lack of appropriate housing, financial security and occupational opportunities? The law has done nothing to address these much wider social concerns.

The role of the public on the success of community care is also an important factor. Quite often, although the public would see the benefits of treating a patient not in an institution, but in a friendly community environment, they would be resistant to having these types of facilities in their own neighbourhood . This is unsurprising, given the nature of education and the level of knowledge society has with regards to the mentally ill. If the public are unable to accept the mentally ill in their neighbourhood, this will surely only serve to increase stereotypes and stigma, meaning any positive effects of community care are lost. This was the attitude of the 1980’s, can it have changed all that much in the 21st Century?

Ben Silcock managed to kick start the government into thinking about patients in the community, yet its effects are not all seen as positive. Community care and its failures show the governments’ approach to mental health policy in the 1990’s – the first signs of coercion and repression of the mentally ill.

Medical Intervention as a Social Control – Iincreasing Care or Increasing Labels?

‘Medical solutions are being sought for a variety of deviant behaviours or conditions.’ It has often been thought that deviancy and mental illness are linked in some way – both are known to be forms of ‘social abnormality’, and as such attract a similar label, whether they are voluntary or involuntary. This has long been the case, ever since the days of lunacy and madness when all types of social abnormality were dealt with in the same way. As mentioned above, it didn’t make much difference whether a person was sick, poor, cripple, a criminal or mentally ill they were confined and hidden together, no treatment or help, just left so that they could no longer be a menace or drain on society. This is a dilemma that has faced civilization throughout history, and social control has been a hot issue throughout time. Many solutions have been applied, and their success or failure can be charted, but throughout the 20th Century, medicine has emerged as the method of choice.

Treatment, rather than punishment is sought for most forms of deviant behaviour, with rehabilitation schemes, institutions and community care being used for variety of different types of people, especially criminals. Medicine has started to replace religion, whose appeal has waned in these cynical times, and even faith in the criminal justice system and its apparent ineffectiveness to ‘solve’ repeat offences has ebbed. As knowledge and science has expanded, so has the expectation of what medicine can achieve, and this has led to its dominance of all that is considered abnormal in the recent past. In its attempts to normalise illness and allow people to rehabilitate successfully back into their role in society, it has managed to capitalise on the term ‘illness’ and use it to cover a multitude of subgroups – are criminals ill? Are they mentally ill? The reality is that whilst the question even exists, medicine will have an important role in this way.

In previous times ‘confinement [was] explained, or at least justified, by the desire to avoid scandal’ , and although the types of people being detained were distinct from each other, placing them together attracted very similar stigma, for whatever reason. Understanding mental illness was not easy at that time, and it was just another form of deviance – not an ailment that should be treated and cared for, therefore this was not much of a problem. ‘Some have argued that the stigmatisation of the mentally ill is one example of the common human tendency to reject disvalued subgroups and blame them for social troubles’ - and despite efforts to the contrary, legislation hasn’t changed this. In fact this problem is only getting worse, just changing to fit the social attitude of the time

Now the emphasis has shifted from confinement to care, through the medium of the medical profession. With ‘deviance’ as a whole now coming under medical practice and influence, the labelling of the mentally ill has not decreased, only changed. Now all those requiring treatment of any kind are part of the same subgroup of society and thus are one and the same – but this time they are receiving care so it is more acceptable to think of them in this way. One can consider it in this way; ‘Today, Americans live under two sets of laws: one applicable to the sane, the other to the insane. The legal regulations binding on the former – with respect to hospitalisation for illness, marriage or divorce, standing for trial, or the privileges of driving a car or practising a profession – do not apply to the latter. In short, individuals categorized as mentally ill labour under the handicap of a stigma imposed upon them by the State through Institutional Psychiatry.’ More accurate diagnosis of disorders and health problems are forthcoming, and doctors are quick to place a label or name on a variety of symptoms and complaints. However, ‘it is the conviction itself that marks the offender with the unequivocally negative sign’ , and this can be fully applied in a mental health context – the sectioning or even the actual diagnosis is often the stigmatising factor. Therefore it appears that medicalisation has only served to increase the prejudices faced by the mentally ill, through the lack of confidence medicine and practitioners invest in them to lead a ‘normal life’, at least, not until they are fully ‘cured’.

But what is society so afraid of? For every doctor or legislator who places these limitations upon the mentally ill, there are groups of society standing in agreement. As much as people have campaigned for patient rights and welfare, with more appropriate care and treatment, better facilities and resources and a system aftercare, people have also been campaigning for themselves, and third party protection. To those who are part of the norm, any abnormalities in life should be feared. Those with mental illness are perceived as dangerous – first dangerous to social standards, then to economics, and now to personal safety.

‘There cannot be an ‘us’ without a ‘them’’