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Do you ever feel the need to go back somewhere to see how your past is faring? Normally, I don't. I don't like going backwards but I've had an interesting few months lately doing a locum for the local mental health services security unit. Going through the doors is like going back forty years, the only real differences are that nurses don't wear uniforms now and the keys are electronic. Apart from that, and the piles of forms that staff have to fill in every day, nothing has changed. All too often, patients have been in and out of the unit (mostly in) for years, if not decades, but nobody has ever taken a proper history. They are heavily drugged and are put in seclusion (solitary) or even shackled on the perception that they may be dangerous. The whole place is based on the idea of managing risk, but not a risk the patient may represent to anybody in particular, only the risk that he may do something that will embarrass the department and thence the minister. Patients spend the day pacing up and down, bored to distraction, while staff spend all their time sorting out who has to be escorted where at what level of security. There are no activities, no workshops, limited facilities for exercise and so patients spend all their time working out how to smuggle cigarettes in since smoking has been banned in the hospital.
The problem is that the psychiatric staff see their role as diagnosing mental illnesses and prescribing drugs. End of story. The weekly ward meeting is mainly a matter of staff complaining about how a patient is "escalating" and needs more drugs, while the rest of the time is spent working out how to discharge somebody to other centres without any risk of "blow back" (an expression filched from American war movies, I'm told) in the form of the patient doing anything wrong that could possibly be blamed on the unit. Patients have to be packaged as saleable commodities before the other places will take them, so it's a bit like a jumble sale where everybody sits around trying to find something nice to say or how to get some government grant or other to make the poor soul more attractive.
It's an interesting experience but the essential point I'm learning (actually relearning) is that all the government interventions over the past twenty years to improve mental health services have gone nowhere. Sure, the amount of money spent per head of population has tripled or even quadrupled; the gigantic old "looney bins" have all been closed and their land sold for suburban developments; most patients sleep in single rooms, often with their own bathrooms; the food is better and so on but the biggest change is the vast bureaucratization of what should be a caring profession. In the old days, if a medical practitioner believed a person was mentally ill and a danger to self or others, there was one form to fill in. One page. If the patient refused to let his relatives take him to hospital, two more forms had to be signed and witnessed by a justice of the peace, ordering the police to pick him up. The first form took about two minutes to complete while the other two took about half an hour, with traveling time.
These days, it takes a cast of thousands because, you see, his human rights must be protected. So there are half a dozen forms to fill in, half a dozen interviews under conditions of some coercion, then there is the mental health tribunal. This is a duly-constituted, semi-judicial body that reviews every order made under the Mental Health Act, authorises treatment and reviews each patient every six months. For this, six to ten page reports must be prepared and circulated to the tribunal for their edification. It soon reaches the point where psychiatrists spend more time writing reports than they do seeing patients.
Then the big day arrives, the patient is escorted to the hearing room by three or four hefty nurses and sits before their eminences on the tribunal. The chairman of the tribunal is a lawyer, and the others consist of an independent psychiatrist and a community member, most often a nice middle-aged lady with a mentally disordered relative. In addition, the patient has a person called a patient's advocate, who takes his side, and a senior lawyer from the attorney-general's department who represents the "interests of the community," for which everybody understands the government. The cast varies from place to place. Some states, the tribunal is a quasi-judicial hearing conducted by a magistrate, or even a duly constituted mental health court. Some places provide a legal aid lawyer to represent every patient, some get a social worker and others can pay for their own lawyer if they wish. That's at least ten people, all of them being paid handsomely, except the patient.
