A speech by The Prince of Wales on the 150th Anniversary …
The Royal Family
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Jul 5, 1991 — We will build a better future for the mentally ill because we know what ‘better’ means, and it means radical change in society’s assumptions.
. . . forcing yourselves to listen to me. However, I can only assume that if your professional reputation is anything to go by, I should at least be guaranteed the best audience I have ever had!
Personally, I think I need my head examined for coming all the way to Brighton merely to reveal my lamentable ignorance about the complex problems with which you have to deal in your professional lives. By the time I have finished this morning, I dare say it shouldn’t be too difficult to diagnose what is wrong with me, and no doubt you will then all argue furiously over the course of treatment to be prescribed. My guess is that you will recommend complete rest for another two weeks accompanied by a total abstinence from stress-inducing speeches…!
Talking of stress-inducing speeches, I am afraid I don’t have a very good record when it comes to the 150th anniversaries of professional bodies. The British Medical Association and then the Royal Institute of British Architects discovered, too late, the folly of their invitation to such an unreliable speaker! I can only imagine you have invited me under the delusion that you can actually cure me! Whatever the case, please know that I come here today as someone who is honoured to be your Patron, who brings you heartfelt congratulations on the achievement of such a distinguished anniversary and who makes no pretence of speaking in any other capacity than as a layman. But you must forgive me if I speak from time to time from the heart – it is a congenital defect!
In this spirit I want you to know how much I sympathise with you in what must be, at times, a literally soul-destroying task. As a profession your calling is to try and bring a measure of healing and comfort to the mental anguish and suffering of countless numbers of people. And yet you have to operate in an environment which I suspect most people who consider themselves sane and ‘normal’ (whatever that is!) prefer to shun or make jokes about. Not only that, but you are also working within the confines of current society, whose attitude and outlook must necessarily colour your approach.
I know that there have been many debates both within and without psychiatry as to what is a helpful definition of mental health, but as yet no proposal has won general agreement. I can imagine, therefore, that psychiatrists are often left with having to respond to people with acutely disturbed behaviour and to try to offer treatment that will lessen or eliminate the extreme behaviour presented – for the person and those around them.
I know, too, of the countless debates there have been within the profession regarding the nature of the task you have set yourselves in the last 150 years – in particular the arguments about psychotherapy and psychiatry, the latter having grown out of a branch of general medicine and which therefore is concerned with finding a physical basis for the major psychiatric disorders.
A hundred and fifty years ago, people had very limited, but nevertheless clear and important, definitions of madness. They had little idea or understanding of the causes but were quite clear that madness was to do with unacceptable behaviour. The term described certain forms of violence, and unacceptable responses to social situations. It constituted a failure to relate to other human beings. In some respects this is a definition from which we have not advanced, but during that time generations of psychiatrists have made major progress towards understanding and treating mental illness. It is, therefore, perhaps disappointing that society’s understanding and acceptance of mental illness has developed so little during the same period, and that there is still somewhat of a social stigma attached to it.
A stigma is ‘a distinguishing mark of social disgrace’, and ultimately comes from a Greek word meaning ‘to tattoo’. This appropriately conveys the image, for the mentally image person, of being branded; perhaps the one who causes a disturbance on the Underground, or someone whose unacceptable behaviour embarrasses family and friends. The quiet, unobtrusive sufferer from depression understandably fears being tarred with the same brush. As a result he dares not admit to symptoms and so does not receive treatment until he or she has suffered greatly for an unnecessarily long time. This stigma makes the whole of life even more difficult for both the mentally ill and the mentally handicapped; it affects the patients themselves, their relatives and all who deal with them. This tends to include mental health professionals, who themselves can become subtly tainted.
I know that the Royal College of Psychiatrists aims to try and remove this stigma altogether and is working to lessen its effect. Providing the facts for the general public about the different mental illnesses is helpful, and efforts in public education such as the College’s ‘Beat Depression’ campaign can certainly help. The media obviously have an important part to play in the process and there are shining examples of what can be done, such as the series of articles by Marjorie Wallace in The Times which not only aid the foundation of contemporary understanding of schizophrenia, but also led directly to the formation of a charity called SANE, of which I am Patron. As Professor Anthony Clare said in his keynote speech two weeks ago, at the start of your celebrations: ‘What SANE has done is to strip back the curtains surrounding mental illness, so that the condition is no longer so mystifying. As a result sufferers and families no longer need to feel so neglected and isolated.’
