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Ken MacIntosh: Psychiatric wards are not always full of the mad


Last month, Labour’s shadow minister for mental health, Luciana Berger, decried the lack of mental health beds within the NHS, labelling the situation “a disgrace”. She echoed concerns voiced by the Lib Dems, who at the last general election made the need for improved mental health care provision their central campaigning issue, a worthy strategy which inspired several dozen people to vote for them. The politicians’ concerns reflect those of professionals, with the president of the Royal College of Psychiatrists, Simon Wessely, having described inpatient psychiatric care in England as a “system at breaking point”. Talk to any charge nurse on an acute psychiatric ward and they will describe a constant struggle to find beds for new admissions. It is hard not to believe that more beds are required.

And yet, and yet… stroll around said wards and you will be struck by the numbers of patients that don’t seem to be very mad. The un-mad stand very much in contrast to the mad of the ward, with the former often intolerant or mocking of the latter. Thus, even within the confines of the psychiatric ward, sanctuary is denied the truly afflicted. Take one group of the ‘un-mad’: those with Borderline Personality Disorder (BPD). To call them un-mad is not to suggest that there is nothing wrong with them; BPD sufferers plough a lonely and desperate furrow. They have often experienced neglect or abuse when young. As a result, they are unable to form normal empathetic relationships. They instead attempt to manipulate and emotionally bully those near to them. They often have an inability to cope with any emotional challenge. BPD is a set of character-traits.

The NICE Clinical Guidelines on BPD state that at least fifty per cent of those diagnosed with the disorder will recover within five to ten years of first diagnosis. They continue, “It is not known to what extent [recovery] is a consequence of treatment – evidence suggests that a significant proportion of improvement is spontaneous and accompanied by greater maturity and self-reflection”. Perhaps uniquely, we have an illness for which the antidote is ‘to grow up’.

Herein lies futility: the symptoms of BPD would be alleviated by an assertion of agency (or ‘growing up’), but in being diagnosed with the condition (and thus told, it’s not you it’s your illness) an individual is immediately robbed of that very agency. Whereas in other illnesses, diagnosis is the point at which any potential recovery must begin, in BPD it can form a trigger-point from which the disorder, in all its manifest awfulness, finally erupts. BPD sufferers often yearn after the victim status that being diagnosed with the condition confers. It feeds into their manipulative behaviour. It offers them an excuse and a reason for behavioural excesses. As a result, such patients will often go to great lengths to be admitted to hospital. Indeed, a craving for hospital admission can become a central symptom of the illness. We have beds occupied by those whose conditions deteriorate directly as a result of having a hospital bed.

Another prominent inpatient group is formed by alcoholics. Whilst an alcohol detox requires the administering of medications and physical monitoring, from a psychiatric point of view, things are not so clear cut. The problem with the modern ‘disease theory’ of alcoholism is that, as with BPD, it robs individuals of agency – It’s not them. It’s their illness. They are no longer responsible for their own actions. And yet, as C.D. Emrick’s vast 1974 review of treatments for alcoholism states, “Once an alcoholic has decided to do something about his drinking and accepts help, he stands a good chance of improving.” The precondition for any treatment to work is that the patient exhibits desire and agency. Again, a paradox is created by the disease label: the identification and creation of the diagnosis renders the problem all the more difficult to deal with.

The expansion of treatments for alcoholism over recent decades has been vast. This 2002 project reviewed controlled studies on the efficacy of no less than eighty nine treatments. And yet the British Beer & Pub association reported a near two-thirds increase in average alcohol consumption between 1971 and 2005 (though this has since begun to decrease again). Compare this to the near 75 per cent reduction in the alcohol mortality rate between 1904 and 1935, at a time when the only ‘treatment’ for alcoholism was to get up off the bar stool and go sign the pledge of allegiance to the local branch of the Temperance Society. Some alcoholics benefit from being in hospital; for others, their time as inpatients possibly weakens their chance of recovery.

For the Left, ‘more’ is always the answer – in the case of mental health, more beds. And sometimes ‘more’ is the answer. But there is also an ongoing churn of mental health patients, habitual residents of the system, who are also, possibly, damaged by the system. Any demand for an increase in bed numbers should also bear witness to this fact. Sound Conservatism is a refusal to blindly worship the Cult of More. It is to search for more nuanced truths. Enoch Powell understood this when he made his ‘Water Towers’ speech in 1961, in which he proposed a policy of deinstitutionalisation. The Thatcher government understood this when they brought in the ‘NHS & Community Care Act 1990’, and in so doing, speeded up the closure of the great old Victorian asylums.

Yes, some mentally ill people have been denied beds, and this is wrong. But the reasons for it are not simply down to numbers.

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Ken MacIntosh
Ken MacIntosh
Ken MacIntosh is an NHS psychiatric nurse and is married with one daughter. Ken is interested in politics and mental health issues.

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