The Sun and the "Mental Patient"

Fuck The Sun. I want to be composed and rational. I want to maintain a distance. But how? 1200 killed by mental patients. So proclaims the headline of The Sun. And so a rage comes to possess me. Anger, the most political affect, seizes my body and makes writing difficult. But I'm going to try to be composed. Let's examine this headline. Let's have a quick look at what lies beneath it: what it says in what it has said and what it says in what it leaves unsaid.

First, we have to understand that this story is coming off the back of a particular murder inquiry. That story is the death of 16 year-old Christiana Edkins at the hands of Phillip Simelane, a patient with the Birmingham and Solihull Mental Health Services. Simelane had been released from prison with no community treatment for his diagnosis of paranoid schizophrenia, by far the diagnosis that most terrifies people who have never had any contact with people experiencing extreme altered states of consciousness. The story has been understandably potently charged with affect. The death of a 16 year old will always strike us as senseless, especially when the victim of an unprovoked attack. Added to this is the fact that the victim was a young woman and that the perpetrator was a criminal and a black male, facts that often play to heighten the affective tensions of the media's audience, whether consciously or unconsciously intended or provoked in either party.

This story has also seen a flurry of similarly themed articles appearing, such as this at the Telegraph's website. In that article we are given some more names, some more murders, and introduced to the personal suffering of victims of so-called "mental patients". I'm not so stupid as to claim that the suffering of the bereaved isn't real or that they don't deserve every sympathy. To lose a loved one is always difficult, to loss a child- I can't even imagine it, not really. Yet the suffering of the people who have carried out these acts, because they have carried them out, is completely ignored by the Telegraph. As the story isn't available to read as I write this, I can only imagine The Sun, being The Sun, will be all to happy to produce a portrait of a monstrous schizo roaming the streets with violence glinting in his eye. This bullshit isn't new bullshit.

In 1992 a man diagnosed as schizophrenic killed another man after stabbing him to death at London's Finsbury Park train station. Christopher Clunis had refused to take his medication and his care had not been properly handled following his discharge from a psychiatric care setting. The death of Jonathan Zito was followed by news stories not dissimilar to those we are reading today. The BBC reported that community care had failed, meanwhile The Daily Mail (29.6.93; (22.7.93) , The Independent (19.7.93), and The Evening Standard (30.6.93) all featured headline stories depicted Clunis as a "killer" who had been "set free" or who was allowed to "roam free".

The implication is clearly that Clunis's horrific actions weren't those of a man who was undergoing extreme mental distress, hallucinating and/or delusional, but the actions of a "killer" who happened to be suffering mental distress. The early media reports on the Zito killing were muted and slow in coming but these stories all exploded once it had been announced that an investigation would be launched into the attack. That Clunis was a murderer was set-up in these reports as if it were a necessary fact and an essential aspect of his being; the distress that had led to his being diagnosed as paranoid schizophrenic was almost accidental and contigent. Except of course that had Clunis not been free to roam and kill as he liked, as the hysterical reports were suggesting he was, then Jonathan Zito would never have been killed. What does this deprivation of liberty mean here? The papers didn't mean that Clunis should have been locked up in prison for a murder he hadn't yet committed but rather that he should have been locked up in a secure psychiatric setting. While it seems like his diagnosis of schizophrenia is accidental, it is really the conditional fact of his being a murderer. The affectively charged message of this is not the rational one regarding mental health services and their failure but the more simple formula: schizophrenic=(potential) killer.

This is an effective formula in part because people with extreme forms of mental distress often exhibit very strange behaviour. They can say and do things that don't meet up with the regulative norms of public behaviour. They say and do things that wrong foot and confound our expectations, those coordinates by which we navigate our interpersonal conduct. In short, they can be weird. It doesn't matter that this weirdness is often an effect of medication rather than the distress itself because phenomenal experience doesn't allow us to peer inside the schizophrenic other's body and know that extra-pyramidal symptoms- so called "side effects"- are causing this odd behaviour. Phenomenal experience also doesn't allow us to grasp the schizophrenic other's strange behaviours as attempts to cope with a disrupted sensorimotor system that makes everyday body movement difficult. Nor does it always allow us the time to sit and listen and realise that delusional speech isn't jibberish or nonsense but often expresses a kernal of meaningful content in a confused way. Instead we see the weirdness, we attribute the person as weird, and we instinctively wonder about threat. The formula that we should fear the schizophrenic because they're probably a killer plays into physiological heuristic or rules-of-thumb that already make us anxious around things that disturb our expectations. Today's The Sun and The Telegraph stories will work on to inspire fear in so many people because it taps into this primordial fear of otherness.

The Clunis case also needs to be contextualised in its historical contigency. The stabbing occurred in 1992, just two years after a new Mental Health Act enshrined the goal of deinstitutionalisation in law. People were already frightened of the prospect of "the mad" wandering the streets. I was only a child at the time but I can remember the 90s being marked by a lot of talk about "care in the community" and how dangerous it was. Coverage of cases like the Clunis-Zito killing only served to whip that fear into hysteria.

