by Kerry Daynes
Marcus faced another, more insidious problem too, something that might have been unconsciously threaded into our ongoing assessment of his high risk of violence. Because not only was Marcus loud and non-conformist, he was black.
In 2002, not long before Marcus came to the hospital, the Bennett Inquiry had been commissioned. It followed the death of David Bennett, an African-Caribbean man, who died after being restrained by staff at a medium-secure unit. The report found that black men were generally regarded by staff in psychiatric hospitals as ‘more aggressive, more alarming, more dangerous and more difficult to treat’ and that they tended to receive higher doses of medication than white people given similar diagnoses. It concluded that people from black and minority ethnic communities were six times more likely to be sectioned, more likely to stay longer as in-patients in psychiatric wards, and more likely to be prescribed medication or electroconvulsive therapy instead of psychological treatment or ‘talking therapies’.
In short, the UK’s mental health services are riddled with racial discrimination. I had seen plenty of blatant, in-your-face racism in prisons, but it is altogether more surreptitious in the psychiatric hospital setting. Marcus’s mistrust of us was perhaps not as irrational as it appeared.
He grew up in Birmingham, as part of a second-generation Jamaican-British family, his father arriving in the 1960s as part of the Windrush Generation. Hostility to black people was still overt, even socially acceptable. His father found a job as a taxi driver, but wasn’t permitted to enter the pubs he drove his customers to and from. Signs saying ‘No coloureds’ or ‘No West Indians’ were commonplace. Just a few years earlier, Conservative MP Peter Griffiths had won a local election in nearby Smethwick with the slogan ‘If you want a n****r for a neighbour, vote Labour’. In fact the racism in the area was so virulent that the US political activist Malcolm X went to Smethwick in 1965. He was shot dead in New York just nine days after his visit.
Marcus told the story of how one day his dad decided to go into the pub, regardless, and family legend was that, for a short time, a sign saying ‘No blacks, No Irish, No dogs’ which he took home from it, became the centrepiece of the kitchen at home.
This pathos-heavy scene was about as good as home life got for Marcus. His much-loved father died when he was six and he lived in a one-bedroom flat with his mother and brother, and occasionally also his grandmother, for the next ten years.
Marcus described himself as a skinny, timid child, overshadowed by his bigger, older and more charismatic brother. He told me that his grandmother was a fearsome woman who was devoutly and extremely Pentecostal. She believed in witchcraft and possession by evil spirits. When one winter a leak had begun to let rainwater in through the wall of the flat’s kitchen, his grandmother had declared it the work of the devil in Marcus. He recounted how she had made Raymond hold him down on the kitchen table while she beat him on the back with a leather belt to expunge his ‘wickedness’. Marcus said that when his mother eventually intervened, it was one of the few times he had seen her stand up to his grandmother.
With this cultural context in mind, Marcus’s references to ‘witchdoctors’ suddenly made far more sense. And while we were certainly not witchdoctors (no chicken’s blood here, although with our insistence on variably effective medications and magic formula therapy manuals, I could see where he was coming from), the esteem in which he held medical doctors might not have been much higher.
*
I was in a room with Marcus, the air thick with boredom as we prepared to get through the upcoming hour that was the Mental Health Awareness Group.
Together with a psychology assistant, we were here with six other patients, most of them fairly new admissions to the hospital, but not necessarily new to this experience. The gloomy mood was matched by the room, a shabby basement with high windows around the top, like holes in a deep pocket.
Channelling the spirit of a middle manager on a team bonding retreat, the psychology assistant pulled back the cover of a flip-chart and invited everyone to name all the different symptoms of psychiatric illnesses. The thinking behind this exercise was to help the patients connect their more unusual experiences to recognized symptoms. Thereby encouraging a light-bulb moment where the group members recognize that they have a medical issue and are persuaded to embrace their diagnostic label and follow the recommended course of treatment. Voila! This is what psychiatry prizes as ‘insight’.
Although we had a few slender contributions (‘not sleeping’, ‘thinking your food is contaminated’, ‘feeling sad’ and ‘saying that you are Jesus, even when you really aren’t Jesus’), most of the group sat stony faced, despite the assistant’s artistry with the flip chart and marker pen. They were there for the biscuits, and to pass the time until lunch.
Apart from Marcus, who was very engaged, but not quite in the way that we wanted. With every answer we extracted from the listless group, he would tut loudly, suck his teeth and mutter under his breath. He would fidget around, crossing and uncrossing his arms and shifting around in his chair. And yet, he was paying close attention.
A couple of times I heard him mumble: ‘They’re telling us we are sick in the head…’
When you have one particularly distracting group member like this, it often helps to give them a job to do, to keep them occupied and to minimize the disruption to the rest of the group.
I invited Marcus up to the front so he could write up the words on the flip chart as the others did – or didn’t – shout them out.
He leapt up and strode to the front, grabbed the felt marker pen from the assistant’s hand and scribbled in giant letters:
PAIN
‘All of this shit is pain…just pain is all,’ he said, waving the marker across the flip chart like a university lecturer who had just revealed the answer to a complex equation. Then, addressing the group members, ‘Don’t let these brainwashers tell you that you are sick.’
