The New Serfdom

by Angela Eagle

  By the 1930s, two major treatments were developed in Europe. The first was electroconvulsive therapy, which entailed passing a current through the brain to induce a seizure. The second was the lobotomy, a horrifying procedure in which steel spikes were inserted into the brain to crudely sever connections to the frontal lobes. It earned its creator, Egas Moniz, the Nobel Prize, but had thankfully fallen into disrepute by the 1950s because of its terrible effects.

  It wasn’t until the discovery of lithium for mania and chlorpromazine, an anti-psychotic, in 1949 and 1950 respectively that pharmaceutical therapies became available to doctors. It made an immediate impact. Since then, we have expanded the range of drugs available for use across a wide array of mental illness: antidepressants; antipsychotics; anxiolytics for anxiety; mood stabilisers; depressants and stimulants. The development of new forms of therapy, in particular Rational Emotive Behaviour Therapy and Cognitive Therapy in the 1950s and 1960s, also expanded the range of options available to psychiatrists.

  Over time, stigmas around mental illness have been challenged, new drugs have been discovered and the range of psychotherapies available has expanded. Our ability to help people with mental illness has improved substantially in a short period of time. However, the British state has not always done a great job in treating mental health as a serious problem, despite the great trauma it can cause to people and our growing understanding of just how prevalent mental illness can be in the population.

  1948 was not the turning point it might have been for the treatment of mental illness in the United Kingdom. The medical profession was starting to realise the interaction between physical and psychological health, local authorities were beginning to provide some care in the community, and charities dedicated to helping those with mental illness were springing up. The new National Health Service, however, did not treat the mentally ill as it did the physically ill; mentally ill patients continued to be housed within the asylums and mental hospitals. By the mid-1950s, there were 150,000 people in these institutions.

  It wasn’t until 1959 that things started to change. The passage of the Mental Health Act saw medical professionals take over from judges and magistrates in deciding who needed to enter a mental hospital. But the institutions remained in place. Two years later, however, attitudes towards mental health were transformed as Ministry of Health civil servants realised the enormous possibility of psychiatric drugs and care in the community. In 1961, the government started to consider shutting down the asylums in favour of greater community care provision for mental health patients and moving treatment of acute mental illness to general hospitals, thus reducing the number of psychiatric beds by 75,000.

  It was as radical a plan as the building of the original asylums. From the 1970s onwards, the number of psychiatric beds fell, with the decline accelerating in the 1980s as more care was delivered in community settings. This wasn’t uncontroversial; many saw the changes as an excuse for cuts. Press reports of people with serious mental health problems committing crimes raised the hackles of the public. The murder of Jonathan Zito by a paranoid schizophrenic, Christopher Clunis, who had been discharged from a psychiatric care setting, led to frenzied headlines in the tabloid press and deep doubts about care in the community.

  The truth is that the transition to community care was complicated. It required new techniques, skills and resources. It called for outreach in place of treatment in institutionalised detention settings. The potential rewards to individuals were substantial though: socialisation and independence have been shown to improve quality of life and reduce the likelihood of admission to psychiatric care units. But this required money. As Angela recalls from her time in COHSE, few people wished to keep the old institutions open, but the fact is that it was much more expensive to look after people properly in their own settings in the community than it was to warehouse them out of sight and out of mind, and the funding simply wasn’t there. Once again, the Conservatives were focused on saving money, rather than making sure the transition was adequately financed, and as a result, a great many vulnerable people – especially those who could not look after themselves or make decisions – were let down. This caused a complete lack of public understanding and lots of prejudice against people with mental illness, fuelled by the reactionary tabloid press.

  By the time of New Labour, the considerable challenge of transforming the treatment of mental illness away from hospitals towards a community model continued, helped by a substantial increase in spending. Although the IPPR’s Commission on Social Justice had not mentioned ‘mental health’ at all in their report, New Labour’s evidence-driven ethos encouraged the commissioning of a raft of studies to improve the community care system. Right-wing tabloids continued to decry the system, highlighting cases in which people with psychiatric illnesses committed serious crimes, and the government was often on the back foot.

  It was only as we moved from the twentieth to the twenty-first century that policy-makers started thinking about general mental health rather than mental illness as a central policy concern. In the early 2000s, Lord Richard Layard, an economist at the London School of Economics with a particular interest in happiness and mental health as well as reducing inequality, produced a series of works that looked at how greater access to psychotherapy could be economically beneficial, chiefly by reducing expense to the welfare state and improving overall economic productivity. A young Ed Miliband and Gordon Brown took a special interest in his work.

  In 2008, Labour introduced Improving Access to Psychological Therapy (IAPT), a primary care service that extended the availability of psychotherapy far beyond the segment of the population that had been the focus of psychiatric care for most of the period since 1948. Assisted by the growing public and political openness to talking about mental health, the new approach gained cross-party support. The Health and Social Care Act 2012, passed by the coalition government, made it a requirement for the NHS to place mental health on a par with physical health. The coalition government, to its credit, stated its desire to expand IAPT, and extend it to children and young people, but it has been plagued by insufficient funding and staffing.