There are, is has to be said, sections of the media which do not take such an enlightened view and (perhaps reflecting the views and prejudices of their readers) will go to great lengths to avoid any serious discussion of mental illness. I believe that the difficulty sufferers have in talking about their illness and treatment, and the secrecy surrounding it, gives an added responsibility to professionals like yourselves to speak up, and in terms that everyone can understand. Heart by-pass operations and transplant surgery attract enormous interest, and there is no shortage of ex-patients to testify to the success of the techniques. But disorders such as severe depression and schizophrenia are largely ignored and opportunities for us all to learn anything about their nature and treatment are virtually non-existent.
This same taboo on the public discussion of what are, afterall, common illnesses has led, I believe, to a general undervaluing of the work of psychiatrists. Not unnaturally, the brilliant work of our best surgeons attracts a certain sort of glamour. We marvel at, and are grateful for, their successes and share their sorrow when a patient cannot be saved. But psychiatry remains largely unsung – perhaps because it is also, inevitably, unseen. Its triumphs are, almost by definition, private; invisible to the public eye. And when there are significant failures how often does anyone register the impact they have on the psychiatrists who have done their best? On the contrary, the public perception is all too often negative, driven by the same stigma which attaches to their patients and, quite possibly, to people who are rash enough to make speeches about the subject!
It is sad that society does not generally seem to recognise what it asks of its psychiatrists. Of all the areas of specialist medicine, you cover perhaps the broadest range of disorders, only outdone by the GP, who also has a key role in the identification and treatment of mental illness. You certainly deal with what is by far the most complex organ in the body. In the absence of anyone else, we would like you to solve all the problems of society. We confront you with the most complex problems, part biological, part psychological, part social and part spiritual, and expect you to unravel them, treat all the parts that belong to psychiatry and at the same time somehow make better all the parts that don’t belong to psychiatry.
I am sure it would be helpful if more people understood that a psychiatrist’s first problem is to decide how to reach out to a patient, how to make them feel understood, cared for, and safe. Frequently, patients are frightened, not only by their pain, suffering or madness, but also by the image of psychiatry which they may have gained from films or highly biased sources. I am told that a recent film ‘The Silence of the Lambs’ portrays psychiatrists in a quite terrifying manner, which is no doubt a help at the box office, but is none at all to the psychiatrists – or to those in need of their help.
In our contemporary society there is every incentive to believe that suffering can be banished, avoided or at worst postponed. Psychiatrists have to confront the evidence to the contrary every single day. Just being with a patient who is frightened or frightening must be incredibly difficult and takes immense courage and dedication; the human contact can awaken shadows in the doctor’s own psyche, testing that inner strength which has the most profound influence on the patient. To listen and share in someone’s pain takes great bravery and it deserves recognition.
In a day’s work psychiatrists and psychotherapists will doubtless hear many dark and terrible stories; of loneliness, isolation, poverty and bereavement. Despite the best efforts of social services, and other caring agencies, children do suffer at the hands of their parents, guardians or other adults. Physical and mental abuse are not uncommon and tend to be perpetuated from one generation to the next. Other children and adults suffer not through the deliberate will of others, but through misfortune, accident, bereavement or other crisis.
Many people are somehow able to re-direct this neurotic energy into creativity, perhaps at work, or through various forms of artistic expression, or in spiritual understanding and healing. But for reasons that you and your colleagues are only slowly unravelling there are also people for whom suffering leads to pain, anxiety, depression, drug abuse and other forms of mental illness.
Between these two groups are a great many other people who respond to medication, and yet at the same time are influenced by the amount of stress or suffering to which they are exposed. I am told that before modern drugs were available patients with schizophrenia were routinely admitted to hospital and for some of them their symptoms would be ameliorated by providing a structured, peaceful and caring environment. Similarly, it is now known that schizophrenia patients receiving medication need more medication if they are in a family environment which is highly stressed and less in a family which is supportive, and yet accepting, and where there is understanding of the illness.
