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The need for asylum
Editorial
The neurologist and psychoanalyst Ernest Jones once related a conversation he had with a fellow medical student in the late 19th century. They were discussing what British psychiatrists—or “alienists” in the parlance of the day— talked about at their conferences. “I suppose they read papers on an improved variety of the Chubb lock”, Jones’ companion joked. In other words, care of the mentally ill was more a matter of incarceration than therapy. Things changed dramatically over the next century. One psychiatric illness—general paresis of the insane— was shown to be caused by syphilitic infection, and was hence both preventable and curable. The introduction of antipsychotic drugs meant that the symptoms of psychotic illnesses such as schizophrenia could be brought under control, liberating patients to return from inpatient care in asylums to their families and communities. But it was not an unmixed blessing. A new paper from the Royal College of Psychiatrists, Do the right thing: how to judge a good ward, sets out standards for inpatient care and documents how often services in the UK fall short. It raises issues of concern to psychiatrists worldwide. The ten standards the College describes are straightforward: bed occupancy rates of 85% or less; ward-size maximum of 18 beds; a physical environment that is fit for purpose; the ward as a therapeutic space; proportionate and respectful approach to risk and safety; information sharing and involvement in care planning; a recoverybased approach; access to psychological interventions; personalised care; and socially and culturally sensitive care. Mental health practitioners everywhere, one would imagine, aspire to provide this basic level of service for their patients. Aspire they might, but they certainly find it hard to deliver in the UK. Care Quality Commission and Accreditation for Inpatient Mental Health Services data quoted by the authors show a worrying level of failure in many of these domains. The report states, for example, that figures from 2009 suggest that more than half of general adult wards were running at over 100% occupancy. Half of patients reported feeling unsafe, and this was a particular problem for women. The opportunity to intervene in the physical health problems that are so often comorbid with psychiatric disorders is being missed: only 44% of patients surveyed felt they had received enough attention in this regard. So what has gone wrong? www.thelancet.com Vol 378 July 2, 2011
A lack of adequate resources is a familiar problem for mental health services worldwide, and the UK is no exception. The Lancet has raised these concerns before. National Health Service staff who read details of the “ring fencing” of the health budget in the newspapers while another psychiatric inpatient unit closes in the name of efficiency savings are understandably mystified and angry. Dinesh Bhugra, outgoing President of the Royal College of Psychiatrists, told The Lancet that as the threshold for admission becomes higher, “pressure cooker” environments might be created, in which high staff-turnover and sickness are inevitable, making the situation still worse. Yet in order to argue for greater resources, professionals must develop a sound philosophy of inpatient care. The fundamental question must be addressed: what is the point of an admission? The answer is simple. It is a word that has long since gone out of fashion in mental health circles, but which must be understood and reclaimed: asylum. Its original meaning is that of a place of refuge and safety. This is what practitioners should attempt to provide. No one doubts that strong community services are a vital part of care; but attempting to treat most patients at home must not result in inpatient admission being seen as a failure. Nor should the emphasis on reducing risk—and the intemperate news reports that follow serious adverse events involving psychiatric patients—mean that people are admitted not for any therapeutic aim, but solely for fear of what might happen if they remain at liberty. This is especially important when it comes to compulsory admission. Legal criteria for such admission might be based on risk management, but they should be written and used with the aim of promoting recovery. “The move of services to the community was the right thing”, said Bhugra, “but we must not forget that there are always people who will need asylum. We need to change—admission is beneficial if it goes beyond containment.” Access to safe, stable, well resourced wards that allow all patients to be treated with respect and dignity should be a basic right. Wards must not incarcerate patients, but liberate them from their illness through a mixture of psychological input, appropriate drugs, physical care, and occupational therapy. ■ The Lancet
Rex Features
The need for asylum
See Editorial Lancet 2010; 376: 205
For the Royal College’s report see http://www.rcpsych.ac.uk/ publications/collegereports/op/ op79.aspx
