Commentary: On the back foot – psychiatry and community care

Dr Persaud's observations on the impact of the media on mental health policy development raise some interesting issues. He clearly does not much like the fact that voluntary organisations such as The Zito Trust have played an important part in setting the agenda and pursuing reform — more effectively, in his view, than psychiatrists, either individually or as a profession.

Crucially, he neglects to say whether any of the reforms proposed and/or implemented by the current Government within the last two-and-a-half years — a new strategy for mental health policy; £700 million of extra funding over three years; a review of the Mental Health Act 1983; a new National Service Framework for Mental Health (put together by a Government group which was chaired by a psychiatrist) and, jointly with the Home Office, an important consultation document on the management of dangerous people with severe personality disorder — meet with his approval or not. If Persaud disagrees with the general direction of these reforms, then perhaps he has some justification for criticising the way they came about. If, however, he is generally in favour of the Government's initiatives for the future of our mental health services, then what is he complaining about?

His complaint, if I read it correctly, is actually quite bizarre. He seems to be suggesting that voluntary organisations — he refers by name to The Zito Trust, SANE and Mind — do not have the right ‘credentials’ to pass comment on psychiatrists and their patients because those who speak on behalf of these organisations have not undertaken the long and arduous training necessary to qualify as psychiatrists. If this kind of thinking was taken to its logical conclusion, and was applied across the board, it would bring about the end of just about all commentary, opinion and intellectual debate in just about all aspects of government, social policy and cultural life in the country; unless, of course, it was left to ‘experts’ with the appropriate qualifications and credentials. Fortunately, it is doubtful whether Persaud seriously intends such a narrow-minded and dangerous state of affairs.

What Persaud has failed to address in his complaint is that, in any case, The Zito Trust was not set up to speak on behalf of psychiatrists, patients or their carers, but to represent the needs and concerns of the victims of community care failures. It certainly does nothing to advance his argument, which seems to be that only psychiatrists should be allowed to talk about severe mental illness and some of the consequences thereof for patients, carers and the public. In an NHS culture increasingly concerned with evidence-based practice, it would be as well to remind Dr Persaud and others of the importance of raw experience, however uncomfortable it is to have to meet it ‘in the flesh’. In just this regard alone, what are Dr Persaud's credentials?

In having as its central aim the support of victims, The Zito Trust is in a unique position to highlight those areas where it feels reform is needed to improve services for patients. It is notable, and somewhat regrettable, that Persaud does not mention victims in his article and this lapse concerning the work of The Zito Trust renders some of his implied criticisms irrelevant. The principal reason the media contact the Trust on a regular basis is because it can put them directly in touch with the families affected by the consequences of the poor, and sometimes negligent, manner in which mental health services have been delivered.

It is undoubtedly true, as Persaud implies, that psychiatry is currently on the defensive. As if community care-related suicides and homicides were not enough, the fallout from the Michael Stone trial in October 1998 exposed psychiatry as confused and disempowered. As Persaud himself says, psychiatry has a “habit of getting caught looking in the wrong direction”. For the first time, the profession is facing the erosion of part of its legal and financial power-base, particularly in the light of government proposals for the treatment of antisocial personality disorder in favour of other equally or better qualified mental health professionals, such as clinical psychology and forensic psychotherapy. Notwithstanding Dr Persaud's initial exposure to psychology, before training as a psychiatrist, his current profession does not have much regard for clinical psychology, and even less for psychotherapy.

These anxieties need to be set in an historical context before they can be fully understood. They emanate from two sources. First, the accelerated, but badly implemented, programme of community care, forcing psychiatrists who are, as Persaud puts it, “used to wielding authority from the comfort of their institutions”, to work in multi-disciplinary teams in the complex and unforgiving deprivations of our inner cities; second, the rapid developments in psychopharmacology, neuroscience and genetics, which have shifted psychiatry away from psychological therapies towards the medical model, from which it will probably never return, as the preferred intellectual and clinical baseline for treatment (Shorter, 1997). These separate, but related, developments pose a real problem for the future role of psychiatry, because what patients want, more than ever, is not just new, cleaner drugs for the treatment of their psychosis, but meaningful, consistent and regular face-to-face contact.

So, are psychiatrists really stigmatised, as Persaud alleges, or have they brought many of their current problems on themselves? Psychiatry is a conservative profession, reluctant to accept change. From the point of view of public relations alone, psychiatry has been poorly served by its own College, a point Persaud makes very clear. Now it is a little late — the horse has bolted. Much as we all view the media with contempt at times, a dismissive attitude towards it is not a clever strategy.

It is probably fair to say that this country clearly has some of the best psychiatrists in the Western world. But we also have some of the worst. One health authority recently complained to The Zito Trust that they find it impossible to get rid of bad psychiatrists through conventional means. They have to find what they called a “back door exit”. Such is the shortage of psychiatrists in the NHS that it is relatively easy to become a consultant in one's early 30s, earning a salary and enjoying a status which might not in all cases be justifiable in terms of what we infer from consultant status elsewhere in the NHS: expert knowledge, ability and wisdom, based on long experience, an inference endorsed by the College's own motto, “let wisdom guide”.

And yet, in terms of accountability for bad practice, there does not appear to be the application of a standard comparable to other branches of the medical profession. As far as we know, and in spite of some truly appalling working practices and lapses in professional judgement, not one psychiatrist (or professional of any description) has been sacked or disciplined as a result of the 100 or so independent inquiry reports into homicides committed by mentally ill people which have been commissioned since 1994. In 1997 the Court of Appeal made it clear that the health authority allegedly responsible for the care of Christopher Clunis did not in fact owe him a common law duty of care (Clunis v. Camden and Islington Health Authority, 1998). This kind of protection, unheard of in other branches of the medical profession, can hardly be described as stigmatising psychiatrists.

But the media, it is true, has been less than sympathetic and, without doubt, had there been no media spotlight on community care failures, psychiatry would have had a much easier (and fairly inconspicuous) ride over the past four or five years. It is doubtful too whether there would be more than just piecemeal reforms on the table. The discomfort felt from exposure, and not bothering to develop a strategy to deal with it, has put psychiatry on a steep learning curve. Hopefully, the experience will eventually bring about the modernisation of the profession and change some of its current attitudes. This difficult and painful process will no doubt see psychiatry losing some of its cherished powers along the way, but it will end up with a much clearer idea of its actual role and actual responsibilities, set within a modern legal framework with better services and resources at its disposal.

In the meantime, The Zito Trust will continue to speak out about community care and other associated issues on behalf of victims because it has the credentials, the experience and the authority to do so.