As I said at the beginning of my lecture, it is not surprising that there has been a lot of discussion about the relative merits of the biological and psychosocial approaches to problems of the psyche. One school of thought claims that mental illness is in the last resort a physical disorder to be treated by physical means. New drugs make this a powerful and effective approach, which has certainly led to a dramatic relief of symptoms and greatly reduced periods of hospitalisation. At the same time the power of the technique is such that a psychiatrist faced with a distressed or unhappy person, and probably in a crisis situation, may have to resort to a ‘chemical cosh’ too readily, in order to calm someone quickly – substituting drugs (which can lead to dependence) for the time and understanding which could conceivably rescue the patient from his predicament.
The other school of thought believes, as you all know better than me, that mental illness is primarily a behavioural malaise, to be treated by methods appropriate to such a disorder. It uses drugs and physical techniques as sparingly as possible, and relies on reaching a close rapport with the patient, helping him or her by psychological analysis in depth to integrate apparently conflicting emotional drives. This view, too, has its undeniable quota of success, but is difficult to apply on a large scale, if only because of the prohibitive cost in time and medical manpower.
Having made my own views on over-reliance on medication known to the British Medical Association some years ago, and having spent time since then in encouraging what I prefer to call complementary practice, it will not surprise you to hear that I am concerned, for what it is worth, that the psychological approach to mental illness should not be forgotten or discounted.
I know that this College recommends the lowest possible dosage of drugs and encourages the use, wherever possible, of psychological techniques, but all the enquiries I have been able to make have suggested that the training of psychiatrists is heavily weighted towards the medical approach. This may be a reflection of a society which some people would say is overly materialistic, with the emphasis too much on doing and changing, and not enough on being and accepting. The power of the medical techniques is undeniable. They have brought real benefits and no-one would wish to deny that. But I would have thought that over-emphasis on drugs can also enable us as a society to lose sight of problems which have their roots in the way we treat each other.
A teenager with hallucinations and strange beliefs may be diagnosed as schizophrenic and be provided with the extensive help and support he or she needs. But another similar teenager may have other serious difficulties – perhaps an inability to form stable relationships, a tendency to violence or to take overdoses during outbursts of uncontrollable rage. Both teenagers need care. The schizophrenic fits neatly into the medical model, whilst the other may be labelled as ‘delinquent’ or assessed as having a personality disorder. Both conditions are treatable and both require a great deal of time and resources, not only from psychiatrists. One is understandable in terms of illness, the other only in much broader terms, which may involve facing unpleasant realities about our society. No doubt there are people who would say that the patient with a personality problem is not the concern of the psychiatrist. But without proper help and discretion such adolescents may go on to deprive and, perhaps, even abuse their own children.
The medically trained psychiatrist could be forgiven for feeling at a loss when faced with a disturbing and frightening young person who neither needs nor responds to medication. I believe there is a need for training which emphasises to psychiatrists that there will be times when they will feel overwhelmed when faced with people who have suffered greatly; that there will be times when it is important to remain with and be with and comfort such a person in their suffering. Psychiatrists rightly emphasise the importance of communicating clearly and skilfully, and I welcome the growing importance being given to listening and counselling skills in all branches of medicine. Sometimes there is a need for doing, but equally there are times for being with, for waiting, for being patient and for allowing spiritual healing to occur. There is a sense, too, in which suffering, if handled sensitively, can be transmuted into a positively redeeming process. I was talking recently to the wife of a Church of Scotland Minister who told me that as often as not she and her husband are left to pick up the pieces with people who have failed to respond to psychiatric treatment. She told me that she has only witnessed a true transformation in such people when they finally discover within themselves that transfiguring dimension we define (or perhaps I should say that some of us define!) as God. Above all, perhaps, students need to be taught that growth and healing are natural processes. Science can accelerate them, but it can also retard or prevent them.
