David Pilgrim

Views on the Patient’s View

There has been a growing acceptance over the last few years that health care, like other human services, should be subject to evaluation. It has been suggested this should not only involve measuring medical outcomes, or economic efficiency, but also whether services are socially acceptable.1 It is this latter aspect, together with the experience of mental health problems, which is the concern of this book. Our central question is this: to what extent are mental health services acceptable to the people who use them? Before going on to address this question in the following chapters, we need to set the scene by putting our study into a wider context of research on the ‘patient’s view’. Some of this, particularly about psychiatric patients, has reflected professional interests and has failed to take the critical implications of users of services seriously. Let us start by reviewing briefly research on non-psychiatric patients.

Getting the Treatment

In this chapter we look at people’s experience of psychiatric treatment. Under British mental health law the term medical treatment includes ‘nursing, and also includes care, habilitation and rehabilitation under medical supervision’ (Section 145(1), Mental Health Act 1983). This legal definition of treatment reflects and underlines the pre-eminence of the medical model and the medical profession in mental health services. Here we limit the use of the term ‘treatment’ to describe people’s experiences of interventions that are specifically directed toward the control of symptoms, such as drugs, ECT, and various ‘talking treatments’. Our data suggest that these treatments are experienced by patients as a fixed part the daily routine of services, rather than regimes tailored to people’s individual needs or preferences. Most patients appear to have received most of the available treatments (in particular, drugs) for most of the time. Thus, whether diagnosed as suffering from schizophrenia or from depression, a majority (56.4 per cent) reported receiving anti-psychotic medication, anti-depressants and minor tranquillisers concurrently. Of those who received antipsychotic drugs, more than half (51.9 per cent) received them as depot injections and in tablet or tot form concurrently.

Early Experiences of Mental Health Problems

In recent years, a controversy has raged about the nature of distressed or distressing conduct. On the one hand, most psychiatrists argue that they are simply a version of illness. In opposition, a minority of their colleagues have argued that mental illness is a ‘myth’ as it has no proven biological cause. Instead, it is claimed that psychiatric patients are not ill but that they have ‘problems of living’. The latter are about difficulties in how to live one’s life. Consequently, what is called mental illness is actually a dustbin label for a variety of moral and existential questions about norms of conduct and the violations of these norms. This view, championed by the American psychoanalyst, Thomas Szasz,1 depicts psychiatrists as agents of social control hired by the state to smooth over the crises precipitated by the actions of disruptive ‘patients’ in the presence of their intolerant fellow citizens.

A Look at the Experts

There are three common and contradictory images of health professionals. The first of these is unambiguously positive and is typified by the selfless heroics of the accident and emergency staff in the popular television series, ‘Casualty’. Not only are these doctors and nurses depicted as being dedicated to the needs of patients, but they generally seem to know exactly what they are doing. A second image, which also haunts our culture, is one of people who come to take you away to the ‘funny farm’ or the ‘loony bin’. As in the film ‘One Flew Over the Cuckoo’s Nest’, angry or frightened victims are callously disposed of without a care for their sensitivities or civil rights. After the disposal, they try to survive in a sinister, incarcerated world of forced injections, solitary confinement and habitual brutality and neglect. The third common mythology about the mental health industry entails the assumption that psychiatrists are all psychoanalysts. Consequently, in this imagined world, it is assumed that they are highly skilled in making interpretations, even to the point of being able to ‘read minds’. Radio programmes, such as Anthony Clare’s ‘In The Psychiatrist’s Chair’, reinforce this notion, as did the Thames Television’s soap opera ‘Shrinks’.

Views on Community Living

The last chapter dealt with mainly hospital-based services. This chapter will explore life for patients living in the community. What do service users think of GPs? What are the stresses of working? Are users helped by services to re-gain or find employment? What sort of accommodation do users want? What are the experiences users have of being unemployed and living on state benefits? The role of GPs will be examined first.

A User-Friendly Future?

At the beginning of the book we discussed the difficulties which both professionals and researchers had found in taking the views of psychiatric patients seriously. We hope that we have broken free of these previous prejudices and set out the case for listening to the user’s voice. In addition, in engaging with the data seriously, we have learned a number of lessons about the sociology of the psychiatric patient’s view of mental health and a user-friendly social policy. These lessons will be discussed in this final chapter.