<b>Mental Health</b>: The Fear Factory

The Government promised a 'safe, sound, supportive' mental health system. Instead it is stumbling into the lock-'em-up and drug-'em-up policies of a shameful past. Here we extend our campaign for a service that has the welfare of patients at its heart. To begin, Jeremy Laurance looks at a system under strain

Public and political alarm over exceedingly rare but catastrophic attacks by mentally ill people reaped a grim harvest last week. When the draft Mental Health Bill was published it contained draconian provisions for the indefinite detention of people with personality disorder and the forcible treatment of patients in the community.

Public and political alarm over exceedingly rare but catastrophic attacks by mentally ill people reaped a grim harvest last week. When the draft Mental Health Bill was published it contained draconian provisions for the indefinite detention of people with personality disorder and the forcible treatment of patients in the community.

The draft Bill, described by Health Secretary Alan Milburn as the biggest reform of mental health legislation in 40 years, drew immediate protests from people with mental health problems, who say it casts them as monsters, and psychiatrists, who fear it will turn them into jailers. It should worry us, the public, too, because instead of achieving the "safe, sound, supportive service" that the Government promises, it risks doing the reverse.

During the last year I have travelled round the country observing the mental health services at work for a book I am writing. I have joined ward rounds, sat in on out-patient clinics, been out with crisis teams, visited patients in their homes and talked with professionals, charity workers and consumer groups. What I have found is a service driven by fear in which risk avoidance through containment – by physical or chemical means – is the priority.

In every encounter with a mentally ill person the question uppermost in the minds of the professionals is: "Will this person kill themselves or someone else?" The fear of being hauled in front of an inquiry if things go wrong concentrates the professional mind. The result is that we have a crisis service, with little to prevent the crisis occurring or to provide support after it is over.

Psychiatry has always been about balancing care and control but over the last decade pressure from a Government and public averse to risk, and bent on pinning blame when things go wrong, has produced a culture of containment seen in increasing detention, rising prescribing, supervised discharge, registers of dangerous patients, locked wards, and a service driven by fear.

One measure of the increasingly coercive service is the increase in the number of people forcibly admitted to psychiatric hospital, up by half in the last 10 years from 18,000 in 1990-91 to 26,700 in 2000-01. In addition to these, thousands more patients go into hospital voluntarily for treatment and are later refused permission to leave, and these numbers are also sharply up. The result is that almost 50,000 people were detained in mental hospitals last year, 20,000 more than a decade ago.

In one psychiatric ward I visited in Norfolk, I met Michael, aged 22 with wide, sloping shoulders, pale skin and the wispy beginnings of a beard. He had been sectioned for waving a Samurai sword around on a bus, alarming the passengers, and then visiting his GP to show her "how sharp it was".

Diagnosed with manic depression, he spoke with a slow drawl, his head hanging and his shoulders slumped – the effect of the drugs he had been prescribed to bring him down from the manic high. "I don't agree with the principle of sectioning," he said. "I don't hurt anyone – I am just a bit frightening. I don't like the drugs. They make me feel unhappy and rundown. I can't play sport." He sat staring at the ground, lazy, apathetic. Everything was an effort.

Most people might feel it was appropriate to detain someone like Michael in hospital – but in Bradford, I saw a different way of dealing with a similar patient. Matthew had smashed the doors of a health centre, harassed shoppers and recently had thrown a road sign at a woman parking her car (it didn't hit her). Instead of bringing him into hospital under section, a psychiatrist and a social worker went out to find Matthew on the streets and spent half an hour negotiating with him, with 40-ton lorries grinding by, while I watched from across the road.

The aim was to engage him – he agreed to let them fetch some shopping for him and, crucially, to meet them again the next week – win his trust and work towards providing him with the treatment he needs in the community.

But when I described this scenario to a London psychiatrist, he responded: "They [the professionals] must be mad. They will find themselves in front of an inquiry panel when that man injures someone." Thus does fear drive the system, inhibiting innovation and encouraging incarceration as the "safe" option.

One consequence has been growing protests from the people who use the services. The rise of the consumers movement in mental health is the most striking development of the last 10 years. There is enormous dissatisfaction with the treatment offered, with the emphasis on risk reduction and containment and the narrow focus on medication. They dislike the powerful drugs with their side-effects and a growing number reject the bio-medical approach which defines their problems as illnesses to be medicated rather than as social and psychological difficulties to be resolved with other kinds of help.

The Government's response to this has been confused. On the one hand it has embarked on a major boost to the community care strategy with extra funding, a national service framework overseen by a mental health tsar and the creation of hundreds of new community teams aimed at providing a more flexible and responsive service – moves which have been widely welcomed by patients and professionals alike.

On the other hand, its proposals for reform of the law pander to public prejudice about mentally ill people and stoke prejudice against them.

Almost every homicide inquiry over the past decade has identified the loss of contact with services as a crucial factor in the subsequent catastrophe. The way to deal with this is not to increase coercion, with a heavy handed new law, but to increase engagement, by providing services that are accessible and attractive to the users. If the Government persists with its misguided proposals, it risks undermining its own community care strategy and driving mentally ill people away from services rather than securing their engagement which is essential to keeping them, and us, safe.

Jeremy Laurance's book 'Pure Madness: how fear drives the mental health system' will be published by Routledge in the autumn