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The drugs don’t work: an analysis of mental health and the modes of social control.
Mental health in the UK has faced a large amount of disparity in regards to the way that people are treated in relation to their human rights. This is an issue that is still difficult to understand as 1 in 4 people will suffer from a mental illness in the UK today. The experience of suffering with a mental illness can be interlinked with inequality and the question of an individual’s freedom and autonomy being taken away from them. It appears that the question of having one’s freedom is directly under attack when suffering from a mental health illness which leads to the question of whether they are ever free. Efforts directed towards achieving autonomy and freedom should not become separate from achieving substantive equality for people with mental health illnesses. Structural factors such as inequality, gender, family living conditions, socio-economic conditions, and discrimination contribute to the ways in which a mental illness can increase and have a negative impact on an individual’s ability to recover from an episode. A human rights approach to mental health is determined on acknowledging the individual who is suffering with a mental health illness by respecting their dignity as an individual, their autonomy and independence, and their freedom to make their own choices. Operating through a rights-based approach instructs us to examine and scrutinise the language, implications, and models of mental health that have been adopted previously, especially when taking health discourse into account. Such an approach also requires us to look at the ways in which human rights have been characterised as being based on a particular mental state and how discrimination characterises the lives of people with mental health illnesses especially when matters of treatment are brought into the question. In this essay, I will look at Michel Foucault’s approach to human rights being based on a particular mental state and the implications of treating people solely through the approach of medication. I will use this approach in the form a timeline dating from the 19th century to the present day, specifically looking at two case studies: the first titled, A Mind That Found Itself by Clifford Whittingham Beers written in 1908 and David’s Box: The Journals and Letters of a young man diagnosed as a Schizophrenic 1960-1971 by Richard Hallam and Michael Bender in order to provide an analysis of how access to the right type of mental health treatment appears to be a case of privilege which can still be seen in mental health treatment today. I will also look at the approach of healthcare within the UK still being centred on excluding those with mental health illness rather than integrating them within their communities as both case studies show. Finally, while acknowledging that healthcare professionals are under a duty of care to provide people with medication as a form of treatment, I would argue that it should be down to the person suffering with a mental illness to exercise the right and agency in their own lives and who, consequently, should be supported in such a way that the barrier between their freedom and autonomy should not work against them in relation to their mental state.
The nature of mental health practices in the UK can be dated back to 1247 when a monastic priory was founded in the city of London on the site where Liverpool Street station now stands. The priory operated in such a way that it was able to provide food and shelter for those who were deemed as being ‘’sick’’. However, from 1330 onwards it was renamed as Bethlem Hospital and was reported as having evidence of providing the earliest treatments of madness. In 1676, Bethlem was granted permission to be built at Moorfields in London making it the first hospital for the insane in the UK. As a result, Bethlem became a unique setting on the basis of it becoming somewhat of an attraction to members of the public and confirming its place as a receptacle for the madness of the nation. I would argue that Bethlem became a way of exposing those in a particularly vulnerable state as being dangerous to the livelihood of a ‘’sane’’ society, and in order to offer protection to those people it appeared that secular confinement was the best way to implement that safety. Throughout the earlier periods of the 16th-19th century, madness was described as a ‘’beastly’’ condition, and for the most part that those deemed as mad ‘’deserved it.’’ The nature of the asylum and its positioning within society then was a daily reminder of what to keep away from – to distance yourself from a particular ‘’mental state’’ that would ultimately separate you from the rest of the world. This isolating treatment of patients with mental health illnesses is still indicative in regards to how mental health services operate today. There is a clear comparison to be made between the geographical positioning of Bethlem in the heart of London throughout the 16th century as a haunting reminder of exclusion to its position now being situated on the outskirts of London in Kent as a people who have been forgotten and failed by the system. Many have questioned the care and support that is offered within hospitals, and whether the balance of power operated under the Mental Health Act is one that seeks to criminalise those with illnesses or in fact empower them to have agency over their own lives. It appears that even today mental health professionals operate on a basis of ‘’knowing what’s best’’ which makes psychiatry on a whole much harder to challenge. However, this essay will go on to explore the impact of lived experiences and how those experiences are able to offer a strong account of being free as an individual when suffering from a mental illness.
