There were still grim Victorian-era asylums dotted around Britain when Penelope Campling started out as a young psychiatrist almost 40 years ago. She began her career in The Towers, one of two such places in Leicester. It was bleak: filled with people admitted decades earlier, often on barbaric grounds such as having an illegitimate baby, who were then forced into effective imprisonment and forgotten. They were rigidly controlled, chemically coshed and often subjected to cruelty. Many staff seemed as robotically institutionalised as their patients; one consultant would prescribe electric shocks as punishment for crying.
Campling moved six months later to a new mental health unit tied to a general hospital. This building seemed to embody a brave new chapter in the history of psychiatry as the huge old institutions began being emptied in Britain. The drive to shift their 100,000 patients into community settings had started in the Sixties as the counter culture confronted traditional institutions across society. Radical psychiatrists such as RD Laing — who described insanity as “a perfectly rational response to an insane world” — challenged the core concepts of control, while a series of scandals exposed the brutal realities lurking behind the locked doors of some state “care”.
Significant strides have been made since in unravelling the mysteries of the human mind. We have greater clarity on the corrosive impact of abusive or chaotic childhoods, along with deeper understanding why some people struggle to cope with life, spiralling into self-destructive behaviour and even suicide. Advances have been made in medical treatment, evidential insights gained into effective therapies. There is more openness on mental health and fewer taboos talking about such issues with celebrities, sports stars and even members of the royal family opening up about their trauma.
On the surface, it seems as if we have made great progress away from those dark days when we hid away disturbed people to suffer in hulking asylums on the edge of towns. But have we really? Campling is unconvinced. “Perhaps the truth is that severe mental illness is just as frightening, just as stigmatising, just as much a taboo as it has always been,” she writes in Don’t Turn Away, a superb account of her life on the psychiatric frontline. “We do not seem to want to face the reality of the suffering of those with more serious mental health problems, nor to fund their care properly. It is easier to tranquillise, restrain, separate, lock them up or ignore them than it is to engage properly with their needs and their pain.”
She is right. I stumbled onto these issues while investigating the dehumanising detention of autistic people and citizens with learning difficulties, discovering they were being stuffed into secure psychiatric units due to the dearth of often-cheaper community services. Almost everyone accepts this is wrong — a shocking denial of human rights that tends to greatly intensify problems — yet still thousands continue to be forcibly sedated, physically abused and locked in solitary cells in NHS-funded hellholes. Then the more I looked into our secretive psychiatric system, the more I saw similar issues of a struggling sector that is buckling under abuse, avoidable deaths and inadequate community provision while being milked by profiteering private firms.
Campling writes sympathetically on cases seen over her career, skilfully describing the complexities of dealing with damaged patients, the dilemmas of assessing risk and determining why some people enduring mental pain end up harming or killing themselves. Some stories are bizarre, some depressing, but all are fascinating.
The significance of her work, however, lies in questions raised over treatment of people with mental illness — especially the estimated half a million citizens with serious psychiatric conditions. Bear in mind Britain has the highest depression rate among children in Europe, along with one-third of the continent’s drug overdose deaths as citizens try to blot out their struggles and traumas. Our jails are clogged with autistic people and prisoners suffering psychiatric problems, many of whom really need support or treatment rather than incarceration. Others end up living on the streets. One study by the London School of Economics earlier this year found all these mental health problems cost the British economy £117.9bn annually.
Yet our complacent society thinks it has learned the lessons of the past because a few prominent people talk more freely about anxiety and depression. While we may have shut the big asylums, abandoned use of straight-jackets and stopped dunking psychotic people in ice baths, there remains a striking lack of empathy for people with acute psychiatric conditions. Whatever politicians and medical leaders might claim, there is no parity of care between physical and mental health as services scrap for resources and reel under siege from citizens. Meanwhile, detention rates under mental health legislation have surged, more than doubling over the past four decades and rising faster than almost anywhere else in Europe over the past decade.
Campling details her long involvement in therapeutic communities, where patients “haunted by the past, terrified of the future” were empowered to take charge of their lives and trusted to run the unit — but as she points out, many months of intensive therapy in a residential home for unpopular patients with a history of self-harm is expensive and sometimes risky, even if it can provide a place that feels safe for them to confront demons. Instead, such community services have shrivelled, managers imposed flawed bureaucratic models of treatment — and the legacy is that doctors squabble to ditch the more difficult cases and patients need to be “waving an axe” to access help now, in the chilling words of one psychiatrist to me.
Therapeutic communities have been steadily reduced while crucial social care support systems have crumbled after local authorities bore the brunt of austerity. Day hospitals and day care centres have shut. Swaran Singh, professor of social and community psychiatry at Warwick University, said even Britain’s much-admired Early Intervention in Psychosis Service — which he helped introduce in south-west London soon after the turn of the century to deliver holistic care for conditions such as bipolar disorder and schizophrenia — have been cash-starved and dismantled. Other experts say Assertive Intervention Teams, which provide integrated models of care for long-term patients, are being decimated.
