Reprinted from Clinical Psychology. Issue 7 pp 28-31

A decade ago, frustrated and despairing about psychiatric practice, I wrote an article expressing my anger and disillusionment (Johnstone, 1993). Last January, after a long period outside the NHS, I returned to the hospital where I had first worked 14 years previously. In the intervening years, much has altered. There has been a plethora of reorganizations and new policies: Health of the Nation targets, clinical governance, National Service Frameworks, clinical audit and so on. There are new treatments: SSRIs, atypical neuroleptics, relapse prevention, early intervention and Dialectical Behaviour Therapy. There are even some new "illnesses": body dysmorphic disorder and compulsive shopping. But how much has really changed?

Certainly the wards looked the same from the outside as I approached them on the first day, clutching one of the departmental alarms; though I was a little taken aback to be met by the sight of an ambulance taking a woman to casualty after she had swallowed a bottle of nail varnish remover, and a police car removing a man in handcuffs. The wards looked the same inside as well. Exactly the same, in fact: the identical grimy nicotine-stained furniture, ill-fitting curtains, peeling magnolia paint and cracked crockery, all ten years older and dirtier. But the earlier vignettes had given an important clue to one major difference. The hospital is now housing a far more disturbed and damaged population than before, and this is having knock-on effects on everything else.

It is, I believe, good policy to keep people out of psychiatric hospital where possible, and only admit those in acute need; but if you have entire wards consisting only of such people, with too few staff, beds and resources and too little support, training and supervision, then you have a recipe for disaster. Entire shifts consist of crisis management, with no time for staff support or debriefing or doing anything remotely therapeutic with the patients. Scarcely has one person been retrieved from the bridge than another slashes her wrists in the bathroom, while a third is breaking windows in the office. Nursing staff are stretched to their absolute limits; my former nursing students, now out on the wards, seem to be struggling to hold on to some shreds of idealism and compassion. On the same ward that was satirised in the 1987 hospital show - we depicted the consultant, an inspiring man who tried to run the place along therapeutic community lines, passing round an enormous spliff and spouting therapy jargon as the staff lounged on cushions - it is often literally impossible to find ten minutes to discuss the patient you have just seen. Therapy sessions have to take place sitting on patients' beds or on the benches outside; when the one interview room is free, there is constant distraction by noise and, once, by a large male patient repeatedly pressing his face against the window and muttering "I'm going to get you afterwards."

Squalid and untherapeutic inpatient settings abound all over Britain (Sainsbury Centre for Mental Health, 1998; The Times, 2000; Mind, 2000), while surveys confirm that the number of compulsory admissions almost doubled from 1984 to 1996 (Wall et al., 1999). Reduced numbers of beds may partly explain the higher concentration of craziness, as may increased use of drugs and alcohol and a more defensive attitude towards risk (Wall et al., 1999), but surely not all of it. What has happened?

There are other mysteries too. None of the patients I knew 15 years ago seems to be around any more; they have been replaced by a completely new generation of desperate people. Where have the others all gone? They certainly didn't look as if they were about to recover last time I met them. Later, I did come across some familiar files, and discovered that the former "schizophrenics" are rapidly being reclassified as "borderline personality disorders". This diagnosis is definitely on the up and up, for reasons that are unclear to me. I now suspect at least three factors are at work. One is the desire to justify keeping out of hospital people whom the staff find difficult, on the grounds that they are "personality disordered" rather than "mentally ill" {Castillo, 2000). It is becoming the received wisdom that "personality disorders don't do well in hospital". How true! But then who does? Why single out this particular group for such a caveat? The "schizophrenic to BPD" switch is simply a newer version of the old mad-to-bad, Rescuer-to-Persecutor game by which people are sucked into the psychiatric system and then shunted out when no one knows how to deal with them. The second factor is the need to find a way of tacitly acknowledging that many of the most disturbed people have a history of such extreme trauma that an "illness" diagnosis is totally implausible as an explanation. Who wouldn't be driven crazy by the torments that they have suffered? The third is the convenience of the term for a government agenda of responding to public anxieties about dangerousness (Pilgrim, 2001).

