Monday, 28 February 2011

To Care, or Not to Care .... in the Community

‘Care in the Community’ is the expression used in Britain for the policy whereby residential psychiatric institutions are either reduced or eliminated, with sufferers of mental health disorders being cared for in their homes with the support of community mental health services.  Similar policies known by various names – e.g. ‘Deinstitutionalization’, ‘Community Release’, etc. – have been followed in many other countries, including the United States.  

In various comments I have made, I’ve tended to speak in favour of the policy – while also acknowledging that it is not without its problems.  Given my particular interest in children’s psychiatric services, I have argued that it is far better for a child suffering with depression (for example) to be cared for in as normal and homely an environment as possible, rather than being ‘locked away’ in an institution as though he or she were a young offender.

In my blog of 21 February 2011, I reviewed Patrick and Henry’s Cockburn’s book, Henry’s Demons (published by Simon & Schuster).  Patrick Cockburn is particularly vocal in his criticism of ‘Care in the Community’.  He describes the expression as ‘one of the most deceptive and hypocritical phrases ever devised by a government’.  As the old psychiatric institutions were closed down in the 1980s and ’90s, Cockburn argues that those patients who had known some level of protection in these places were suddenly flung out onto the streets to become ‘sidewalk psychotics’. 

I have some sympathy for Patrick Cockburn’s position. After all, he has faced the difficulty of trying to secure the safety and effective treatment of his son Henry, a sufferer of schizophrenia, in a world of what he calls ‘couldn’t care less in the community’.  Indeed, Cockburn presents a persuasive argument, seeing the closure of many psychiatric hospitals as nothing more than a money-saving measure leading to ‘cruelty and unnecessary misery’.

It is, of course, perfectly true that community-based psychiatric services are often poor to non-existent (depending on region), and that many troubled people are left neglected.  But just take a look at The Light in My Mind by Joyce Passmore (published by Speak Up Somerset), or my own book, Delivered Unto Lions (published by CheckPoint Press), to see the other side of the coin.  These are reminders of the horrors of institutional ‘care’ in the recent past.  Surely, whatever the failures of ‘Care in the Community’ might be, we cannot wish to return troubled people (young or old) to these repugnant places of incarceration.

It is also the case that we have been seriously misled if we are to believe that residential psychiatric care no longer exists.  It is true that the larger Victorian-style asylums have gone, as have many of their associated children’s units, but that is not to say that in-patient mental institutions have completely disappeared.  I was very surprised to discover that there are roughly seventy-five children’s and adolescents’ residential mental units run by the NHS (National Health Service) in the UK today (plus several more privately run units).

My hope is, of course, that these units of today are more caring and empathetic places than the ones that existed in the past.  But given that their existence is hardly common knowledge, what happens inside them – good or bad – is hidden from our view. 

And this, I think, brings us to what might be the central issue.  These places are hidden, and maybe this is what we as a society prefer; we don’t want the mentally and emotionally disturbed living among us.  Perhaps this is why many of us don’t like ‘Care in the Community’.  Maybe we would prefer damaged and troubled individuals adults and children – to be shut away where we can’t see them.  It isn't nice to think about these things, so perhaps we prefer the easy option of not having to that is, until we or our families are affected personally.

In this time of austerity, when already hard-pressed services are likely to face further cuts, I would dare to suggest that ‘Care in the Community’ can still work, and work well, but only if we as a community actually start to care.  After all, even in hard times, we are perfectly prepared to do our best in supporting the people we care about.


Delivered Unto Lions by David Austin is published by CheckPoint Press
ISBN 978-1-906628-21-5
For more information visit

Monday, 21 February 2011

Book Review - Henry's Demons

Henry’s Demons by Patrick and Henry Cockburn (published by Simon & Schuster) tells the story of a family’s testing experience of schizophrenia. 