  Today, we are on the cusp of a third revolution after the asylums and care in the community. The drugs, the technologies, the therapies and the clinical protocols have evolved and improved rapidly. We have cross-party agreement that mental healthcare has to include helping people to live healthier lives overall, not just dealing with serious mental illness. We have a much more progressive public discourse on mental health, aided by high-profile people such as Alastair Campbell, Kevan Jones MP and Charles Walker MP, who have been incredibly brave in talking openly about their own mental health problems. Mindfulness and meditation classes are now commonplace not only in the posh enclaves of Notting Hill but far more widely.

  We understand that the stresses of modern life can contribute to the degradation of our mental health and so – as we are trying to do with physical health – we aim to nip it in the bud. We have a long way to go to deliver on our aspiration of preventing mental illness before it manifests by protecting the mental health of our citizens. One approach we might consider is that of the Mental Health Foundation, which recommends a ‘life-course’, with ‘interventions and approaches across the lifespan, including before birth, early family-formation years, adolescence, adulthood and working age, and older adulthood. In each area, different challenges present themselves, as well as opportunities to intervene and support mental health.’ That’s going to require a lot more innovation to join together the myriad institutions that have the capacity to intervene and improve mental health; it’s not just the NHS, but an array of state services that will be required. It’s also going to require funding.

  So, what does the mental health of the nation actually look like? Firstly, it is important to realise that measuring the actual frequency of mental health disease in society is beset with problems. Diagnostic practises vary across the country, and NHS treatment statistics by d
efinition exclude people who haven’t been diagnosed and so underestimate the true number. Measuring change over time is even harder. As we’ve become a more open society and started discussing and helping people to understand their own mental health, more people have been aware that what they may have thought of as a sense of overwhelming sadness or apathy, for example, is in fact a curable form of depression.

  The Adult Psychiatric Morbidity Study is carried out every seven years by the NatCen Social Research with Leicester University for the NHS. It tries to build a truly representative picture of mental health across the country by asking questions about mood and behaviour to identify any problems. It’s not perfect, but it gives us a picture.

  Their most recent report contains some key statistics:

  TRENDS IN MENTAL ILLNESS

  One adult in six had a common mental disorder (CMD): about one woman in five and one man in eight. Since 2000, overall rates of CMD in England steadily increased in women and remained largely stable in men.

  Young women have emerged as a high-risk group, with high rates of CMD, self-harm, and positive screens for posttraumatic stress disorder (PTSD) and bipolar disorder. The gap between young women and young men increased.

  Most mental disorders were more common in people living alone, in poor physical health, and not employed.

  TRENDS IN TREATMENT AND SERVICE USE

  One person in three with CMD reported current use of mental health treatment in 2014, an increase from the one in four who reported this in 2000 and 2007.

  Since 2007, people with CMD had become more likely to use community services and more likely to discuss their mental health with a GP. There is a particular concern about young people in much of the recent analysis of mental health in Britain. A 2017 study, undertaken by academics from University College London and the University of Liverpool and funded by the Economic and Social Research Council, found that 24 per cent of fourteen-year-old girls and 9 per cent of boys have depression: over 200,000 in total. This is double the rate compared to a decade earlier. The survey found that girls from lower income groups were more likely to be depressed than higher income groups. The Guardian analysed NHS data in September 2017 and found that ‘the number of times a girl aged seventeen or under has been admitted to hospital in England because of self-harm has jumped from 10,500 to more than 17,500 a year over the past decade – a rise of 68 per cent. The jump among boys was much lower: 26 per cent.’ The report’s author identified highly visual social media, such as Snapchat and Instagram, as driving this anxiety and depression.

  A New York University professor, Adam Alter, specialising in how the psychology of marketing and addiction works, explained to Business Insider:

  The minute you take a drug, drink alcohol, smoke a cigarette if those are your poison, when you get a like on social media, all of those experiences produce dopamine, which is a chemical that’s associated with pleasure.

  When someone likes an Instagram post, or any content that you share, it’s a little bit like taking a drug. As far as your brain is concerned, it’s a very similar experience. Now the reason why is because it’s not guaranteed that you’re going to get likes on your posts. And it’s the unpredictability of that process that makes it so addictive. If you knew that every time you posted something you’d get a hundred likes, it would become boring really fast.

  One of the problems with Instagram is that everyone presents the very best versions of their lives. So, you can curate Instagram, you can take 100,000 shots if you want to before you actually share anything. What that means is, every time you look at someone’s feed, you’re getting only the very best aspects of their lives, which makes you feel like your life, in comparison, with all its messiness, probably isn’t as good. Seeing the best version of everyone else’s life makes you feel deprived.