This brings me on to another point. Sexual abuse was widely acknowledged as a feature in many patients' early lives last time I was around, but surely it wasn't, or at least wasn't known to be, quite as common as now? Just about all the women, and a good proportion of the men, have appalling abuse histories, frequently involving multiple physical and sexual assaults spanning many years. Where are all the abusers? The answer, unfortunately, is often on the same ward. My partner works in probation, but there has never been such an overlap in our work before. His client, with a record of assaulting women, has been harassing my client, who has a history of abuse and has to share the same living space. No doubt the erosion of distinctions between the "bad" and the "mad" is partially attributable to the widespread availability of street drugs, both on and off the wards. I know very little about working with addictions, but even so it is often impossible to untangle the complex web of social deprivation, emotional neglect and substance abuse underlying the newly fashionable term "dual diagnosis".

In the interests of precise and scientific classification -still an aspiration in psychiatry -I shall divide the rest of my points into Good Things and Bad Things. (Please note: there may be some overlap between the two categories; cf. DSM IV, ICD-10.)

It isn't all bad. I spend one day a week in a community mental health team. We no longer see any of those slightly anxious people who can't use buses or dislike spiders or aren't very happy with their husbands (where do they all go now?), so a lot of the work is quite demanding, but the team is extremely friendly and cohesive and offers a range of excellent psychological and practical forms of help - along with diagnosis and medication, of course, which seem to be necessary preconditions to being seen by any team.

Cognitive-behaviour therapy, always a winner in terms of claimed evidence-base and effectiveness, has gone from strength to strength, but it has mutated along the way. The most sophisticated practitioners are doing something indistinguishable from what I would call psychodynamic psychotherapy. They talk about feelings, relationships, unconscious meanings and transference reactions (under slightly different names) just as other therapists have been doing for decades. It's quite convenient, because it means that I can take on referrals which ask for "a cognitive-behavioural approach, please" (in other words, every referral) in good faith. Somewhat to my surprise, I have been reborn as a cognitive-behaviour therapist.

Service users are far more prominent. There is an excellent patients' council at the hospital, which sends representatives to meetings and runs a drop-in for inpatients. Hearing Voices groups (staff-led) are widely agreed to be a good thing. This may or may not have something to do with the fact that they are invariably described in the same breath as cognitive therapy for psychosis. No one seems to have noticed that the two approaches start from radically different, indeed contradictory, assumptions and philosophies: voices as the symptom of an illness versus as an understandable response to trauma and a widespread and natural human phenomenon. So maybe this is a Bad Thing, or at the least an example of what has been called "the British cultural tradition of incorporating new ideas and practices in order to obstruct more radical shifts of thought or practice" (Pilgrim, 1990).

Another Good/Bad Thing is that mental health staff are now officially allowed, indeed encouraged, to talk to mad people about their madness, under the general heading of Family Intervention or Cognitive Therapy in Psychosis. Some of the things we are meant to say to them when we meet them are, in my opinion, pretty dubious; still, this does provide another useful permit to gain entry to a world previously closed to us, and more or less do what you think best when you get there. I have met several Family Intervention workers who admit to using these brand new, evidence-based approaches in exactly this way. Thanks, Leff, Falloon et al; I'm only sorry that this kind of collusion may give FI and CT credit that is not really its due.

