Over here in the UK, a tempest is raging about the care and treatment of the sick and the vulnerable. How much any of this will mean to non-British readers of this blog I cannot guess, but I hope some of the broader points I’ll raise will be of interest to anyone who interacts with mental health services, either as service-user, physician or relative of a patient. The UK's Care Quality Commission (CQC) is the governmental body that oversees conditions in all hospitals, care homes, and other such facilities, with the power to intervene and even to shut down institutions that are deemed to be failing. Now, every week it seems, allegations of ineptitude and cover-ups by the CQC, and bullying and intimidation of whistleblowers, have led to resignations, dismissals and the call for a public inquiry into the running of the CQC.
The treatment of the mentally ill and people with learning difficulties falls under the CQC’s remit, and the recent picture in those particular sectors has been bleak indeed. BBC television captured on film the persistent physical and verbal abuse of learning disabled youngsters at the Winterbourne View care home near Bristol (closed down one month after the footage was shown on national TV).
Statistics released last month reveal thirteen restraint-related deaths since 1998 among people detained under the Mental Health Act; the use of Tasers on the mentally ill by police officers within psychiatric institutions occurred 52 times in the past three years, indicating either inadequate staffing levels or poor training in pacifying techniques on the part of healthcare workers.
Some 9,000 people were detained in police custody in the year 2011/12 under the Mental Health Act because no hospital place was immediately available for patients deemed to be at risk of serious self-harm or of harming others. Meanwhile, the highly controversial ‘face-down’ restraint method was implemented at least 3,439 times in the UK’s mental health units in the year 2011/12 (a number of health trusts refused to give any data, so the true figure will be higher).
The UK’s Mental Health Act 1983 requires detailed and accurate record-keeping of all incidents of restraint and injury in mental health institutions; but somewhere along the line this aim has fallen by the wayside, and the minister of state for care services himself, Norman Lamb, has expressed his astonishment at the lack of transparency: ‘We just don’t know enough about what goes on in mental health,’ Mr Lamb told the BBC last month, ‘how resources are used, what the practices are, and that needs to change.’
Further questionable practices became apparent when it was revealed earlier this summer that 7,000 Britons had been subject to ‘deprivation of liberty orders’ without the correct legal procedures being followed; these orders are intended to limit the movement of those suffering from mental incapacity, if such freedom would seriously threaten their physical safety. Only 37% of such orders applied for in 2011/12 had been requested in ‘appropriate’ circumstances, it has been found – indicating that a vulnerable adult may have had their freedom curtailed for either malicious or trivial reasons by the person applying for the order.
Whenever abuses come to light, it is always tempting to suppose a falling away from a notional ‘Golden Age’, when everything was done so much better. In fact, though, it’s possible that accumulations of bad news are revealing that the reporting and publicising of wrongdoing is functioning more efficiently and effectively – rather than that cruelty and neglect are becoming more prevalent. Perhaps the fact that we are now able to access incontrovertible proof of such behaviour is a sign that we are more watchful, more engaged with abuse issues than in previous decades, when very little ended up either on the record or in the public consciousness.
I hope that doesn’t sound glib and dismissive; the stark and depressing fact is that we will never obtain the data to prove whether things have become better, worse, or have stayed the same, with regard to assaults and mistreatment of the mentally ill over the past 200 years or so of recognisably ‘modern’ care. But what is easier to monitor is ambition and aspiration – those are the things that did get set down on paper and have passed into the archives.
In the nineteenth century, ‘restraint’ was the filthy-dirty word: the Commissioners in Lunacy – the Victorian predecessor of the CQC – had as their main aim the tracking down and punishment of asylum proprietors and staff who continued to use the strait-waistcoat, manacles, the darkened room, the soft cell, iron whole-leg hobbles, handcuffs, and finger-confining instruments. The log-books and letter-books of the Commissioners in Lunacy, available for modern researchers to consult at the National Archives, in south-west London, reveal the Commissioners’ investigations of alleged physical abuse and the reprimands they issued.
Superintendents of all types of asylum – from retreats for aristocrats to huge pauper madhouses – were requested to come to the Commissioners’ office (just south of Trafalgar Square) and to justify themselves if it had been discovered that physical restraint had been used. If the patient had been anything other than in a raving state, and capable of causing physical harm, the restraint would have been deemed unacceptable. The asylum’s licence could have been revoked; or, re-issued for just a short period, during which a more humane regime would have to be put in place. Attendants were sacked, some were tried and imprisoned for persistent attacks upon patients.