Most of the reporting of Clunis's attack and the subsequent enquiry didn't happen until 1993. As I've said, Clunis was a black man and in 1993 Britain was undergoing a period of huge racial tension. There had not long ago been riots by young blacks and the reasons for their rage were far from being addressed, and remain so. It was in 1993 that the institutional racism that infects the police reached its symbolic height in the handling of the brutal murder of Stephen Lawrence by a gang of white racist youths. This was not a period in British history when race was could even be treated as if it were of no consequence. The rage of black people, their ongoing criminalisation, and the fact that Clunis was a physically imposing black man would have all combined within a racist climate to provide us with another simple formula: black=dangerous.

Clunis and Simelane have both been presented as somewhere between mad and bad. "Mental patient" and criminal; schizophrenic and murderer. They are example of what Michel Foucault identifies as the "dangerous individual" (here). Foucault traces a brief history of the 'psychiatrisation of criminal danger' in order to argue that

At the time when the new psychiatry was being established, and when the principles of penal reform were being applied nearly everywhere in Europe and in North America, the great and monstrous murder, without reason, without preliminaries, the sudden eruption of the unnatural in nature, was the singular and paradoxical form taken by criminal insanity or pathological crime.

For Foucault the 19th Century invention of criminal psychiatry, what today we call forensic psychiatry, was less about the kind of psychiatric colonisation that Will Self identifies and which I discussed in my previous post. Rather than a medico-imperialism in a domain of knowledge, forensic psychiatry was born in order to justify the use of a specific form of power. Psychiatry and psychiatrists were able to recodify conduct that was seen to threaten the social order into symptoms of psychiatric illness or behavioural disorders.

This isn't the place for a full account of this process so I will simply end with Foucault's conclusions: forensic psychiatry is a form of social order that operates through a decision that distinguishes what is normal from what is pathological, and by conflating the pathological with the dangerous. This process was carried out with an emphasis on the notion of 'homicidal mania'. Homicidal mania, the madness for killing that grips only the mad, was determined as a threat that always lurked invisible beneath the surface, waiting to explode at any given moment.It is in the name of 'social defence' that the madman must be placed in an institutional setting- the Asylum. The justification for this is that the person will receive therapeutic intervention and will be consigned to a place where she can do no harm. The institution is thus both predicated on therapy and punishment but is finally to do with controlling the danger that the dangerous individual presents. The fear of the mad other is thus not simply the fear of otherness but like fear of the black other is also historically produced to legitimise specific practices of power.

Out of the Clunis-Zito enquiry came a now famous paper 'All tragedy is the failure of communication' that has become required reading for anyone training to work in the psych-disciplines. That paper highlights many of the failures of the psychiatric services that were supposed to support Martin Clunis and they are frankly shocking. Basic things like interagency communication hadn't occured; no one had bothered to maintain contact with Clunis; no one had bothered to complete adequate assessments; no assessment of his previous violence was taken into account. The report also relays some of the recommendations for improved community psychiatric care. While it is important for mental health workers to be protected and to have the right resources and strategies for their often crucial work, it is telling that these recommendations came off the back of a high profile murder case. Just as Foucault had it the therapeutic and the management of social danger were already rolled into one. The mad were dangerous and society had to be defended from their latent homicidal rage.

The dangerous individuals in these cases are clearly Clunis and Simelane. Yet these individuals aren't simply reported as individuals. Nor are they reported as people experiencing extreme distress, people whose actions are not under their usual amount of control, people whose responsibility is diminished. In the Simelane case there seems so-far to be less emphasis on failures of care than there were in Clunis's. What they share is the characterisation of being "mental patients".

People who are undergoing psychiatric care are routinely described as patients. They are patients insofar as they are receiving medical care. Putting to one side whether psychiatry can legitimately claim to be a branch of medicine, we need to focus on the fact that "mental patients" isn't a neutral description of these facts. This is a process of subjectivation, or the dynamic production of a specific subject. This subject "mental patient" is a construction that isn't reducible to particular individuals or populations but that is deployed in order to marshal one population into accepting treatment and psychiatric power, whilst simultaneously providing another population with group that can be safely vilified, hated and, potentially sacrificed. This sacrifice can take the form of a social death or a literal one; the two have both appeared in history, not always separately. By social death, I mean that this subject, this type of person, is thought of as always being x (dangerous, meaningless, deviant, abnormal etc) and therefore requiring regulation, disciplining, punishment and, the most important terms, exclusion and control.