Consultant psychiatrists are definitely less powerful than they used to be. I take referrals directly from nursing staff on the wards, and work alongside and report back to them; the once obligatory attendance at ward rounds feels like an irrelevance. On the other hand, the power that has now been transferred to the managers is often used just as damagingly. A case in point: a client of mine with a horrific abuse history became highly disturbed each time she made more disclosures. Each time, there were not enough staff to contain and keep her safe, nor any vacant beds on the high dependency unit, and she was shipped off elsewhere. She ended up going to five different institutions, in three cities, within a six-month period. Each enforced transfer precipitated agonizing feelings of rejection, terror and self-hatred. All of these moves were driven by lack of resources, and at least one of them was forced on the clinical team, entirely against its wishes and advice, by the management, who were playing their usual game of manoeuvring patients and beds like pieces on a chess board. I found myself in the unusual position of writing a letter of complaint in support of the consultants and the team. More than ever, psychiatrists seem like straws buffeted in the winds of social disintegration, trying desperately to keep their morale up with brave talk of neurotransmitters and atypical neuroleptics.

We seem to be getting on to the…

It will be apparent that the main Bad Thing, the adherence to an unfounded biomedical model of mental distress, is as rampant as ever. Although in the community it is diluted with (but not replaced by) new therapeutic approaches and a more democratic hierarchy, the dire hospital situation means that "treatment", whether by choice or by default, consists almost entirely of medication. Medical jargon still abounds. One consultant introduced himself to a patient at the start of a CPA with the words, "You do accept that you are a paranoid schizophrenic?" Refusing your medication or questioning your diagnosis is still sternly opposed, and at the last case conference I attended the audience was still playing the old game of "What's her label?" Bewildered SHOs still try to cling to some semblance of usefulness by taking detailed lists of "symptoms". Ward rounds still consist largely of juggling medication in a doomed attempt to create sense and order out of the overwhelming human despair and chaos.

One of my clients said to me the other day: "Your job must be very depressing. You spend the whole time trying to help people get over abuse, and out there, the abusers are just creating hundred more victims." He had a point. Hospitals seem more and more like warehouses for the sedation of the utterly victimized and powerless, a process for which the theories of biomedical psychiatry provide an increasingly unconvincing justification. Progress in community treatment has been gained at the cost of a worse deal than ever for the most vulnerable group of all. The Borderline Personality Disorder literature, if you disregard the insulting and nonsensical term itself, actually implies that it makes more sense to regard such people as suffering from traumas with psychological consequences than illnesses with biological causes, and to develop interventions accordingly. Taken to its logical conclusion, and with due regard for the massive amount of trauma and deprivation present in every inpatient population, this would imply that a trauma model should replace medical diagnosis and treatment for most, perhaps nearly all, psychiatric inpatients. This is already happening in some places (Ross, 2000). In Scandinavia, a psychotherapeutic model is seen as the most appropriate and effective for those who fall into the broad category of psychosis (Alanen, 1997) .

Is there any chance that this will happen? Is there any sign of a sea change on the way? That partly depends on whether we, as individuals, as professionals or as a society, actually care at all about what happens in these factories of despair. Health of the Nation targets and National Service Frameworks notwithstanding, I have little confidence that a visitor in ten years' time will find much to celebrate.

Alanen, Y (1997) Schizophrenia; Its origins and need-adapted treatment. London: Karnac

Castillo, H (2000) You don't know what it's like. Mental Health Care, 4, 2,42-43

Johnstone, L (1993) Psychiatry: are we allowed to disagree? Clinical Psychology Forum 56: 30-32

Mind (2000) Environmentally Friendly? London: Mind Publications.

Pilgrim, D (1990) In R. P. Bentall (ed) Reconstructing Schizophrenia. London: Routledge

Pilgrim, D. (2001) Disordered personalities and disordered concepts. Journal of Mental Health, 10, 3,253-265

Ross, C. A. (2000) The Trauma Model; A solution to the problem of co-morbidity in psychiatry. Richardson, TX: Manitou Communications

Sainsbury Centre for Mental Health (1998) Acute Problems; A survey of the quality of care in acute psychi- atric wards. London: Sainsbury Centre for Mental Health

The Times (2000) Mental Health wards "not up to the job". The Times, 9 November

Wall, S, Hotopf, M, Wessely, S, and Churchill, R (1999) Trends in the use of the Mental Health Act: England 1984-96. British Medical Journal 318, 1520-1521