After everybody is seated and duly introduced (it makes it seem less formal but I suspect it's just to waste more time), the psychiatrist has to state the facts of the matter, followed by an opinion as to whether the patient is mentally ill (note that word) and dangerous to self or others. Some places even allow a person to be detained on the basis he is likely to damage his reputation, even when his reputation is as the town lunatic. Most times, the patients say nothing, either staring at the floor in some sort of bemused stupor, or gazing out the window, bored to distraction. Others are old hands at this game and challenge every word the psychiatrist says, which means the chairman has to try to quieten them without the confidence that comes from being able to chuck malcontents into the cells to shut them up. So, after an hour or two of highly expensive to and fro, everything the hospital asked for in terms of banging the patient away for six months and pumping him full of drugs while locking him in a penitentiary, all is approved, down to how many hours per week he can walk in the hospital grounds with or without escorts (I am perfectly serious), and he is shunted back to the wards for a cup of tea (but not a smoke). The whole thing is a charade.
These medieval exercises in semi-judicial self-deception were dreamed up by lawyers who decided that a single psychiatrist signing an order was an affront to the patient's human rights. Thus, the incredibly simple and cheap old system had to be swept away in favour of a vast expansion of the growth industry of legalised mental health. We could go on about how much it costs (the Queensland Mental Health Tribunal spent $8,029,000 in 2010-11), how much better it would be if that money were spent on providing more housing for the mentally-troubled, or how it diverts psychiatry from a caring profession into some sort of cryptic forensic bungle, but one vitally important and oft-overlooked point is this. In the Good Old Days, one medical officer signed the form. His name was on it, and his address. If he got it wrong, the patient could sue him. Therefore, as junior medical officers, we made sure we didn't get it wrong. We erred on the side of caution, meaning we preferred to make false negative errors rather than false positive. That is, it was better to say somebody was not mentally ill when in fact he was, than to mistakenly say he was crazy when he wasn't.
No great harm came from giving a person a few more days of freedom; if he was genuinely mentally troubled, he would come back one way or another. But putting the wrong person in a mental hospital could produce mental disorder, we all knew that. Today, the boot is on the other foot. Not detaining a person leads to more trouble, in terms of court cases and complaints to the Medical Board, than wrongly detaining a person and forcing him to take treatment he doesn't need. Like, if he didn't need treatment before he went into the mental hospital, he sure will after he's been there a few weeks.
Compounding it, these days, even though gross abuses of psychiatry are just as common as they were forty years ago, there's nobody for the patient to sue. Because nobody is accountable, everybody errs on the side of caution, of not being the person who let a crazy person loose. The reason nobody is responsible is because the modern system was designed by lawyers, and lawyers don't like to be held responsible. In fact, they abhor responsibility and believe it is best spread around the system like a slime mould, hidden in the nooks and crannies of an arcane act that only they dimly understand, one that patients can't even read, let alone understand. This means that responsibility cannot be pinned on a single person and everybody gets to sleep well at night. Except the patient, but he can be given more drugs if he protests.
But if nobody is responsible, we end up with a human version of the Tragedy of the Commons. This is an economic concept that says that if some good or property is held in common, then it is economically rational for everybody to get as much of it as they can before it runs out. Consequently, it runs out much quicker than if they rationed it. The other side of the coin is that people won't care for something if they don't have anything in the game, they will use it but not invest any time, energy or money in it. Common property is soon lost, stolen, wrecked, neglected or run into the ground. People never look after common property as well as they look after their own (just think of the tea room in your office, compared with the kitchen in your home), so the mental patient, who is common property in the modern mental hospital game, ends up like the sink in your office kitchen: everybody dumps on him and nobody remembers to clean up.
It turns out that a very large chunk of all the extra money being spent on psychiatry these days is spent on tribunals and committees and lawyers and review panels and nurses filling in forms that nobody reads (more on them next time) and social workers filling in half a dozen different ten page application forms to have patients moved to a hostel (they couldn't use the same form), psychiatrists writing legalistic ten page reports analysing the patient's static risk and vulnerability factors, and so on. As an example of institutionalised inefficiency, there are two parts to the security unit I'm working in, high security and medium security. The units are separate buildings, about a hundred metres apart. When we want to move a patient from one building to the other, guess how many meetings, involving how many people, over how many days, it takes? Answers at the end of this newsletter.