Foucault has described the principles of madness as being rooted in many varying aspects with the main two branches being divided between melancholia and mania. In this instance, ‘’the aspects of madness’’ are directly linked between what mental state becomes violent and what remains contained. Melancholy, has been described as being a state that ‘’never reaches violence’’ and proceeds on the basis of a concentration of nervous power and of its fluid in a certain region causing the mind to be in a state of sleep. Applying Foucault’s theory of melancholy to Clifford Whittingham Beers’ A Mind That Found Itself illustrates how the instances of varying mental states described in Madness and Civilization do not take into account the lived experience of an individual who has encountered melancholy and differing states of mania. It also highlights the clear battle between freedom and mental health rights on the basis of an individual such as Clifford Beers not being ‘’violent’’, but him as an individual, being deemed so on the basis of his thoughts. Throughout the course of his personal accounts there are many instances where he is struck with the battle of whether or not to commit suicide. The passage below illustrates how he is aware of his actions in such a way that proceeding with suicide on the basis of his intellectual mental state is something he is not able to do.
‘’Considering the state of my mind and my inability at that time to appreciate the enormity of such an end as I half contemplated, my suicidal purpose was not entirely selfish. That I had never seriously contemplated suicide is proved by the fact that I had not provided myself with the means of accomplishing it, despite my habit, has long been remarked by my friends, of preparing even for unlikely contingencies. So far as I had the control of my faculties, it must be admitted that I deliberated; but, strictly speaking, the rash act which followed cannot correctly be called an attempt at suicide—for how can a man who is not himself kill himself?’’
If we are to analyse this passage in direct link to the acts of 1842 and 1845 whereby the erection of county borough asylums was mandatory and Acts of Parliament gradually transferred the organisation of these institutions into the hands of the medical profession it does present a detrimental flaw in acknowledging thoughts of suicide as being enough for an individual to be placed in an asylum. Beers wonders ‘’how can a man who is not himself kill himself’’ demonstrating a sense of awareness which confirms his state of melancholy not ‘’reaching a state of violence’’ yet he is still deemed as not being within the realms of sanity. Similarly, in This is Madness  there are first person accounts from individuals who have been treated with restrain within the hospital environment on the basis of them being considered a threat to the natural order. However, if as noted by Foucault these thoughts rarely ‘’reach violence’’ then the basis of institutionalisation solely relies on the power of those operating under the ‘’psychiatric empire’’ being granted the ability to take away the rights of those individuals based on a mental state that only appears to be a threat to themselves.
Foucault also explains mania and melancholia being rooted in individuals being focused on the idea of a particular mental such as death or fear, and in accordance with those tendencies, perhaps seeing themselves ‘’to be beasts, whose voice and actions they imitate.’’ However, I would argue that this is just one of the ways that those suffering with a mental health illness are conditioned by their surrounding social factors rather than it being a reflection of themselves. For example, if we are to consider Beer’s moment of suicide thought:
‘’ I really wished to die, but so uncertain and ghastly a method did not appeal to me. Nevertheless, had I felt sure that in my tremulous frenzy I could accomplish the act with skilful dispatch, I should at once have ended my troubles.’’
It appears that his contemplated suicide is depicted as a moment of frenzy as mentioned above to be a signifier of melancholy, and in understanding that it reveals the relationship between freedom of thought and mental health. As it states in Article 9 of the Human Rights Act:
‘’Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief and freedom, either alone or in community with others and in public or private, to manifest his religion or belief, in worship, teaching practice and observance.’’