The room was silent, as everyone quickly considered whether he’d just said something mind blowing or was talking utter nonsense.
This wasn’t the textbook Mental Health Awareness Group answer (and, of course, the psychology assistant and I were working from a thick textbook, with accompanying illustrated handouts for all group participants), but it was very hard to deny the truth of Marcus’s response. Because his life had been undoubtedly painful, and all of the ‘symptoms’ that the group had outlined were indeed just examples of what can happen when people suffer.
Immediately after this fleeting moment of existential clarity from Marcus, the assistant thanked him for his help and ushered him to sit down. Which he did, with his arms folded once more and his eyes tightly shut. We’d had a brief opportunity to connect with him and we’d missed it.
While the earth didn’t seem to move for anyone else in the room, that session was groundbreaking for me. It brought into dazzling focus the misgivings I’d been harbouring for some time.
*
There is a growing queue of well-intentioned celebrities lining up to tell us that mental distress is an ‘illness just like any other’, and that we should seek help for our broken minds in the same way as we would a broken leg. While being open as a society and ready to discuss mental health problems is a positive thing, the evidence that mental ‘illness’ can be tested for, diagnosed and treated with the same certainty as a physical disease is far from conclusive.
With a physical illness, having a diagnosis can be a relief – finally knowing what is causing your symptoms and being able to put a name to it means that you know what you’re dealing with and may even be on the way to recovering. In the same way, being given a psychiatric diagnosis is helpful for some people – it acknowledges the real difficulties that people experience and can allow them to obtain the help and support they need. But for a lot of others, having their mental health problems described as ‘illnesses’ feels oppressive.
The components of what we tend to think of as an illness can be restrictive – it’s
typically something that we can catch, something caused by diseases, something that can be cured, something that is wrong with us. But many mental health issues simply don’t share these characteristics. Referring to mental illness suggests that a mental health problem is qualitatively different from your garden-variety emotional pain or confusion, and results from an underlying brain disease. It negates the fact that psychological distress, in whatever form it is exhibited/plays out, is frequently a plausible reaction to the slings and arrows that life throws at us.
Some diagnostic labels are easier to swallow than others. ‘Anxiety disorder’ or ‘depressive disorder’, for example, don’t tend to carry such negative associations in the public mind as ‘schizophrenia’. As psychologist and former psychiatric patient Dr Jay Watts puts it, ‘Yes, there is stigma, but not the rampant sticky, staining discrimination one gets with diagnoses associated with serious mental illness.’ As a result of this prejudice, for someone experiencing phenomena such as hearing voices, or being convinced of things that others find bizarre, their psychological distress is often as much a result of facing people’s reactions to their experiences as of the experiences themselves.
There is evidence that purely physical causes are more at play with some diagnostic categories than with others. For example, there is some evidence for neurobiological underpinnings to ‘bipolar disorder’, yet, for a great many people, the anguish that leads them to seek professional help has far clearer established links to social disadvantage: poverty, poor housing, insecure and low-paid jobs, missing out on formal education, living in stressful environments or having to move home frequently. Problems that may be difficult for others to understand (believing that you are Jesus, for example) are often related to stressful events and life circumstances, particularly abuse or other forms of trauma. Between half and three-quarters of people receiving mental health care report having been either physically or sexually abused as children. In short, mental distress is more likely a product of complex, overlapping personal and social factors than simply wonky brain chemistry or unfortunate genetics.
Being given a diagnosis can be both a positive and a negative thing, so what is the best thing to do? A frequent response from professionals and service users involved in debating the issue is that people should be free to choose how, or if, to name and make sense of their experience. Certainly, in Marcus’s case, he was unwilling to accept the illness explanation that he was being forcefed. Yet he had killed somebody. And that’s what got me thinking – did that mean he had forfeited the right to choose whether or not to accept his diagnostic label?
*
Luckily for both of us, there was no Fratricide Group on the hospital curriculum. I began to have one-to-one sessions with Marcus and never referred to ‘schizophrenia’, or used any other medical language in front of him again.
We met twice a week, in a small consulting room on the main ward (at least until a directive came through that all patients, regardless of need, must be offered individual time with a psychologist of one hour a week – no more, no less – to meet audit requirements). No longer stuck in a perpetual deadlock over what was ‘wrong’ with him, we started piecing together and making sense of what had happened to him.
The young Marcus had left home as soon as he could, moving in with his girlfriend, who he’d met at a lively cafe that he used to visit at lunchtimes and after work. The pair, both just 20, had a daughter together, and Marcus said it was soon after her first birthday that he began to hear voices.
Many of us will have auditory hallucinations at some point in our lives. Hearing your name being called when there is no one around, or someone speak just as you are drifting off to sleep, is a common enough experience. In one small study of British mental health nurses, 83 per cent described at least once having heard a voice ‘as if someone had spoken aloud rather than a thought or feeling’. Hearing the voice of a deceased loved one is often reported by those who are recently bereaved, and is mostly described as a comforting, rather than upsetting, phenomenon.