  This is especially true in richer countries. A 2009 WHO study found – remarkably – that mental health problems are far worse in richer countries, like the UK, that are socially and economically unequal, because ‘greater inequality heightens status competition and status insecurity across all income groups and among both adults and children’. The report’s author explained that she had looked at international studies on ‘mental health, inequality and resilience’ and concluded that ‘injustice and inequality are deeply toxic to us’.

  It seems almost cruel, then, to consider that the very creation of inequality as an incentive to economic growth – an idea at the very heart of market fundamentalism, with its worship of money as a proxy for success and virtue – is crippling the minds of those people who grew up in its shadow and are now living in a society in which its effects have been fully manifested. Turbocharged by new technology – which is itself owned by some of the richest people in the history of humanity – our youngest citizens are facing those inequalities in visceral, visual formats on a daily basis. A recent report by the Royal Society for Public Health, #Status of Mind, based on surveys of young people, found that they themselves said that social media platforms made their anxiety worse. We need to start listening, understanding and taking action. Leaving aside the serious delays and underfunding of Child and Adolescent Mental Health Services (which do of course need fixing), it is the root causes we must address – and inequality is at the heart of it.

  Beyond the clear moral imperative that we as a society should care about our fellow citizens’ mental health, it’s worth thinking about what happens when we fail to do so. The false economies of the current government’s approach to spending are never starker than when looking at the sheer misery and cost of dealing with mental illness. When mental illness goes untreated, it can lead to catastrophic breakdown in people’s lives. Stigma, embarrassment, as well as a lack of local provision, can all contribute to a failure to receive treatment. Sometimes it’s just that the drugs don’t work as they should. Some anti-psychotic drugs, for example, cause a condition called tardive dyskinesia with prolonged use, which causes involuntary movements of the mouth and of the body. Sufferers may stop taking their drugs due to physical impairment or social embarrassment, putting them at risk. Whatever the reason, untreated, mental illness can spiral rapidly, and as mental health worsens, a huge range of physical symptoms can appear. Increased levels of stress hormones can lead to problems like headaches, muscle pains due to tensing, gastrointestinal symptoms and a worsening of cardiovascular symptoms: it can literally cause a heart attack. If an untreated sufferer finds themselves unable to get up, or feels averse to social situations, they are at risk of losing their job or damaging their relationships, which can make things even worse. In extreme cases, they may end up on the wrong side of the law or find themselves homeless or forced to sleep rough.

  Our prisons have for a long time been filled with people with unresolved mental illnesses. The Centre for Mental Health’s deputy chief executive, Andy Bell, told The Guardian that the last reliable survey on the prevalence of offender mental health problems was carried out in 1998. One reason may be that the government simply doesn’t want to admit the degree to which our soaring prison population is a symptom of systemic failures in mental healthcare provision.

  Lord Bradley, a former Labour Home Office minister, was asked by the government in December 2007 to assess mental health problems in the prison system. His report revealed that ‘the prevalence of psychiatric disorder is even higher among young offenders and juveniles, with 95 per cent suffering from mental disorder, substance misuse problems, or both’. The Prison Reform Trust, which campaigns to ensure our prisons are just, humane and effective, says that its own analysis shows

  Ten per cent of men and 30 per cent of women have had a previous psychiatric admission before they entered prison. A more recent study found that 25 per cent of women and 15 per cent of men in prison reported symptoms indicative of psychosis. The rate among the general public is about 4 per cent.

  Forty-nine per cent of women and 23 per cent of male prisoners in a Ministry of Justice study were assessed as suffering from anxie
ty and depression. Sixteen per cent of the general UK population (12 per cent of men and 19 per cent of women) are estimated to be suffering from different types of anxiety and depression.

  Forty-six per cent of women prisoners reported having attempted suicide at some point in their lives. This is more than twice the rate of male prisoners (21 per cent) and higher than in the general UK population amongst whom around 6 per cent report having ever attempted suicide.

  A National Audit Office report in 2017 noted that the government simply did not have the data they would expect on mental illness among the prison population. However, they did worry that

  rates of self-inflicted deaths and self-harm in prison have risen significantly in the last five years, suggesting that mental health and well-being in prison has declined. Self-harm rose by 73 per cent between 2012 and 2016. In 2016 there were 40,161 incidents of self-harm in prisons, the equivalent of one incident for every two prisoners. While in 2016 there were 120 self-inflicted deaths in prison, almost twice the number in 2012, and the highest year on record.

  Our prison system is there to both punish and try to rehabilitate those that have committed criminal offences. It should not and must not become a warehouse of those we have failed to help adequately. It is not only morally unacceptable, but self-destructive economically. The vast cost of our prison estate could be reduced considerably if we provided targeted intervention for those prisoners who are clearly suffering from mental illness and ensured that, within prison, offenders have their particular problems – whether that be mental illness or substance abuse – dealt with appropriately.