Henry (one of the co-authors) is diagnosed with this condition in 2002 at the age of 20.  While an art student in Brighton, Henry’s behaviour rapidly becomes more eccentric and hazardous, until he ventures, fully clothed, into the sea at Newhaven.  This leads to his admission, as a mental patient, to the Priory Hospital in Hove.   

Parts of the story are narrated by Patrick Cockburn (Henry’s father) in a considered documentary style.  He interweaves explanatory details with narrative account, but what is immediately striking is how little any of the background information on schizophrenia contributes to his (or the reader’s) understanding – the reason for Henry’s development of the condition largely remains a mystery (though cannabis use is heavily implicated as a possible cause).  And so the reader is drawn into the anxiety and bewilderment associated with the situation.

Other parts are narrated by Henry himself, in an almost hurried, but extremely arresting, style.  He talks of experiencing the onset of his condition as a spiritual awakening, with his perspective on the world becoming significantly altered.  As some of the events described take place in Brighton – somewhere I’m reasonably familiar with – I personally find it fascinating to see particular experiences unfolding against recognisable backdrops.  For instance, there’s a vision of the Buddha on Brighton beach and the planting of a banana tree outside the Concorde 2 music venue.  This locatedness – whether in Brighton, Canterbury, Youghal (in Ireland), or elsewhere gives an additional tangibility to these occurrences. 

As the story unfolds, via one or other of the narrators, a growing sense of the enormity of Henry’s condition becomes apparent.  There is no quick fix for what had happened; in fact, there is no fix at all.  What is more, Henry himself is not always convinced that he has a problem, and so his willingness to take his medication (olanzapine, clozapine, etc.) is intermittent.  When he takes it, his delusions and erratic actions are somewhat controlled (though not reliably so); when he doesn’t, he seems to positively revel in extreme and disturbing behaviour (climbing to great heights, walking close to railways lines, running naked through snow, and so on). What Henry doesn’t necessarily realise, but what becomes clear to his family (and to the reader), is that this is a life sentence.

One particularly valuable service this book does is to underline the injustices associated with mental health problems, especially schizophrenia. Various truths are highlighted, including the fact that the media often demonise sufferers as violent (statistically, very few are), that society in general often treats them with (at best) disregard, and that sufferers are far more likely to be dismissed from their jobs than if they had a physical condition.  It is also pointed out that, on occasions, sufferers placed in hospital wards can be allowed less fresh air and exercise than would a convicted offender.

Given the downbeat quality of the story and many of the associated observations, it is tempting to wonder if there’s any chance of the book ending on a positive, uplifting note.  I won’t give anything away, but it I will say that the reader does not finish the final chapter with a sense of desolation.  Instead (for me, anyway) there is a sense of worthwhile insight bordering on enlightenment.   

Henry’s Demons: Living with Schizophrenia, a Father and Son's Story by Patrick and Henry Cockburn is published by Simon & Schuster
ISBN 978-1-84737-703-6

Delivered Unto Lions by David Austin is published by CheckPoint Press
ISBN 978-1-906628-21-5
For more information visit

Tuesday, 15 February 2011

What Then and Where Now?

Sometimes as I prepare to write my blog I start to wonder if there’s anything left to say. But then some little thing will happen that makes me realise that there is nearly always something to say.

This week, two questions have come to mind: (1) ‘What then?’ and (2) ‘Where now?’ I’ll deal with the ‘What then?’ first.

Thanks to the wonders of social networking, I received a message this week from one of my old school classmates from the mid-1970s. This was someone I knew immediately before I experienced the events that ‘inspired’ my novel Delivered Unto Lions. She told me that, as far as she knew, I had just ‘disappeared’ from school with no explanation. Having become aware of my book, she now realised what had happened – that I’d been taken away from school (and home) and placed in a psychiatric unit because I was depressed.

This made me think of three other children who went to that same school who were also (at different times) ‘spirited away’ to the very same psychiatric institution. I didn’t know any of them while I was at that school, but I got to know them at the institution. This makes me wonder whether their sudden absences went unexplained in the same way that mine did. After all, I certainly hadn’t been aware of anyone ‘disappearing’ like that, but at least one of those ‘disappearances’ had happened before mine.