Dr Alan Frances, eminent critic of DSM-5, has been in the news lately. Firstly, after thirteen years gestation, DSM-5 finally saw the light of day. I haven't seen it and, unless somebody gives me a free copy, I won't, but Dr Frances has. Hardly had the cash registers at the American Psychiatric Association started ringing than Frances threw a stink bomb into the launch party. His critique has attracted a lot of attention but I'm afraid I haven't seen that, either. Not much use reading it before reading DSM-5 itself, but if anybody else has read it and wants to send in a review, please feel free to hit the keyboard.
But he's not the only critic taking aim at the APA's misshapen offspring.
The Book of Lamentations, one of the wittiest and most incisive critiques I have read in a long time, comes from a writer who describes himself as "a writer and dilettante surviving in London." Sam Kriss has a website called
Idiot Joy Showland, in which he skewers anybody silly enough to stick his head up while Kriss is around. Unfortunately for the APA's legions of well-meaning but essentially ignorant journeymen on the DSM "Task Force," Kriss was awake and on the prowl when they threw open the doors to their shop. They would have been better to pretend they weren't ready.
Dr Frances also has an entry on his regular blog on
Psychiatric Times, in which he describes a conference he recently attended.Overdiagnosis, held at Dartmouth College in September, was, he said, the most important conference he has ever attended. If that was the case, then it was the most important conference I've ever missed. I was scheduled to give a paper there but had to pull out because of family commitments. Damn, but you can't win them all. My paper argued that the epidemics of bipolar disorder and ADHD are largely artificial, brought about by the insensate drive to prove that all mental disorder is brain disorder, coupled with the total absence of anything that approximates a biological model of mental disorder. You know what they say: If the only tool you have is a hammer, then everything looks like a nail. Same goes for psychiatry: if psychiatrists are paid to put people on drugs, then everybody will seem to have a biological disturbance of the brain. This is greatly aided by the fact that, these days, most psychiatrists, especially academic psychiatrists, can't take a history.
Of course, they will say that they don't need to take a history as the symptoms are all that counts, and symptoms are independent of the history, or context-free, in the modern idiom. Who says they are context-free? Academic psychiatrists, of course. So we have people who can't take a history telling us that histories are irrelevant. But because they don't have any real sense of what is normal, which you only gain by taking thousands of histories (and probably by leading a normal life after hours, which involves avoiding academics like the plague), everything seems crazy to them, so the boundaries of mental disorder keep spreading. There's also the minor problem that any young psychiatrist who wants to make a for himself has to find a new field to plough. There's no fame attached to being the thousandth person to realise that distressed people start to think of suicide, you have to find something to suck in the medical reporters in the media, because that's the only way to start the ball rolling in the steeplechase for grants. Hence the cancer of overdiagnosis. I'll be going to the next conference, in two years.
Talking of the steeplechase for grants, Dr Francis also Tweeted a shot at Australia's Pride and Joy, the saintly Professor Patrick McGorry, he of the slightly tarnished halo: "Australia's unproven, risky & premature prevention model goes for profit and markets internationally - http://t.co/XNW96qlnJ9", quoth Dr Frances.
McGorry's highly lucrative efforts (like, turnover of hundreds of millions a year) to carve out the field of "Early Psychosis" are a textbook example of how academics manufacture new fields to plough. Luckily, this one failed to get in the DSM-5.
Question: How many psychiatrists are responsible for transferring a patient?
Answer: None, because nobody is responsible.
In fact, it takes at least twelve people about fifty hours of reviewing the files, writing recommendations, filling in forms and so on, making dozens of phone calls, attending half a dozen meetings, writing memos notifying the superintendent and head office (in separate reports), the tribunal and various other worthies, spread over seven (that's 7) days, to move one small body one hundred metres, out one gate and in another, trussed up in a van. That's not even walking and enjoying the sunshine. Now who's the mad one?
Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, 1961). I read it in about 1974. Nothing has changed, only the forms.