Ladies and gentlemen, I was interested to observe that the motto of your College is ‘Let wisdom guide’. For what it is worth, I believe we need to be reminded occasionally that wisdom has a far more profound meaning than just the acquisition of knowledge in the modern scientific-materialist sense. Should we not be asking ourselves pretty carefully where scientific materialism has been leading us – and, indeed, what kind of society it has been creating? Is there not an imbalance that needs correcting; an abandoned element that requires rehabilitation? It is perhaps worth recalling that Jung himself told one of his associates that he did not want anybody to be ‘Jungian’. “I want people above all to be themselves. As for ‘isms’, they are the viruses of our day, and responsible for greater disasters than any medieval plague or pest has ever been. Should I be found one day only to have created another ‘ism’ then I will have failed in all I tried to do.”
At the risk of being controversial, (which at least has the advantage of providing a useful source of conversation over lunch!) I would like to pose a few thoughts to you.
In Ancient Greece, sickness of the soul or psyche needed not the care of ancient medicine or a physician, but exclusively a god or saviour named Asclepius. The reason for this was that classical man saw sickness as the effect of a diving action, which could be cured only by a god or another divine action. Thus a clear-form of homoeopathy was practised, where the divine sickness was cast out by divine remedy. “When the sickness is vested with such dignity, it has the inestimable advantage that it can be vested with healing power.” Thus said CA Meier in his ‘Healing Dream and Ritual’.
Such explanations, of course, run totally counter to ‘modern’ explanations of mental illness. The modernist will doubtless accuse the proponents of theocentric views of wanting to tip psychiatry back into the dark ages, and bring back ghouls and ghosts and other irrational explanations that muddy our scientific understanding. But perhaps, then, we can ask for an explanation as to how and why such illness does arise? Although it may be categorised and its manifestations damped down, I would suggest it is very hard to explain its intrinsic cause.
Is it not because the irrational forces of the universe have been ignored so completely for so long that they can come with such power into the lives of people who have no conception of what is happening? Without experienced people who work in those worlds, containment, transformation and healing are surely very difficult.
It seems to me that the meaning that illness has for us is, to a large extent, conditioned by our view about the purpose and goal of the life we are given on this planet. In other words, for the materialist, enlightened self-interest would lead us to see illness as of no value and with no meaning, whereas someone with a religious view of Creation will need to think about it in a much larger frame than merely the restriction of the individual’s ability to do all that he or she could. If wisdom is to be your guide then Shakespeare makes a few salient points when Macbeth speaks to the doctor about Lady Macbeth, thus –
‘Canst thou not minster to a mind diseased, Pluck from the memory a rooted sorrow, Raze out the written troubles of the brain, And with some sweet oblivious antidote Cleanse the stuffed bosom of that perilous stuff which weighs upon the heart?’
The conclusion of the matter was ‘more needs she the divine than the physician’. I do not expect you to agree with me, but I believe that the most urgent need for Western man is to rediscover that divine element in his being, without which there never can be any possible hope or meaning to our existence in this Earthly realm. As Wordsworth wrote with such profound insight –
‘And I have felt A presence that disturbs me with the joy Of elevated thoughts; a sense sublime Of something far more deeply interfused, Whose dwelling is the light of the setting suns And the round Ocean and the living air, And the blue sky and in the mind of man; A motion and a spirit that impels All thinking things, all objects of all thought, and rolls through all things.’
At the heart of many religious, psychological and psychiatric writings is a recognition of the importance of the way in which all the members of our society are inter-connected and inter-dependent, and the need to look at the whole person in the whole society. This, of course, runs directly contrary to our natural instinct to attempt to deal with the complexities of contemporary life by breaking it down into different components. Yet experience shows that if we do not address the whole of a person’s needs within the whole of the society in which that person lives, treatment will fail.
I do believe that we are in danger of cutting ourselves off into a world that recognises only mind and body. But in the treatment of mental illness we must surely recognise the importance of understanding and respecting the culture and beliefs of the individuals concerned and of those close to them. When – as is too often the case in our generation – there seem to be no beliefs, but simply a spiritual vacuum, there are no foundations on which to build an acceptance of our own weakness, respect for the unique worth of others, and a reconciliation between those classed as mentally ill and the society in which we must all live.