It is a horrible thought that, on certain (comparatively rare) occasions, children could simply be plucked out of their schools almost unnoticed. Their friends would wonder what had happened to them, of course, and no doubt some vague words of non-explanation would have been offered. But unless a child eventually returned to his or her school (some children did, some didn’t), life for everyone else would just go on, and that child would be gone and (in the end) virtually forgotten.

And that brings me to the ‘Where now?’

I have been greatly encouraged by the shift towards Care in the Community which began in the late 1980s, and which by the mid-’90s had seen many of these old children’s units closed. Care in the Community has its critics, of course – and often for good reason – but I tend to focus on the idea that a child with depression, anxiety, or some other similar condition, is far better off in as normal environment as possible, rather than being ‘incarcerated’ in a clinical and often hostile mental unit.

The hope is that things are far better these days, and that far fewer troubled children get institutionalised. But how can we be sure of this? The fact is that, prior to the rise of Care in the Community, very few people were aware that it happened anyway. So, if it was still happening today, would we notice?

This may sound like I’m being a little alarmist. Perhaps I am. But what prompts this is what I've found (which isn't much) from my attempts to discover exactly what does happen today. Unless you are a mental health professional, your are unlikely ever to have come across the Royal College of Psychiatrists' directory of children's units. This, however, lists all the child and adolescent mental health in-patient units in Britain and Ireland – and there are actually quite a lot of them!

I'm not going to start flinging wild accusations about. My hope (and my belief) is that these present-day units are far more compassionate and empathetic places than the ones that used to exist. But they are still well-hidden. Unless you go looking for these places, you'll never know anything about them.

My book is about exposing a hidden world from the recent past (and Wikipedia helps too!). But there remains a hidden world in the present. What I would like to see is more transparency, so that society as a whole – as well as healthcare providers – can scrutinise current practice and ensure that it is just and caring.

Delivered Unto Lions by David Austin is published by CheckPoint Press
ISBN 978-1-906628-21-5
For more information visit

Wednesday, 9 February 2011

Book Review - Welcome to My Country

Lauren Slater is a psychologist who obviously enjoys a colourful turn of phrase.  In Welcome to My Country (published by Penguin), Slater recounts her experiences of working at a clinic in Boston alongside the schizophrenic, the chronically depressed, the sociopathic, and the otherwise troubled.  She positively revels in vivid description, describing one patient as having ‘skin the color of deep coal’, another as having a spine ‘standing out like a string of pearls’, and yet another as having a ‘voice as bleak as a British moor’ (though, given the context of this last phrase, I can’t help wondering how many British moors the author has actually seen!).  This very much underlines the fact that this is not a textbook containing dispassionate case histories, but an experiential account of engaging with mentally and emotionally disturbed individuals.  

Slater’s academic grounding at Harvard and Boston Universities has not fully prepared her for suddenly entering a foreign land populated by people who seem to experience reality very differently.   This is a world where women can also be paintbrushes, where spaceships can rest on people’s stomachs, and where intimate relationships can be maintained with albino girls in the sky.  It is among disparate individuals with disparate delusions that Slater – uneasy and occasionally offended – has to conduct group and individual therapy, encouraging patients out of their bizarre individual world experiences into a more common shared world experience.

As Slater’s story unfolds it becomes apparent that she often succeeds in entering into the worlds of her patients – even when those worlds remain stubbornly unintelligible.  She comes to empathise with her patients, even when initially revolted by some of their characteristics.  This is a very striking aspect of the story, especially given her admission of how little confidence she often has in formally understanding her patients’ needs.  