I experienced something fundamentally similar to voice-hearing during my own stressful times, hearing the telephone ringing when it hadn’t. The first and second time it happened, I picked up my telephone to nothing but the dial tone. The third time it happened, I thought that perhaps it was time to book myself a holiday. After that, it didn’t happen again.
When Marcus started hearing a female voice, commenting about what he was doing when he was at home alone one evening, he thought little of it at first. But she became more frequent, more critical. She made comments about how his car was dirty. Minor nagging at first, but then calling him lazy, useless. Hearing this so clearly but with no physical human in the room to attribute it to, he searched for the most reasonable explanation, coming to the conclusion that, as she was the only woman he lived with, it must surely be his girlfriend who was somehow behind it.
He started to hear the voice even when he was away from the house, and she was gradually joined by a chorus of others, all talking at the same time. He began to shout at them – ‘Why are you doing this to me?’ ‘Are you spying on me?’ ‘Leave me alone!’ – but they were louder, stronger and more confident than he was. More voices joined in; some were less hostile, friendly even, and he said he felt they were supportive and useful to him. Some were funny and made him laugh, they sang nursery rhymes to him that his girlfriend sang to their daughter, and talked back to him if he ‘thought’ in response to them.
Having satisfied himself who was behind the voices, Marcus described how he turned his attention to the questions of how and why. The only plausible explanation that he could come up with was that his girlfriend was unhappy in their relationship and was practising witchcraft on him – a conclusion that isn’t so out of left field when we remember his grandmother’s beliefs.
I have seen plenty of unusual belief systems in this job. If someone feels that external forces are controlling their mind or body, it often starts to make sense to them when they attribute it to something religious or supernatural. Another common possessive experience is aliens, who like to beam thoughts via radioactive light waves into the carrier’s brain (arguably at least as plausible as gods and demons – if not more so. It all depends on your unique way of looking at the world).
Marcus confronted his girlfriend, angry at what he saw as her attempts to control him, but also terrified by what was happening. With their young daughter in the flat, his girlfriend was frightened by his odd behaviour and threw him out. He couldn’t go back to his mother and grandmother, with whom he’d had very little contact since he left, so with nowhere else to go he began to sleep in his car. It was the start of a sustained period of misery and rejection for Marcus, who, it seemed to him, no one wanted to be around.
Just a few weeks after becoming homeless, he was fired from his job. And he had been particularly upset one day when he was thrown out of the cafe where he had been a regular for years. He shifted in his seat and hit the arm of his chair defiantly with his outstretched palm as he told me how the boyfriend of one of the owners had come over to him and told him he needed to get out because he was ‘talking to himself and freaking everyone out’. He came back to that story a few times; it had obviously been a nail in his coffin, seeing it as proof that, as he put it, he had been cursed.
I could imagine Marcus openly talking to voices no one else could hear, wandering the streets at midday when the rest of the world was busy working. He had become the guy you cross the street to avoid. When he told me about his ejection from the cafe, I couldn’t help but think about the parallels with his father’s experience of being denied entry to the pub, all those years before.
With his living conditions worsening, the critical voices in his mind became stronger and more forceful. He’d begun self-medicating with cannabis, ‘to get some peace from it’, he explained. But it had only made things worse. Marcus had stayed in touch with his older brother, Raymond, who had a family of his own and lived close by. Raymo
nd agreed to facilitate contact between Marcus and his daughter, being present during the short trips to the park and occasionally the cinema, which his ex-girlfriend permitted on the condition that Raymond stayed with them. Hearing of his drug use, however, his ex-girlfriend denied him access to his daughter, and, in a double blow, Raymond’s wife would no longer allow Marcus in their house because he made her uncomfortable.
He had lost his home, his job and the only people he had to rely on. When he talked about this period he kept returning to the cafe, a place where he’d once been so welcome, and how he’d been told not to come back. The critical voices were telling him he was bad and wicked, words that seemed to echo his grandmother’s criticisms of him as a child, and felt all the more onerous as a result.
As Marcus began to explain what his voices had begun to tell him, I saw how the story had come to its sorry end. The voices started telling him to hurt himself. He scratched himself on his arms until he bled, hit his head on a brick wall – the voices bickering over who was in charge and what he should do next. As his external life became more difficult and unhappy, so his voices became more shrill and urgent. He described feeling how the voices were by now so much more powerful than he was that he knew he would never be able to ignore them, or defy them.
To the excluded Marcus, Raymond began to emerge as the focal point of all his worries.
Feeling that life was spiralling out of control at a faster pace than he could cope with, he described how his hallucinations were responsible for ‘brainwashing’ him into believing that all his misfortune was because of his brother, and that Marcus needed to eliminate him. They described how Raymond was possessed, and being tortured by, demons that were cursing Marcus and causing all of his unhappiness. Marcus decided that it was now his task to kill Raymond, therefore killing the evil spirit that had possessed him, and in doing so reclaim his family.