To take just one example, I believe that one of the conditions most commonly encountered by psychiatrists is depression and anxiety. One of the main causes seems to be the lack of acceptance of suffering in a society which focuses on immediate gratification. We find it hard to accept that there is a need to adapt to loss, and to grieve, and we are intolerant of people who are emotionally distressed. Often their distress is made worse because they do not have the inner resources and spiritual development which would enable them to see that there is a meaning beyond themselves.
Treating the whole person within the whole society should perhaps be easier to achieve under the policy of community-based care, with local services designed to help people live as fully and productively as possible, despite their problems or disabilities. I know there are problems and challenges in making the new system work properly, but it does seem that the debate about whether community-based services (in which the role of the hospital is clearly defined) are right in principle, is over. The challenge now is to put those locally-based services in place in every district, in keeping with the need for them.
At this point and at the risk of repeating what you already know only too well, it may be worth reminding ourselves of the scale of the problem of mental illness. Quite apart from the cost in terms of human misery, the Mental Health Foundation has calculated that in 1989 no less than 71 million working days were lost in the United Kingdom because of mental illness; this represented 17% of all sickness absences from work, and cost this country nearly £4 billion in lost working days. Other research has shown that in every thousand people, 250 will suffer from a diagnosable mental illness. Of those 250, 17 will go to a psychiatrist and six will subsequently enter hospital. That is perhaps a salutary reminder of how much larger the problem is than even you encounter, and I have no doubt at all that some of those you do not see are just as ill as those you do.
But what sort of service do the mentally ill want, what do their relatives want? As you know, most want to live at home, to live their separate lives as far as possible like the rest of society. Patients tell me that they do not wish to go to hospital, and yet relatives tell the most awful stories of the deprivation, suffering and terror that they endure in trying to help their loved ones through their illness at home. It seems to me that if community-based care is really going to provide proper support we will need to find ways of giving greater strength, solidity and dependability to local services. But there must also be proper provision for those patients whose overriding need is for refuge and asylum. There will always be people who need a place of sanctuary where they can work through their pain and suffering, with professional support available 24 hours a day, and learn to adjust to their illness and all that it means in terms of loss of ability and potential. To recognise this would be a useful step forward in national policy.
I realise how difficult it must be to make such a complex and far-reaching change in the system as the current move to a community-based service. Though the mental hospitals could be stultifying and disabling, they must have been easier to manage than a network of smaller, sometimes almost invisible, local services. Developing and coordinating all these different community services is difficult, too, in part because many of the critical variables are outside the direct control of mental health professionals, planners or managers. Housing, for example, is a vital ingredient which regrettably is often lacking at present, causing all sorts of problems for individuals and for those who are trying to provide the service. It must be very depressing and de-motivating for psychiatrists to do their best for their patients and then be unable to discharge them to decent housing and the prospect of work. At the moment I know there are times when some of you have to discharge patients into poor accommodation, without supervision, often in a deprived area, and without the knowledge that this is going to aggravate their illnesses and result in their return to hospital. Clearly we need to forge new partnerships, not only between health and social services, but also involving housing authorities and housing associations.
What is also frustrating is how confusing the reports on all this tend to be. No one seems to know on a national basis what is really happening to people being diverted or discharged from mental hospitals. Studies of those resettled from hospital are generally very encouraging, but we know much less about those who have fallen through the cracks and those who might have been hospitalised in a previous era. I believe there is a need to monitor what is happening more carefully in order to get the national picture into focus. As a BBC Panorama programme earlier this week illustrated, there are undoubtedly people appearing in the accident departments, the courts and the prisons who represent the casualties from current policies.
These problems should not lead us to suggest, however, that we abandon the idea of locally-based care. But we do need to find a constructive middle path between over-protection in institutions and abandonment to uncaring communities, impoverished lives and, at worst, homelessness or incarceration.
I am told that good examples of such progress can already be seen here in Brighton, , but also in such places as North Lincolnshire, Exeter, Torbay, central Birmingham, Nottingham, Bath and Newcastle. The need now is to speed the spread of this good practice throughout the country.
I realise that accomplishing all this in a time of financial stringency is far from easy. But I do think it is important for all the key players to come together in a variety of ways at national, regional and local levels to clarify what needs to be done and how best to do it. This will require a general spirit of collaboration that cuts across old territorial boundaries – never, I realise, an easy thing to achieve.
