Mental health legislation

  Psychiatry is unique within medicine in being able to compel treatment against a patient’s clearly expressed wishes. Consequently most countries have evolved specific legislation to permit this and to monitor it. The whole of the asylum movement was firmly based in such legislation. The developments in England in the 19th century are easy to follow because it was an early nation-state with centralized government and little scope for regional variation.

  The first legislation was to regulate madhouses. All this did was to register them. It set no standards but could close an individual madhouse in the event of flagrant abuse. The purpose of the Asylum Act of 1808 and the Lunacy Act of 1845 was to ensure that care was provided and prevent exploitation of the vulnerable mentally ill. It allowed for ‘the removal of the furiously mad’ from workhouses to the asylum.

  Over the next half century, public concerns shifted from the neglect and abuse of the indigent mentally ill to the spectre of malevolent incarceration of the sane to rob them of their wealth. The ‘Alleged Lunatics’ Friends Society’, with an admiral of the fleet as chairman, gained considerable parliamentary and public support in late 19th-century Britain. Georgina Weldon (a ‘spirited, attractive, wealthy and well connected woman’) filled the Covent Garden Opera House in London in 1883 for a rally to challenge her recent incarcerations, and eventually won her case. Increasing public disquiet was reflected in the 1890 Lunacy Act. This highly legalistic document, several hundred pages and 342 sections long, prioritized the protection of patients’ rights to such an extent that early and voluntary treatment became virtually impossible. The leading historian of mental health legislation, Kathleen Jones, wrote that ‘it stopped progress in mental health policy in its tracks for half a century’.

  So swings the pendulum of public attitudes to mental health. Virtually every developed land is struggling to balance legal rights and therapeutic needs, to balance society’s needs with the patient’s. We will return to this in Chapter 6 but it is sobering to be reminded that we have been here before.

  Asylums limped onwards for another 50–60 years, mired in legislation and inhibited from innovation apart from the welcome treatment advances in the 1920s and 1930s. It was to be another 30 years before this awesome international institution was finally challenged and moved towards its end. This is the subject of Chapter 3.

 

Chapter 3 The move into the community

  After decades of being hidden from view, the mentally ill are now very much in the public eye. Hardly a week goes by without some headline about the plight of the homeless mentally ill or an incident involving a disturbed individual. ‘Care in the Community’ has become an international preoccupation with much soul-searching and fear of violence and disorder. How has this situation come about? Is it really so disastrous and, if so, what can be done about it?