At the end of the eighteenth century, Dr Philippe Pinel (1745-1826) had famously ‘struck off the chains’ at Bicêtre, the Parisian asylum for lunatic males; now a generation of British gentlemen physicians wished to show their achingly fashionable sensibility and be seen to be humane in their treatment of the insane. And so it does have to be asked, to what extent was ‘non-restraint’ a posture, an aspiration more discussed than achieved? Was it good old Victorian humbug? The Commissioners in Lunacy were as embattled as today’s CQC. They faced enemies on two separate fronts: firstly, there was a judicial system that seemed ill-adapted for facilitating criminal prosecutions for cruelty and even for the manslaughter or murder of patients. In one of the most notorious cases, the 1856 case against Charles Snape, superintendent of a huge county asylum in south London, was thrown out before going to trial. Snape had subjected 65-year-old Daniel Dolly to the controversial cold-water treatment after Dolly had become aggressive. (Think of water-boarding mixed with electro-convulsive therapy, and you’ll get the idea: the concept was that the physical surprise would shock the patient out of his/her mania.) The shower comprised a narrow wooden box, 8ft tall, with no window or aperture, locked from the outside; from a faucet above the patient’s head, 600 gallons poured down on to Dolly in his half-hour of being locked in the box. On removal, he was dosed with tartar emetic as a purgative, and died as soon as he lay down on his bed. The Commissioners in Lunacy had mounted the prosecution in the belief that Snape had used the shower treatment as revenge against Dolly – and not for any alleged therapeutic purpose. The judiciary saw things very differently, however, to the disgust of the nation; Snape even got his old job back.
Seven years later, the Commissioners came up against local obstinacy in the west of England, when county justices refused to intervene to remove the licence of the notorious Belle Vue Asylum in Devizes, in Wiltshire. The Commissioners – a centralised governmental body – found they had little sway over local administrative machinery when they could not demand the prosecution of an attendant for the manslaughter of a patient following violent restraint; fearing to appear too heavy-handed against county officials, they reluctantly backed down.
Despite such defeats, the Commissioners believed that they were doing a good job, in slowly whittling away at the worst-run institutions, refusing to re-license, insisting on the sacking of vicious keepers, demanding decent food, warmth and therapeutic occupation in the 177 or so establishments they visited on a constant, exhausting circuit. These six men (three lawyers, three doctors) were elderly – and their ages were a target for criticism. The Commissioners were well-paid; but it is also true that their work took a huge toll on their health. Their letters are filled with references to ‘the dragon called Lumbago’; oral boils; bad colds; diarrhea; gout; swollen feet, and a swollen prostate; and an unspecified case of ‘something dreadful and incurable’. One of the Commissioners wrote to another, of his working life: ‘I hear nothing, I see nothing, but tunnels and railroads, madmen and chambermaids.’
These misfortunes were of no interest to the second enemy the Commissioners were fighting. In the late 1830s, the Alleged Lunatics’ Friend Society was created by a number of former patients who had each witnessed dreadful assaults during their spells of incarceration (and in one case, of 1838, a murder). The ALFS were determined to be a constant thorn in the side of the Commissioners, seeking out fresh abuses and trumpeting these in the national newspapers to shame the Commissioners and to goad them into greater activity. The ALFS were not happy at the gradualism of the Commissioners’ approach, accusing them of being merely ‘a cloak to a vicious system’, and complaining of their ‘incompetency’ and of being ‘dumb dogs’. The successor campaign group, the Lunacy Law Reform Association, founded by Louisa Lowe in 1873, was even more trenchant: ‘who or what, then, are they?’ Mrs Lowe wondered on paper: ‘A triplet of briefless barristers, and another of patientless doctors, put round a big table... men who, hopeless of winning the great prizes of their respective professions, have renounced all chance of them, and accepted itinerating obscurity... needy and quite commonplace men.’
Today, the CQC is accused of incompetence, fudging, covering-up, and persecuting whistleblowers and its internal critics; it is said that its lack of specialist knowledge has combined fatally with lack of staffing and over-centralisation, in place of local on-the-ground inspections by individuals with clinical experience. The Commissioners in Lunacy’s enemies accused them of being of generally low calibre, overworked and understaffed; too timid to take strong and effective legal action against the private sector and/or any of the more illustrious medical men. Accusations about centralisation over local expertise were also loudly made – and neither camp has yet won that particular argument.
Today, the campaigning group Compassion in Care, set up by former whistleblower Eileen Chubb, carries on the good work of the Victorian campaigners. And now that the newspapers and television are on its case, it seems that the CQC will have no choice but to alter its working culture. A simple change of name will not be enough.
In 1858, one of the supporters of the Alleged Lunatics’ Friend Society stated of this sort of ruse: ‘Tyranny takes new shapes, but the evil principles are as active as ever.’ The UK really does need to take drastic steps in order to prove that maxim wrong.
© Sarah Wise 2013
Inconvenient People: Lunacy, Liberty, and the Mad-Doctors in Englandby Sarah Wise Counterpoint
National Archives shelfmarks for the papers of the Commissioners in Lunacy: MH 50, MH 51, MH 45, MH 83 and MH 94. http://discovery.nationalarchives.gov.uk/SearchUI/
The Forster Collection at the National Art Library at the Victoria & Albert Museum: MSS 48, letters f.48. f.45
Louisa Lowe’s criticisms: Medium & Daybreak magazine, 25 July 1873
Alleged Lunatics’ Friends’ criticisms: letter at the National Archives dated 5 April, 1861, at shelfmark HO 45/7102; and British Lunatic Asylums, Public and Private by Thomas Mulock, 1858
Present-day media reports:
Winterbourne View abuse: http://www.bbc.co.uk/news/uk-england-bristol-20078999
Detention in police cells: http://www.bbc.co.uk/news/uk-22979198
Deprivation of liberty orders: http://www.bbc.co.uk/news/uk-22026308