1
The neurologist and psychoanalyst Ernest Jones once related a conversation he had with a fellow medical student in the late 19th century. They were discussing what British psychiatrists—or “alienists” in the parlance of the day— talked about at their conferences. “I suppose they read papers on an improved variety of the Chubb lock”, Jones’ companion joked. In other words, care of the mentally ill was more a matter of incarceration than therapy. Things changed dramatically over the next century. One psychiatric illness—general paresis of the insane— was shown to be caused by syphilitic infection, and was hence both preventable and curable. The introduction of antipsychotic drugs meant that the symptoms of psychotic illnesses such as schizophrenia could be brought under control, liberating patients to return from inpatient care in asylums to their families and communities. But it was not an unmixed blessing. A new paper from the Royal College of Psychiatrists, Do the right thing: how to judge a good ward, sets out standards for inpatient care and documents how often services in the UK fall short. It raises issues of concern to psychiatrists worldwide. The ten standards the College describes are straightforward: bed occupancy rates of 85% or less; ward-size maximum of 18 beds; a physical environment that is fit for purpose; the ward as a therapeutic space; proportionate and respectful approach to risk and safety; information sharing and involvement in care planning; a recoverybased approach; access to psychological interventions; personalised care; and socially and culturally sensitive care. Mental health practitioners everywhere, one would imagine, aspire to provide this basic level of service for their patients. Aspire they might, but they certainly find it hard to deliver in the UK. Care Quality Commission and Accreditation for Inpatient Mental Health Services data quoted by the authors show a worrying level of failure in many of these domains. The report states, for example, that figures from 2009 suggest that more than half of general adult wards were running at over 100% occupancy. Half of patients reported feeling unsafe, and this was a particular problem for women. The opportunity to intervene in the physical health problems that are so often comorbid with psychiatric disorders is being missed: only 44% of patients surveyed felt they had received enough attention in this regard. So what has gone wrong? www.thelancet.com Vol 378 July 2, 2011
A lack of adequate resources is a familiar problem for mental health services worldwide, and the UK is no exception. The Lancet has raised these concerns before. National Health Service staff who read details of the “ring fencing” of the health budget in the newspapers while another psychiatric inpatient unit closes in the name of efficiency savings are understandably mystified and angry. Dinesh Bhugra, outgoing President of the Royal College of Psychiatrists, told The Lancet that as the threshold for admission becomes higher, “pressure cooker” environments might be created, in which high staff-turnover and sickness are inevitable, making the situation still worse. Yet in order to argue for greater resources, professionals must develop a sound philosophy of inpatient care. The fundamental question must be addressed: what is the point of an admission? The answer is simple. It is a word that has long since gone out of fashion in mental health circles, but which must be understood and reclaimed: asylum. Its original meaning is that of a place of refuge and safety. This is what practitioners should attempt to provide. No one doubts that strong community services are a vital part of care; but attempting to treat most patients at home must not result in inpatient admission being seen as a failure. Nor should the emphasis on reducing risk—and the intemperate news reports that follow serious adverse events involving psychiatric patients—mean that people are admitted not for any therapeutic aim, but solely for fear of what might happen if they remain at liberty. This is especially important when it comes to compulsory admission. Legal criteria for such admission might be based on risk management, but they should be written and used with the aim of promoting recovery. “The move of services to the community was the right thing”, said Bhugra, “but we must not forget that there are always people who will need asylum. We need to change—admission is beneficial if it goes beyond containment.” Access to safe, stable, well resourced wards that allow all patients to be treated with respect and dignity should be a basic right. Wards must not incarcerate patients, but liberate them from their illness through a mixture of psychological input, appropriate drugs, physical care, and occupational therapy. ■ The Lancet
Rex Features
The need for asylum
See Editorial Lancet 2010; 376: 205
For the Royal College’s report see http://www.rcpsych.ac.uk/ publications/collegereports/op/ op79.aspx
1