If we are to consider the freedom of thought as a rights bearing entity in relation to one’s mental state then surely, as an individual, the act of thinking, whether good or bad, cannot be enough to consider whether one is in fact a functioning member of society. Beers is able to acknowledge himself from a place of intelligence when he states: ‘’after refusing for a long time I finally weakened and signed the slip; but I did not place it on the book. To have done that would, in my mind, have been tantamount to giving consent to extradition’’ which ultimately demonstrates the constraints of not being able to exercise his freedom or autonomy as a result of it being taken away from him. Thus, the notion of ‘’disciplinary power’’ is brought into focus as melancholy is dependent on a particular type of intelligence which could also equate to a positive form of mental state. Intelligence is considered as a desirable trait when understanding personality formation which suggests that the ‘’power of the state’’ comes into governing what perception of intelligence the nation understands. Surely then, the notion of freedom and autonomy as rights bearing entities become blurred as it is a ‘’madness at the limits of its powerlessness’’ providing the ultimate paradox to how someone who is clinically insane would operate. Foucault specifies that ‘’melancholia, finally is always accompanied by sadness and fear; on the contrary, in the maniac we find audacity and fury’’ highlighting the history of psychiatry being based on its ability to socially exclude individuals. His approach to psychiatry illustrates the complexity of power and sensitises us to the destructive impact of ordering the human world in terms of simple binary distinctions such as good/bad, right/wrong, truth/ideology, illness/non-illness. Critiquing individuals on this basis then highlights the position of psychiatry as depriving individual mental rights on the basis of conforming to a constructed order of power rather than understanding its place as a process. Whilst in hospital, Beers described experiences of his physical health also being affected by his undergoing treatment for his mental health. For example, ‘’my brain was in a ferment. It felt as if pricked by a million needles at white heat. My whole body felt as though it would be torn apart by the terrific nervous strain under which I labored’’ illustrates his lack of mobility as a result of being under such severe mental distress. The force of this indifferent power demonstrates how immobilisation also acts as a form of discipline as it operates in the form of an asymmetrical relationship with the person in control and the individual. In this instance, Beer’s is able to understand that position by being under ‘’terrific nervous strain,’’ but he also identifies this when going home from the hospital and speaks of his brother as ‘’acting as a detective’’ and ‘’finding himself still under surveillance.’’ It is governance in this form that acts as control in the form of surveillance which on a whole the creation of the mental health act feels constituted on. I propose, therefore, that immobilising an individual of their mental and physical rights acts as a form of surveillance whereby taking agency over the minds and bodies of individuals leads to the deprivation of freedom and autonomy.
By representing Beer’s as both the ‘’maniac’’ and the ‘’melancholic’’ suggests that between mania and melancholia, the affinity is evident: not the affinity of symptoms linked in experience, but the affinity – more powerful and so much more evident in the landscapes of the imagination However, I would argue, that again, displays a flaw in psychiatry as it is conditioned on individuals adhering to a set mode of behaviours in order to be deemed as ‘’free’’. It alludes to my starting statement on psychiatrists or mental health professionals not being challenged on their perception of ‘’knowing what’s best’’ when the likelihood is that it will lead to a failed analysis, and ultimately prescribing limitations on freedom that are considered legitimate.
Throughout the course of the second half of this essay I will look at the accounts of a young man named David and how his diary sheds considerable light on the nature of madness and on the services available to people diagnosed with schizophrenia in the 1960s. The 1960s appeared to be a time that saw the ‘’anti-psychiatry movement’’ become dominant with the key message being: madness is a product of a mad family or a mad society. A number of psychiatrists such as R.D.Laing and Thomas Szasz have been seen as the most important representatives of the anti-psychiatry movement in highlighting the damaging effects of psychiatric diagnosis, drugs, ECT treatment, and involuntary hospitalisation on individuals.
