Talking About Madness

“So you’re indifferent to the patients?”
“I’m emotionally indifferent it’s true, but that doesn’t mean I don’t think about the situation. I probably think about it too much. I think the whole damn place is a sham and a con, and it’s actually doing harm to the very people you’re defending. They need self-respect, not spoon-feeding like babies…….”
“But there are compelling reasons why they behave the way they do. Some of them come from abusing families, poor backgrounds, traumatic circumstances…..”
“Yes… yes….you sound like a full-on advert for the therapy industry Kate. But for every person who blames their disordered life on past circumstances, there are many others who have experienced the same sorts of problems and lived without disorder. These things aren’t really ‘causes’ at all, they’re more like negative influences in a person’s life which can be either overcome, or accepted, depending on the person’s character. That’s the critical variable.
“So, people choose to be mentally disordered?”
“Well, people don’t wake up one morning and make a single life-changing decision to be mentally ill – of course not. What I’m saying is that some people end up in care because they drift through a lifetime of expedient decisions. They evade immediate social responsibilities so often that they finish up either unnecessarily over-dependent, or dangerously anti-social. In their cases, the whole process is driven by personality disorder, not mental illness – just look through a few histories and see what I mean…..”
“Oh, that’s rubbish, Steve. They do need therapy. Medication, support, care…….”
“There isn’t any medication for the absence of willpower or conscience, Kate. That’s why the existing drugs rarely ‘cure’ mental health problems where personality disorder is an underlying feature. And that’s exactly why psychiatric settings have to give direction and motivation.”
“These people need compassion, Steve….”
“No!” I shouted “that’s just where you’re wrong. They need more structure around them, a positive working environment, and less time to fixate on their own problems. They need to be part of a constructive community, not an open-ended institutional charity which effectively encourages people to be self-obsessed and asocial. Some people need to be parachuted into Africa or Iraq to see what a big problem actually looks like…….”


6 Responses to “Talking About Madness”

  1. These two have different opinions on treating patients. I do believe in Kate but I also affirm Steve. Mental illness is more on personality disorder. It’s about hiding and running from things that some people cannot handle. However these people really needs care and of course health care workers in scrub jackets must not just give them care but also let them decide on them all, not letting them feel that they are so dependent and very invalid persons.

  2. Hi Penelope,
    Yes, this dialogue between Kate and Steve is probably the most important piece in my book. It tries to crystalise the tension between liberal mental health policy (which sounds good but often fails), and traditional mental health policy (which sounds crude but often works). I think there will be a swing back to the traditional view within the next ten years…..
    Thanks for your comment,

  3. Hi Rob,
    Thanks very much for your comment.
    I think that there are many reasons for the divergence of ‘official’ liberal policy and practical professional experience. Most importantly, governments since 1990 have convinced themselves that community care is cheaper than any other programme – so it continues, notwithstandng the evidence. Managers are too sychophantic to question their political masters and practitioners are poised between fashionable political correctness (meetings!) and the growing suspicion that their interventions are too frequently ineffective. The system is terminally corrupt with failure, but difficult to turn around while community care legislation remains intact, so individual practitioners stay publically quiet out of resignation and self-preservation.
    But all things change, and I believe mental health policy will begin to re-emphasise personal responsibility on the back of general welfare reform in UK society. Because the nation is virtually bankrupt the bean counters will eventually work out a more constructive course for community care patients. That is, care of the community not care by it….
    All the best.

  4. Beautiful piece of writing, Leo… and ever so true.

    Working “against” the “system”, however, to effect “change” is difficult and fraught with all kinds of resistences (including loss of ability to again work in the field.) Jesus was a change agent–He was crucified. It hasn’t yet come to that to this “change agent”–but it is being worked upon–and attempted already.

  5. Hi Christina,
    Thanks very much for your kind comments. If the individual takes on the organisation there’s usually only one winner, but when the organisation resists the State – that’s another question. I detect the political pendulum swinging back towards social responsibility again. Finance underpins Western society and we simply can’t afford to do anything else.

  6. How right you are, Leo…

    I actually had a “psych” nurse comment on a post of mine that I didn’t know how much struggle was involved in “mental illness”… and thought “your heart is in the right place, but your thinking is flawed.” I have a strong feeling she didn’t even bother to read the whole post (lengthy). My God! When a person has worked at twelve different psych facilities all over the country for thirty years–and been subjected to incompetent, degrading, demoralizing “torture” (with all the attendant sx of torture) at the “word of the State”, who simply did not know what was going on (I was never allowed to see the judge face-to-face; nor was I allowed a face-to-face encounter with the “court psychologist” who wrote the false document that maintained the detention!) I became rather passionate in my reply. Her “assumptions” were typical of the kind of “testimony” that got me in the predicament in the first place.

    “Words” can be so messy, can’t they?

    In all due respect–I love your blog (see mine at

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