From Psychiatric Abuse to Psychiatric Neglect? by Helen Spandler

When Asylum magazine was launched, in 1986, I was immersed in what was dubbed ‘anti-psychiatry’ literature. I didn’t get involved in Asylum until a few years later, but I was already a reluctant observer of the mental health system.
My dad had been in the local psychiatric hospital, and was out of work due to ongoing mental health problems. His death was not, I believe, unrelated to psychiatry. The diabetes and stroke he suffered are known to be related to certain psychiatric medications, and his physical complaints were routinely dismissed as part of his mental health problems. My brother has been periodically immersed in the psychiatric system for nearly 30 years – more than a dozen admissions, mostly under section, including locked wards and a Community Treatment Order. I’ve suffered myself, alongside family and friends, over the years. During this time I have tried to be a good ally, advocate, mental health worker, teacher and researcher.
So what’s changed in all these years?  I still believe in alternative approaches to madness and distress, but I want to focus on some ‘inconvenient truths’ to anti-psychiatry politics today. After all, openly discussing contentious issues was always the vision for Asylum magazine. No-one embodied this spirit more than our co-founder, the late Alec Jenner.
When Asylum started, followers of ‘anti-psychiatry’ and the emerging user/survivor movement were, quite understandably, highlighting psychiatric abuses. However, critics like Peter Sedgwick warned us that radicals over-emphasised psychiatric abuse at the expense of psychiatric use. I think he had a point and I’ll explain why.
There is nothing more exciting to a young radical than challenging the latest oppressor and identifying with its victims. It’s a good instinct, even if it’s often oversimplified (note recent scuffles over transphobia). Whilst psychiatric survivors have never been a fashionable oppressed group, psychiatry itself has been an easy target: at the sharp end, labelling people as ‘mad’ or ‘mentally ill’, locking them up against their will, and giving them drugs and electric shocks.  In this context, stories of resistance are understandably appealing – faking normality; hospital break-outs; and other forms of psychiatric refusal.
Although these stories are seductive, it’s possible we’re entering a new phase of psychiatric resistance in the UK. This relates to a wider shift – from psychiatric abuse to psychiatric neglect. I am not suggesting that psychiatric abuses are no longer important. Nor that it has to be either/or, i.e., choosing between challenging psychiatric abuse or challenging neglect. We need to do both. However, I think the shift is important to understand where to focus our energies. In order to change the future we need to see the present clearly.
Despite fears of the ever increasing ‘psychiatrisation’ of everyday life, contrary to popular opinion it is not that easy to get psychiatrised these days.  In the UK, at least, we are a far cry from the ‘Don’t mention you hear voices or you’ll get locked up’ scenario, immortalised in the classic Rosenhan et al. study Being Sane in Insane Places. It’s true we have witnessed an expansion of psychiatric categorisation and increasing medicalisation and individualisation of complex human problems. That argument is well rehearsed.
Yet psychiatric classification doesn’t automatically result in psychiatric or psychological support or intervention (other than medication, which is increasingly administered by your GP and managed by the individual concerned). Unfortunately, in order to receive mental health services (or welfare support), psychiatric classification is necessary, but it is certainly not sufficient. This is especially the case in a mental health system which is under-funded, understaffed and inflexible.
It’s true that rates of compulsory detention and treatment are on the rise. This is very worrying. But it needs to be seen in a broader context. Currently, it’s actually very difficult to get a bed in a psychiatric unit, certainly as a ‘voluntary’ patient. Sometimes mental health workers feel that the only way to ensure services will provide emergency accommodation is to use the Mental Health Act. Similarly, it can be difficult even to get an appointment with a psychiatrist, or be eligible for mental health services, and it’s increasingly hard to access mental health services. That is, unless you pay privately or you’re considered an imminent and serious risk to yourself or others.
Community Treatment Orders (CTOs) are often seen as coercing the individual to comply with treatment – which, of course, they are. However, there is some evidence they are being used to coerce services to provide support. In the current system, where workers have to provide written ‘justification’ for providing ongoing support, these sorts of measures may be increasingly used to plug gaps in services. After prolonged resistance to the introduction of CTOs, it would be a bizarre irony if their strategic use became a new form of resistance.