As a result of the movement, there were a number of things that did change in terms of bringing to light the policy of incarcerating people in large mental institutions. Many people became politically active throughout this period in order to prevent people from having to face such treatment from the NHS. The charity, MIND which was originally known as the National Association for Mental Health campaigned for the closure of large mental hospitals and also for the human rights of current hospital patients as well as ex hospital patients. However, the process of hospital closures didn’t take place until the 1980s and 1990s. Mental hospital patients were then described as ‘’service users’’ yet, the act of integrating them in the community with the support of health professionals became scarce as larger efforts were being administered to help those suffering from family breakdowns and child abuse rather than mental illness. The link between ‘’mental disorder’’ and ‘’psychiatric illness’’ is one that is blurred now as the definition of mental disorder has always been legal rather than medical. However, the recent change in the law since the 2007 Act makes it possible for a person will a mental disorder to be closely monitored in the community and to be detained against their will if it is expected that they could pose a serious risk to others in the future. This shows that the possibility of integration within the community still isn’t viewed as a social and human right of those suffering with a mental health illness. The issues that have prevailed for many years between the medical and social model are still apparent with the main concern being over the word ‘’treatment’’ and how it is implemented. Detaining an individual is only permissible for the purposes of ‘’psychiatric treatment’’ which sheds light on the fact that detaining them for having certain beliefs isn’t possible, but deciding that they need to be treated on behalf of their mental state is deemed as acceptable. The act of ‘’treatment’’ typically implies medication and it is seen that people adhering to medication is a way of minimising the risk of disturbing behaviour, however, it shows how it acts as a form of control.
In the case of David, there are many factors that I will explore in relation to medication being a form of control depriving him of his freedom and liberty as an individual suffering from Schizophrenia. Taking into account his early teenage years, David was described as a highly intelligent young man with an IQ of 123 however, as a result of taking Largactil, now known as Chlorpromazine there was a sudden shift in his ability to process information, and as a result he became much slower in regards to academic education. It was noted by his school teachers that he was often ‘’unhappy’’ and in July 1957, the school became concerned about David’s ‘’state of mind.’’ The head teacher of his school wrote to his to his father to inform him that enquiries were being made about David’s mental health illustrating that looking at effective ways in which they could help David within a local environment were cast away. Erving Goffman spoke of stigma as a social identity that becomes ‘’discredited’’ by possessing an attribute that makes an individual different from others in the category of persons available for them to be, and of a less desirable kind – in the extreme a person who is quite throughouly bad, or dangerous, or weak. I feel that this is true of David’s ability to form relationships with people without being judged as an individual who is inferior or one that cannot be trusted on the basis of his ‘’mental state.’’ For example, when he speaks of the horrible effects of medication robbing him of his memory he states:
The horrible possibility that my memory, visual imagery, and whole state of mind have been horribly mutilated and permanently disfigured by treatment makes me wish for a good fairy to rescue me from the ghastly realities of the situation. I only have to look around me, read the papers, watch the television, to realise that ‘’to all intents and purposes’’ the human body is a machine, complex but vulnerable, so vulnerable. I fear being marred by such things as rheumatism. I fear physical exhaustion. I fear the utter collapse of my mind. I predict ultimate disaster.
The treatment that he encounters when in hospital becomes the basis of David understanding the process of what is making him ”mad.’’ With this in mind, he exercises his right as a patient to write to the Chairman of Managers to make an appeal in relation to Section 26 of the Mental Health Act 1959. David explains in his letter:
‘’Since a person can only be detained from outside a hospital if his condition is sufficiently retarded to warrant detention, why does this not apply inside a hospital, and why is such an order not rescinded immediately the patient regains his faculties? And how can (one assume in one way) a person under Section 26 be allowed to wander at will outside the hospital grounds, unless he is legally sane, and certainly in a medically fit enough condition to warrant this. And if he is legally sane, how can he be under Section 26, the Section used (I think) for the utterly incapable.’’
