The complexity of mental illness

There has been a strong political focus recently on mental health, with pledges to reduce waiting times for those in need of interventions and to put mental illness on a par with physical illness. There is also a movement to change people’s perception of mental illness, thus reducing stigma and enabling people to talk about and understand mental illness in the same way that they do physical illness. These moves have sprung from people having to wait many weeks before receiving treatment for mental disorders, with this, on occasion, resulting in suicide as patients despair of ever receiving help.

All of this is very laudable. It will be wonderful if we can reduce the stigma and get people talking about, rather that shying away from, mental health issues. However, I have experience of mental illness from a rather different angle, an angle that people may be less familiar with. One of my close relatives has suffered from schizophrenia—one of the most serious mental illnesses— for the whole of their adult life. The symptoms of schizophrenia include delusions (of persecution, for example), auditory hallucinations (hearing voices), and disordered thought patterns. The delusions, in severe cases, become overwhelming and replace the sufferer’s ‘normal’, rational view of the world. It is not uncommon that people who suffer from schizophrenia also suffer from a complete lack of insight into their condition—their delusions appear so real to them that they are incapable of recognising that they are ill, a condition known as anosognosia. My relative falls into this camp.

For someone who recognises that they are ill and actively seeks help, there is a good chance of curing that person (or at least of controlling the symptoms of their illness). But for someone who cannot recognise that they are ill, the outlook is much less bright. From my experience, try as you might, it is impossible to persuade someone with anosognosia that they need help. And suggesting to them that they are ill (or even failing to express agreement with their delusional beliefs) makes them extremely angry and, sometimes, violent. The situation becomes intractable.

What, then, happens in situations like these? Well, the simple answer is that nothing can be done, until the person exhibits behaviour that makes them a danger to themselves or others, at which point they can be detained under the Mental Health Act and forcibly treated. In these cases, pressure on the nearest relative becomes intense. (The ‘nearest relative’ is a legal term, defined in the Act, and it is not possible to stand down from the position of nearest relative.) The nearest relative is ‘consulted’ at every stage of the detention because, legally, someone cannot be detained under the Act without the consent of their nearest relative. But this process makes a mockery of the concept of ‘consent’ since, although the nearest relative has the right to object to the detention and, for example, discharge their relative from hospital, the responsible clinician can simply intervene if s/he believes this to be necessary (typically, if they consider the detainee to be a danger to themselves or others, which they have to be anyway in order to have been detained in the first place!).

As the nearest relative I found myself in an impossible situation. My relative was clearly desperately ill and in need of help, but refused to accept this. My relationship with my relative was pretty much non-existent, as a result of the years that I had spent struggling to cope with their schizophrenia. My relative demanded that I object to their detention under the Mental Health Act, which clearly I wasn’t prepared to do. The authorities persisted in demanding information from me about my relative’s condition and symptoms, information which I couldn’t provide because of my lack of a relationship with my relative. And, in all of this, no support whatsoever was provided to me, as the nearest relative.

So, my point is this: while it is entirely proper that we should provide help to people with mental health issues when they seek it, mental illness is so much more complex than this. There are a whole host of people who are ill but who do/will not seek help. What should we be doing for these people? And, perhaps even more importantly, what should we be doing for those individuals who are caught in the crossfire—usually relatives—for whom there is currently zero support or provision?

Hospital aftercare

Some time ago, I wrote a blog post about psychiatric hospitals and what it is like visiting a relative who is detained there.

Something else that we have become familiar with over the past few months is the after care that people receive once they are released from psychiatric hospital. This support is (predictably, I suppose, given the strain that the NHS is currently under) pretty minimal.

Our relative was released from hospital, but was still detained under the Mental Health Act. This meant that they were obligated by law to take the medication prescribed by their psychiatrist and to comply with any request to attend out patient clinics or indeed to return to hospital.

But the only support or monitoring they received was one visit per week from a psychiatric nurse. And when it was half term and the nurse was on holiday, our relative received no visit at all. Shortly afterwards, our relative was discharged from detention under the Mental Health Act.

Interestingly, our relative reduced the medication that they were taking as soon as they were released from hospital and stopped taking it altogether within a few days of being at home. This was obvious to us and so was surely obvious to the mental health experts as well. But it seemed to make no difference. Our relative was still discharged from detention under the Mental Health Act on the understanding that they would continue to take their medication -- even though they had already stopped taking it when they were still obligated by law to do so!

This is obviously a very difficult area to manage. It's all about balancing the safety of the public against the liberty and rights of the patient. I don't think our relative ever posed much of a threat to the public, but clearly some people with severe mental health issues do. And, given our experience of care and support following release from hospital, it's not surprising that sometimes poor judgements are made and tragic consequences result.

Psychiatric hospitals: what are they really like?

Before Christmas, we spent quite a bit of time visiting a psychiatric hospital. One of our elderly relatives was ill--suffering from schizophrenia--and we travelled to see her when we could at the weekends.We learnt an awful lot over that period, not only about the illness itself, the therapies used to treat it and the legislation surrounding mental health, but also about the physical institutions in which people suffering from severe mental health problems reside.

People's perceptions of mental illness have, I think, softened over recent years. There probably still exists fear of mental illness, but not to the same extent. It's talked about more openly--is in the media even--and is no longer considered something to be ashamed of.

Our relative has been ill for a long time, so we're very used to the symptoms of mental illness, but this was the first time that we had set foot in a psychiatric hospital. And it was quite an eye-opener. The hospital is situated in an affluent town on the south coast and you reach it via a pleasant drive past what look to be very expensive executive homes. The hospital is indicated by an innocuous NHS Primary Care Trust signpost--no mention is made of 'psychiatric', just 'hospital'.

But once you are on site, things feel quite different. In order to gain admittance to the hospital you have to report to the (very friendly) receptionist, explain who you are visiting, sign in and put on a visitor badge. Much the same procedure as when visiting any workplace, you might think. But going onto the ward is quite different again. The doors are locked, because most of the people on the ward are being detained under the Mental Health Act, which means that they are only allowed out unaccompanied if they have been granted leave by their doctor. All entry to, and exit from, the ward must be noted by a member of staff. Thus, when you arrive at the ward, you must ring a bell for admittance and, because the staff are very busy, it can often take a long time before anyone answers the door. Children aren't allowed on the ward, which meant that when we weren't taking our relative out, we had to meet her in the hospital's designated 'family room', away from the other patients.

Walking around the wards is also quite an experience. The patients are suffering from all kinds of mental health issues. Some are very pleasant and friendly, but others can be unpredictable and verbally aggressive. In the 'acute assessment unit', the ward to which all patients are initially admitted, it is common to see police officers, since new patients are, often, brought in as an emergency by the police.

I wouldn't exactly describe the hospital as Dickensian, but despite friendly and helpful staff, it is undeniably a bleak place, and the locked doors and police presence lend it an air of detention rather than one of caring treatment. Our relative has now been discharged, thank goodness, but there's a high likelihood that she will need to return at some point in the future. And that is something that none of us will relish.