It could be you or me

Jack Straw's plans to lock up the mad and the bad should frighten us all. Here is one mother's story

T

he emergency clinic at the Maudsley Hospital is protected by a massive metal gate. It's not clear whether its purpose is to keep intruders out or to reduce the chance of escape. When we arrived on Sunday evening with our 25-year-old daughter Lucy, severely anxious and in the grip of a psychotic breakdown, the sentry box at the gate was unmanned.

A notice told us to press the buzzer, but repeated buzzing produced no response. We must have been visible on the video monitor in the porter's office, but they had to be persuaded to let us in. Another security door with a metal detector has to be negotiated before you gain entry to the clinic itself. his was not working properly and after the external door had clanked shut behind us, the nurse had to wrestle for several minutes with the lock of the inner door to let us into the windowless waiting room.

Until then, I suppose, I had shared the view which most of us have about mental illness. It was something which happened to other people. o people who were, well, different. People who were, as Jack Straw might put it, "a danger to others". Just as well that, as the Home Secretary proposed this week, they should be locked away, even if they had not actually committed any crime, for the protection of others.

But that was before Lucy - an attractive, intelligent young woman with a good job, a steady relationship and a loving home life - suddenly, without warning or apparent reason, underwent a terrible change in which she began to develop paranoid fantasies and exhibit dangerous behaviour such as hurling herself from moving cars. We tried to cope at home, but the wildness of her behaviour brought us eventually to the Maudsley, the hospital which has the popular reputation as the centre of excellence in British psychiatric care.

We had been told that a bed was available for Lucy, who needed emergency admission for psychiatric assessment, but on arrival we were told we must wait several hours. Lucy's anxiety and paranoia were increasing alarmingly and we all felt the effects of claustrophobia during the interminable wait in the airless room.

Eventually we were led through a poorly signposted maze of buildings to a mixed ward on the third floor of a distant block. he lift was broken, so we trudged up the stairs. hrough the glass door we could see a group of aggressive-looking male patients. We rang the bell and eventually a nurse came along. Another struggle with locks ensued while the nurse attempted to calm the patients on the inside.

he welcome on the ward was anything but warm. Lucy was allocated a cell- like room in what was referred to as the "High Support Area". It had a plastic-covered bed, two broken items of plywood furniture, no chair, a torn and dirty curtain and no means of locking the door from the inside. No one had bothered to change the notice on the wardrobe which bore the names of a former patient's consultant and primary nurse. he way to Lucy's room took her past a notice which read "Male corridor, female patients not allowed".

here were dead plants on the shelf by the communal television. he shower outside her room was out of action and the light did not work in the washroom. hree days later the only other shower for female patients had also broken down and the only bath was dirty.

Lucy was given the names of several different "primary nurses", but she rarely saw the person supposedly allocated to her care. here was heavy reliance on agency nurses, few of whom seemed to have much experience of mental health nursing. heir main function was that of guard or warder, an essential role in a crowded acute ward where many of the patients are there because they are considered to be a risk to themselves or to others.

Medication was administered by the night staff. In her terrified and paranoid state, Lucy was suspicious of these strangers who handed her unmarked pills in plastic cups and was frightened by their references to the ominously named "Crash eam" when she was reluctant to take them. Her response was to try to escape. Her voluntary patient status was rescinded and she was sectioned under the Mental Health Act.

In just a few days, our vivacious daughter had become a detained patient in an acute psychiatric ward alongside people with the most severe problems imaginable. he shock to us - her parents, sister and boyfriend - was terrible. For Lucy herself it was a nightmare made even more dreadful by the conditions on the ward. Only a few weeks previously she had been doing an interesting job and happily sharing a south London house with friends. Nothing had prepared us for the rapid descent into psychosis, the terrifying delusions and extreme fears. Psychiatry had little to offer in the way of explanations or predictions. Friends with specialist knowledge admitted that the toolkit was limited and diagnosis and prognosis imprecise. he prospect that under Jack Straw's proposal a decision could be made, on the basis of such tenuous knowledge, to lock up someone found to have an unspecified "personality disorder" fills us with horror.

We had heard about the problems facing London's psychiatric services, but the Maudsley's reputation as an internationally renowned teaching hospital had misled us into believing it would somehow be immune from the pressure faced by the other 3,000 patients in secure units throughout the UK.

We could not have been more wrong. he atmosphere on the ward was anything but therapeutic. Almost all the patients are difficult or dangerous, since these are the main criteria for allocating beds. Frequently the staff have to drop everything to deal with "situations" which arise when extremely ill people are incarcerated with little to distract them. he hospital offers occupational therapy and other activities and some patients are free to come and go, but for those sectioned and unable to leave the ward, time passes very slowly.

It takes courage and extreme patience to be a good mental health nurse. It is not surprising that it is hard to recruit suitable candidates in central London, where more lucrative and less stressful jobs are abundant. urnover is high. he tendency to control by sedation is ever present; in Lucy's case this was often resorted to.

Staffing difficulties were compounded by the decaying state of the building. No one seemed surprised when the shower broke and there was little expectation that it could be fixed in the near future. Resigned tolerance of poor conditions seemed endemic and management energy and resources appeared to be directed elsewhere. In the face of even greater problems, the physical and emotional comfort of patients was a secondary concern.

After five days in this terrible place Lucy was desperate to leave. Ideologically committed to the NHS, we had no private health insurance but contemplated remortgaging our house to pay for a private clinic. Friends warned us that although we could probably buy more comfort in a private hospital, the clinical care might be even worse. hen, when we were at our wits' end, Lucy was offered a place in a specialist unit at the Maudsley's sister hospital, the Royal Bethlem in Bromley. his was an altogether different sort of place: bright spacious wards in attractive grounds, with dedicated and experienced staff. he care she received there went a long way towards rebuilding our confidence in NHS psychiatry. Yet the fact that two such regimes can exist within a single policy framework inspires no confidence in the decisions which will be made, if Mr Straw's proposal passes into law, to lock some people up and throw away the key.

Psychiatric patients exercise little political muscle and their complaints are easy to dismiss. Since most of us never expect to see the inside of a psychiatric hospital, we give little heed to what goes on there. he shift to community psychiatric care has undoubtedly given many chronically ill patients the chance to live a more normal life and no one wants a return to the horrors of the long-stay institutions; but there will always be a need for asylum (in the best sense of the word) for people in the acute phases of mental illness. As well as psychiatric assessment, they need old-fashioned tender loving care, and their carers need support as well. At the Bethlem we saw how things can be made to work well.

More than most medical specialities, psychiatry is subject to changing fashion. At present the danger is that treatment regimes will fall prey to the overriding concern for public safety which is driven by political rather than medical imperatives.

Psychiatric hospitals have been allowed to become simply places where dangerous and difficult people - the mad and the bad - are locked away. If psychiatry is to emerge from the Dark Ages, prison-like regimes must give way to a more humane and patient-centred approach. Jack Straw's proposal is a step in the opposite direction.

Lucy is now out of hospital and living at home with her parents.