In this connection I very much welcome the setting up of the Centre for Mental Health Services Development as part of the Institute of Health at King’s College London. I understand that this is supported enthusiastically by both the Mental Health Foundation and the Department of Health and that its Advisory Board is graced by the presence of your President.
So far as money is concerned, the re-shaping of the mental hospitals really does release a lot of money, on which the first call, I suspect, ought to be funding community care for the mentally ill. At present, I understand that over half of the £1.5 billion spent on hospital and community services supports just 40,000 patients in the remaining large hospitals. Less than half supports many hundreds of thousands of patients in the community, many of whom are at least as disabled by their illness as those in hospital.
I believe it is also important sometimes to listen to those who actually use the mental health services. I have been impressed by what I have heard about what is known as the ‘self-advocacy’ movement. In a previous era no one would have believed that people diagnosed as schizophrenic or manic depressive could eventually be capable of providing advice on policy and planning. But this is just what is now happening. Clearly, even people with very real illnesses and disturbances don’t remain so all the time. And some get very much better and can become an inspiration for others. It is therefore encouraging to learn that the College has already set up a Patients’ Liaison Group.
Another group with a major contribution to make is the General Practitioners. Very many people with psychological symptoms consult their family doctor, but in about half of all cases the GP does not recognise the condition as a psychiatric disorder, and even where the condition is regarded as psychiatric it may go untended. This is hardly surprising as it is still possible to enter general practice as a Principal with as little as eight weeks experience of studying psychiatry. I would have thought that there was an urgent need for training for GPs in psychiatry, both in the identification of mental illnesses and in their effective treatment. Since I am about to become next year’s President of the Royal College of general Practitioners (they need their heads examining as well!), I was interested to learn about an exciting development in community psychiatry which aims to foster close working ties between these two groups of professionals. The Liaison in Community Psychiatry programme (known as LINC-UP) begins with a nationwide survey of all psychiatrists at this conference, and I hope you will all be able to give it your support.
Another area which I hope you will support and encourage is the perhaps somewhat undervalued task of research. This country has a proud reputation in this area, and I know that biological researchers in psychiatry and allied fields are currently beginning to make significant inroads into our understanding of the functioning of the brain. Of course such research is expensive, and last month SANE asked me to launch an appeal to enable the founding of an International Schizophrenia Research Centre in this country. It was the most wonderful start to be able to announce immediately that no less than £1.75 million has been pledged to the Centre by King Fahd of Saudi Arabia. The task now is to match this most generous contribution from other sources.
Ladies and gentlemen, I would like to end by suggesting that any vision of a better future for people who are afflicted by mental illness must have its roots in a better understanding of mind and body, and in values that go far beyond the material. We will build a better future for the mentally ill because we know what ‘better’ means, and it means radical change in society’s assumptions.
It is terrible to have made you sit here for so long (you will all end up with bad backs before I’ve finished!) but there are just three main points that I would like to leave you with. Firstly, my encouragement and admiration for your intensely difficult, undervalued work with the large group of people who bear the stigma of mental illness.
Secondly, it is clear that the current national and international policies in psychiatry are moving firmly away from the large closed institutions. That is understandable, but we still need places of sanctuary and we must make community care work. There are now good models of success; projects where community care is working really well. But we have a long way to go before those models of excellence are the universal pattern. That is the challenge in our generation.
Finally, my feeling that there is a need for greater recognition, even among such an enlightened group as yourselves, that mental and physical health are not simply about medical repairs. We are not just machines, whatever modern science may claim is the case on the evidence of what is purely visible and tangible in this world. mental and physical health also have a spiritual base. caring for people who are ill, restoring them to health when that is possible, and comforting them always, even when it is not, are spiritual tasks. Training people for your profession and maintaining your professional skills are not simply about understanding and administering the latest drugs but about therapy; in the original Greek sense of healing – physical, mental and spiritual, and also about wisdom, in the ancient sense of understanding the true nature of our existence enabling those who are ‘seeing through a glass darkly’ then to see face to face. If you lose that foundation as a profession, I believe there is a danger you will ultimately lose your way.”