“In-patient care is now terrible,’ said Prof Singh. ‘The staff are demoralised and they rely on coercion rather than compassion and care.” And these problems are escalating: the mental health emergency among children has become so profound that it threatens the country’s prosperity, warned a devastating report by former children’s commissioner Anne Longfield last week.
Longfield demanded a £1bn boost for the overstretched system that is turning away sick children. Money is vital, but only part of the equation. The sums skimmed off into tax havens or to pay off debt-financing by some of the abysmal private firms indicate other factors are involved. These fat cats — now providing one in four NHS-funded mental health beds and close to half the spending on child and adolescent services — skim off hefty profits behind opaque corporate structures as overloaded health services send more and more sick citizens into their secure units. Often they are backed by financial wizards who see disturbed children, teenagers with autism, suicidal adults or elderly people with dementia simply as cash cows.
The Priory group is the biggest private mental healthcare provider, but has been criticised for failings in the care of 30 patients who died over the past decade, including the son of a friend of mine. Built up originally by a prominent Labour donor, it passed through a bank, private equity outfit and US healthcare giant before being sold last year for £1.08bn to a Dutch private equity operator. Yet why are many of the most problematic and high-risk patients dumped by the NHS on such badly regulated firms — in stark contrast to private subcontractors in physical care, entrusted only to carry out routine surgeries such as cataracts, hernia repairs and hip replacements rather than more complex procedures?
The answer betrays the lack of concern for people with severe mental health conditions, autism and learning disabilities. We spend £2bn a year on outsourcing psychiatric health services, yet the wider system remains shockingly inefficient as well as often inadequate. It is based on excluding people from obtaining restricted services, then limiting duration of any contact due to financial constraints rather than a focus on the best treatment. Even for children, there can be a wait of almost three years for outpatient services while fewer than a quarter are seen within the four week target — yet delays fuel anxieties and heighten any feelings of abandonment, failure or low self-esteem. “It is a terrible thing to say, but I have seen many people made worse when they try to contact mental health services,” concludes Campling. “We are so used to excluding people in this callous system that we hardly notice the impact any more.”
Others agree that the culture of mental healthcare in the UK has tilted to risk management over attempts to understand and address the patient needs. SP Sashidharan, honorary professor at Glasgow University’s Institute of Health and Wellbeing, said soaring mental health budgets are being soaked up by coercive secure units that simply control individuals in extreme distress. “This is a scandal. There has always been a conflict in psychiatry between control and care since sometimes people are locked up for treatment but the dial has shifted sharply towards control. The culture is all wrong now.”
He also fears rising budgets are being drained by “well-being” with surging demand for milder mental health concerns such as anxiety and depression. Yet even here, experts say patients can wait almost half a year to see a psychiatrist — and then simply get an online appointment. Often it is based on box-ticking risk assessments. Some trusts have even turned to use of psychiatrists based in India, paid to sit at their computer all day discussing problems with patients in Britain. Yet the one consistent finding in therapy is that success depends on strong relationships, the precious “therapeutic alliance” between patients and therapist.
There are glimmers of hope. One group filling the gap with low-cost counselling is Headstrong, a community-interest group that has adopted the Teach First model by offering cut-price therapy delivered by 500 trainee counsellors and psychologists who are supervised by 50 experienced practitioners. Or we can look to Trieste, the north Italian city that pioneered an alternative model of community-based psychiatric care, a humane system based on consensus, consultation, and patient rights rather than reliant on coercion, forced sedation and high-security fences. It is recognised as a world-leading model; I found it incredibly uplifting to visit.
Sadly, the Government last week rejected this approach that bans long-term admission of low-risk patients. So we struggle on with a dismal system that starts with general practitioners doling out too many drugs such as anti-depressants given pressures on their time and the delays to access therapeutic services. The pandemic has turbo-charged the problems and pressures, as highlighted by Longfield’s report.
State failures mean mental health concerns — especially those at the most serious end of the spectrum — are left untreated until they explode. Campling notes that even people requesting private therapy seem “increasingly desperate”, often after months waiting in vain for NHS services. She admits that despairing clinicians must often prioritise “one group of desperate patients over another” and argues that their role has become largely reactive, dealing with emergencies and people in crisis, rather than providing pro-active, therapeutic care that could reduce overall costs to taxpayers — as well as providing a more humane path for patients.
She concludes that the only hope to obtain treatment for some “severely-damaged, highly self-destructive patients” is to commit a crime, even if they are being abused by violent partners, pimps or predatory parents. This is such a damning indictment — and not just of a floundering mental healthcare system, which has moved less than we like to think from those days of abusive incarceration in giant asylums. It is also a savage condemnation of a selfish society that averts its gaze from so many of its most vulnerable citizens. The sad truth is that we have moved over the course of this doctor’s career from a system of shocking control to one of shameful neglect — and we all share the guilt in this failure.