Despite Slater’s robust theoretical knowledge, much of what she seems to do in therapy – in terms of procedure – is little more than trial and error.  Slater’s strength (and her vulnerability) seems to lie in her ability to empathise.  Indeed, aspects of her patients’ stories stir up personal memories and emotions for her, leaving her pondering on the content of therapy sessions long after she has finished work for the day, and forcing her to confront certain aspects of herself.  Slater even expresses the general observation that the mentally disturbed sometimes ‘force you into things you’d rather not see, not say.’  And she expands on this by confessing that, in knowing certain patients, she finds herself returning to a state of shame followed by emptiness.

What is so disarming about this book – and what only gradually becomes apparent – is that Slater is personally familiar with psychological torment.  It is this which finally gives contextual meaning to the entire book in an exquisitely moving final chapter.

Welcome to My Country is a beautifully written memoir, expressing well-informed insight through a fusion of imagination, poetic language and technical knowledge.  An extraordinary book.

Welcome to My Country: A Therapist’s Memoir of Madness by Lauren Slater is published by Penguin Books
ISBN 978-0-14-025465-5

Delivered Unto Lions by David Austin is published by CheckPoint Press
ISBN 978-1-906628-21-5
For more information visit

Monday, 7 February 2011

Accepting Difference

The speech on multiculturalism, delivered in Munich by British Prime Minister David Cameron on 5 February 2011, has been generating a good deal of discussion in the press.  Comments like ‘We need a lot less of the passive tolerance of recent years’ have gathered a good deal of support from some papers (e.g. The Times) while being greeted with suspicion by others (e.g. The Guardian).  Cameron was, of course, primarily criticising alleged tolerance of one very particular and small subculture, i.e. ‘extremists’ of the Islamic faith persuasion.  But multiculturalism (depending on how you define it) encapsulates far more than this one single issue.

So what does multiculturalism have to do with the usual topic for discussion on this blog, i.e. matters related to mental health?  The answer to that lies in the issue of ‘difference’.  Difference of the cultural variety may not seem obviously related to mental health.  When presented with the word ‘culture’, I suspect many of us will think either of ‘high culture’ (e.g. opera) or something vaguely connected with ‘national culture’.  But many groups have their own cultures, such as families or members of a particular profession.  And other groups are often seen as though they were a culture, such as the so-called ‘disabled community’. 

Society, very broadly speaking, can sometimes appear to regard people with mental health problems – or past sufferers of mental health problems – as if they were an identifiable cultural group.  In this way, a whole swathe of people with little or no connection to one another get marked out as ‘different’.  

David Cameron has said, '[W]e have encouraged different cultures to live separate lives, apart from each other and the mainstream.' 

Cameron was not, of course, talking about mental health.  But he may as well have been.  Because many people with present or past mental health difficulties are marked out as different by society (as are many people of certain national, ethnic or faith backgrounds) they are not really welcomed into the mainstream.  As such it is only natural that some should choose to live separately from those around them.  And by segregating themselves, they become even less welcomed by the mainstream, and so they segregate themselves further.

What has prompted me to post these observations is hearing the story of a physically disabled woman (whom I will not identify) who is so fed up with the verbal abuse she receives when venturing out into public areas that she often avoids it, feeling very uninclined to ‘integrate’ with the mainstream.  This is, no doubt, an experience she has in common with people with many conditions – mental and neurological, as well as physical.

Cameron says, ‘We need a lot less of the passive tolerance of recent years.’  Given that so many people, through no fault of their own, are not tolerated by much of society – passively or otherwise – leads me to conclude that this was a very unfortunate statement.  Clearly I am interpreting it in a way that was not intended, but surely politicians should be aware that the ‘enemies’ they target are not always the ones who take the hit.  I am sure this is not what Cameron wants, but many people will get (and, apparently, have got) the message that it’s good and proper to be intolerant of difference.

So when it comes to people with mental, neurological or physical difficulties (along with many other people), I say that what we need instead of ‘passive tolerance’ is ‘active acceptance’.

Delivered Unto Lions by David Austin is published by CheckPoint Press
ISBN 978-1-906628-21-5
For more information visit