INTRODUCTION

This book is about my experience working with people whose mental suffering has taken them right to the edge of human experience – many of them facing it with great courage.

It is also a reflection on our relationship as a society with mental illness,* about the precarious state of our mental healthcare services, about the fragility of progress and how easy it is for things to go into reverse.

Most importantly, it is about the potential for change, about how things can be turned around if we can only engage wisely and nurture the creative opportunities that are there even at the darkest and most chaotic of times.

I started my career as a psychiatrist nearly forty years ago at the Towers, one of two Victorian asylums in Leicester. It was a profoundly flawed institution where I encountered patients who had been locked away and forgotten for years – institutionalised, infantilised, their individuality eroded. And yet I began that first job full of optimism. We all knew that change was under way: plans to close the Towers were already in place, and the generation before us had taken huge steps towards humane care, reforming the Mental Health Act and breaking down the barriers between the asylums and the community. We believed in progress. It was an era filled with hope.

Just six months later, I moved on to a brand new mental health unit attached to the General Hospital. It was a hugely significant change, one that reflected the reforms taking place throughout the country, indeed throughout most of the richer countries in the world. The building itself seemed to embody a new and hopeful chapter in the history of psychiatry. At the time it felt as if I was part of a great leap forward, playing a small part on the right side of history, my future career glittering in my imagination with grateful patients, exciting discoveries, and a palpable sense of progress.

And indeed some things did improve. We now understand a lot more about the human mind and have a growing evidence base informing us how best to help people who are struggling. There has also been a sea change in attitudes to mental health more generally. People are more open about their feelings, and mental health problems are no longer the taboo they were a generation or two ago. Celebrities – even royalty – talk publicly about their battles with mental illness. Mental well-being and mindfulness have become part of everyday language and therapy is increasingly seen – in some sections of society, at least – as a normal, healthy thing to do. Public health campaigns reassure us that there is no shame in sharing feelings of despair and thoughts of suicide and remind us that mental health problems will affect as many as one in four of us at some point in our lives.

But despite all of this, mental health services have not thrived in recent years. Morale is desperately low on the front line. People with serious mental illness are likely to die on average fifteen to twenty-five years earlier than those without SMI, largely from preventable diseases such as heart disease and diabetes.1 Report after report has confirmed what every mental health worker knows: that the service is in a terrible state and that the shocking chasm between what is needed and what we are actually resourced to provide is getting larger, leaving an increasing number of vulnerable people and their families in dark and desperate states of mind. The theme tunes seem horribly familiar as the potential for depriving, brutalising and dehumanising mental health patients re-emerges in different settings. To my great sadness, we seem to be moving backwards: the progress made during my early career steadily eroding.

Now we have services where desperate patients wait for months to see a psychiatrist or therapist; where the bed shortage is such that we end up sending severely ill adolescents hundreds of miles away from their families; where traumatised refugees are housed in detention centres that are more like prisons than care facilities. Why, at a time when we seem so much more comfortable talking openly about mental health and have so much more knowledge than previous generations, do we put up with sparse, inadequate and sometimes even abusive services? There seems to be some sort of paradox here: a shadow as dark and gothic as those lunatic asylums of old.

Funding is, of course, a huge issue. Health ministers talk recurrently about ‘transforming’ services and promise more money, but action doesn’t seem to follow the rhetoric. Despite all the positive talk, the gap between