This reminds me of debates about Assertive Outreach Teams in the 1990’s. Due to worries about people being harassed by mental health workers, many dubbed them ‘Aggressive Outreach Teams’. Now you’re unlikely to find a mental health worker, let alone be visited by one!  All this means that rather than resistance taking the form of ‘faking normality’ (for example, to be discharged from psychiatric hospital), we are now faced with the perverse situation where people may have to exaggerate their madness (and emphasise their dangerousness) in order to access or retain services. This is very worrying.
The 1970s and 80s were marked by the setting up of Patients’ Unions and Councils in psychiatric hospitals, often to advocate for release or to protest against detention and treatments. Now, many user groups find themselves fighting to keep psychiatric wards open and even demanding admissions and treatment. Whilst this isn’t new – user groups sometimes fought to keep the older mental hospitals open too – it is becoming an increasingly bitter irony.  Some argue these user groups are backward, parochial, and perhaps suffering from ‘false consciousness’. Yet, without any genuine alternatives to the prevailing mental health system, especially when in crisis, perhaps it’s not surprising that some user groups seem to demand more psychiatry, not less.
The current user/survivor movement is divided on these issues.  Put crudely, some believe in psychiatric abolition and see any dents in psychiatric provision as a step forward in the struggle for liberation.  Others demand more and/or better psychiatric services. Most agree that we want better support, more understanding and real alternatives. Indeed the user/survivor movement has consistently demanded alternatives. There are a number of promising developments in this regard in the UK, including Soteria and various survivor led initiatives. However, they usually rely on the tireless and dedicated efforts of a few, and remain elusive for the majority.
It’s easy to say, ‘We just need to listen to users and survivors’.  However, with such diversity of views and experiences, it’s no good just listening to those we agree with. It means listening deeply – to those who want to abolish psychiatry, as well as those who want to preserve and improve it. Ultimately, I suspect, they’re not so far apart.
Thirty years ago we were debating post-asylum care. What would community care look like? Would it be adequate? What can we learn from the Italian experience in ‘democratic psychiatry’?  Perhaps we have now entered a phase of post-community care. If the asylum era was synonymous with psychiatric abuse, will the recovery era become synonymous with psychiatric neglect? Certainly ‘recovery’ is increasingly used as a justification not to provide support and services.
Maybe, just maybe, this isn’t such a bad thing. Perhaps, like the title of Liz Sayce’s book, it’s part of a progression ‘from psychiatric patient to citizen’. After all, people like Franco Basaglia argued that community facilities were merely a transitional step in progress to full equality and liberation.  Maybe it will force us, as a society, to truly embrace madness and distress. Maybe users and survivors will be free to develop their own support systems – away from psychiatry and the state. Hopefully we will see a proliferation of genuine ‘alternatives’.
Rather than being hived off into mental health service ghettos, maybe madness will be ‘mainstreamed’ – like most things these days. Perhaps this is the ideal culmination of the neo-liberal project. Or maybe it’s the real meaning of ‘market madness’ – each to their own, with no collective responsibility for those in need. Hands on hearts, can we say we’d do a better job than the ‘psy’ professionals we so readily condemn? Do we, as individuals, families and communities, have the necessary resources, capacity and humanity?
I have no easy answers.  I do know that being with people experiencing extreme altered states, psychosis or suicidal thoughts, is essential – but never, ever easy. It can be exhausting, stressful, and sometimes terrifying. I don’t think this can simply be reduced to ‘stigma’ or ‘sanism’. Rather, it’s about negotiating the complexities and vagaries of being human. Over the years, I’ve seen lots of grandstanding and radical posturing, but (with some notable exceptions) insufficient attention to the challenges of this task.
One thing seems clear. Thirty years on we still need forums like Asylum magazine to discuss these issues – as openly and honestly as we can.
This is a sample article from Asylum 23.2.  To access the latest issue in full,  SUBSCRIBE HERE.