It appears that David is questioning whether being ‘’insane’’ is the basis for being ‘’detained.’’ Especially in regards to their being different warrants on what appears to be acceptable on hospital grounds and outside them that question the requirements of being ‘’legally sane.’’ It highlights the same process of private and public modes of complying to sections of the Mental Health Act in regards to medication too. For example, it is noted that David wrote ‘’large parts of his diary under the influence of choral’’ and ‘’became addicted to chloral, and also to Mandrax, originally introduced as a supposedly safe alternative to barbiturates.’’ This demonstrates that the act of receiving medication was presented to David in the form of a ‘’favour’’ as though the drugs he became addicted to were better than any other way he would have been able to relieve himself of tension. As mentioned above, an individual should be in receipt of being able to comply with their right to freedom of speech, but David isn’t able to exercise this right on the basis of being ‘’mentally ill’’? He also isn’t able to view his ‘’human body’’ as his own, but one that is specifically being used for the basis of social control through medication. Therefore, Goffman’s analysis on ‘’stigma’’ being based on an individual’s behaviours and characteristics making them ‘’different’’ becomes linked to Foucault’s account of discipline as it is on the basis of an individual being different that controlling them is considered acceptable. In order to keep the ‘’crazy’’ away you must medicate them regardless of it being against their will (punishment), control them through their social environments (hospitals), and monitor their ability to reconnect with their own lives (discipline). As David goes on to say ‘’my memory is growing worse with the passing of each. On occasions, my happiness coefficient’ is at a lower level than on the 13th June. But my main problem is my memory – destroyed (partially) by that fiendish concoction originated in North India – chlorpromazine – trade name Largactil… Saw in the ‘book’ that night, Largactil 50 or 100 mg as necessary!!! This shows the extraordinary natures of these idiot psychiatrists.’’
Mental health represents an area of one’s lived experiences that are challenged and conflicted with the state. As explored within this essay, the factors on which that becomes applicable are on the basis of limited access to support, the trust of health professionals, and the right kinds of treatment. Although, there have been further changes to the Mental Health Act in regards ‘’towards upholding the rights of the individual to choose what’s best for them.’’ I would argue that the notion of ‘’consent’’ is one that still fails to be addressed in mental health discourse. In accordance to the current Mental Health Act of today, there appears to be little improvement on the basis of working with individuals on the right kinds of treatment for them. The modes of medication such as the ones that David was in receipt of throughout the 1960s such as ECT and Chlorpromazine still operate today which leads to the question: how likely is it that these modes of ‘’treatment’’ are worthwhile if there are no signs of improvement over 40 years later? Thus, there remains a need to introduce other forms of treatment such as talking therapies and allow individuals the right to such treatments at the most earliest signs of struggles with their mental health. The therapeutic space would be one where problems, although experienced individually, could be contextualized; internalised oppression from parents, school, work, peers or wider society could be spoken about, witnessed, thought about and put into context. Such an approach would work with individuals and reinforce the nature of them having the right to make their own decisions and not being dictated by health professionals or psychiatrists. Therefore, the future of mental health services should aim to understand the perspective of the individual suffering as it no longer remains the case of prescribing drugs that have been categorised into groups such as ‘’anti-depressant’’ and ‘’anti-psychotic’’ as it is not possible to control what side effects they will have in the future. A positive presence is needed in reasserting the principle that the characteristics of what someone can be deemed ‘’mentally ill’’ for such as low self-esteem, paranoia, confusion, despair, and loneliness are experiences that us as humans will experience in our lifetime. The Foucauldian theories explored within this essay such as surveillance, discipline, and control illustrate the similarities between that of the hospital and the prison. These spaces are created deliberately in order to protect the ‘’non criminals’’ or in this context the ‘’sane,’’ and simultaneously limit the rights of the ‘’criminals’’ and the ‘’insane.’’ It highlights that as long as these systems are in place the freedom of those suffering with mental health illnesses will always be in jeopardy. Consequently, the first step towards ensuring those suffering with mental health illnesses are no longer incriminated is by ‘’representing the rights of people psychiatry is monitoring,’’ and creating a system that is based on experience such as from ex-patients and service users who have lived through the same process.
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 Same as above.
 Same as 37.
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