When I say that the "mental patient" is a construction I mean it quite literally. Discourses of mental illness, techniques of psychiatric assessment and diagnosis, discourses of criminality, normality and abnormality, material organisations of space into institutional and community treatment settings, psychopharmacology, the physiology, behaviours and language of distressed people are all marshalled in order to build a type of person that is a "mental patient". That so much of what goes into this building has almost nothing to do with the people in question is almost an irrelevance from psychiatry's perspective. Part of the point of subjectivation is that you come to adopt that form of subjectivity as your own so that you recognise yourself as a mental patient responsible for their own illness. If you are brought into a hospital because you are experiencing psychosis or an extreme depression and you refuse to be subjugated by this construction, if you argue you aren't sick or ill but are experiencing distress that can be otherwise explained than on the basis of behavioural or biochemical disorders you are simply displaying your "lack of insight". Acceptance of the subjectivity of the "mental patient" is part of the evidence that you are recovered. You must actively proceed to reproduce and intensify your identification as "mental patient".

It is clear that this involves a complex ontology. The "mental patient" exists but it only exits insofar as it has been constructed and regulated a given populations subjectivity. It is a performance and if that performance ceases then the "mental patient" ceases to exist. While this performance is choreographed on the body of the person experiencing distress it is not reducible or identical to that body. Strategically, we can claim that the "mental patient" does not exist except as a political device and effect of psychiatric power.

Thus, the Telegraph's headline ("Truth about dangerous mental patients let out to kill") is no less than The Sun's an attempt to deploy the powers of this kind of subjectivation in such a way as to intensify the construction of psychiatric patients as necessarily dangerous individuals. The extent to which The Sun and The Telegraph are full of malicious bullshit that the word "stigmatisation" barely manages to capture can be fully revealed when we replace "mental patients" with any other subject formation we care to name. If the story was 1200 killed by men, what would the consequence be? Or, departing from subjects, what if the story were 1200 killed by poverty? 1200 killed by war on terror?

What these exposes and truth-telling articles don't tell us is that this particular murder is happening in conditions similar to those of the Clunis-Zito case. What these reports won't tell you is that as the NHS is slashed to pieces mental health services routinely get hit the hardest, as they have historically been regarded as a 'cinderella service' that currently accounts for 11% of a beleaguered NHS budget. None of the "debate" that will come out of this case will focus on the need for a radical reorganisation of the psychiatric service; it won't tell you that in roughly the same 10 year period there were 3,628 deaths of people detained in mental health settings, 501 of which were the result of suicide; the debate won't inform you that this accounts for 61% of all deaths in UK state custody, significantly outweighing (but not making unimportant) the number of deaths in police custody; I am also certain that the debate won't feature anything about the increased mortality rate that sufferers of mental distress are subject to or the fact that a good deal of long-term psychopharmacological treatment is either useless, productive of symptoms or increases the mortality rate further still; nor will it explore the links between mental distress and austerity;or the countless reports on the fact that people diagnosed schizophrenic are more likely to be the victim of violence than the perpetrator; and it wont' discuss that at the exact same time that this story is being picked over that there are calls for the increased presence of the police force in psychiatric treatment.

First of all the chronically understaffed and underfunded Royal Cornhill Hospital had announced that it intended to plug gaps in its provision of nursing care by putting police on the wards in their place. Aberdeen's Cornhill is the psychiatric hospital for most Scottish people north of the central belt and in the Islands. It is also home to Scotland's only publicly funded specialist eating disorders in-patient unit. The idea of police filling nursing posts is both disturbing and revealing. It is disturbing because it accelerates the criminalisation of the mentally distressed population and revealing because that use of the police is even thinkable means that psychiatry and policing have never been far apart.

Elsewhere, the proposal of the street triage team would see mental health nurses and the police working in tandem to identify and isolate individuals who were at risk of harm or of harming others. What message will be sent out to people (with or without experiences of mental distress) when the psychiatric nurse and the police uniforms walk side-by-side. For a much more nuanced understanding of the police triage system I'd recommend reading the MentalHealthCop blog, especially this entry that concludes that the triage teams will have little impact that isn't potentially negative.

Meanwhile psychiatric workers are bemoaning the loss of the police in assisting them with control and restraint procedures. These procedures frequently consist of up to six people holding one in a position of immobility on the floor whilst being "rapidly tranquillised" by an intramuscular injection of 1mg Haloperidol or equivalent. I don't think that all forms of restraint can be dispensed with but this isn't the best way to go about ensuring everyone's safety.

In 1992 Gilles Deleuze wrote in the 'Post-script on the societies of control' that we had moved away from Foucault's disciplinary society based on making bodies docile and passive by placing them in enclosures and separating them from other enclosures was finished. We had, he said, passed into societies of control that were marked by putting bodies into regulated motion and ceaseless activity, letting them pass from one place to another without finally separating this space from that. Deleuze gives mention to phenomena like pharmaceutical control and molecular engineering. Writing precisely at the moment of deinstitutionalisation, Deleuze comments that the crisis of the hospitals as enclosures that separate people from "the community" was giving way to a system of community treatment centres and day care that could either offer new freedom or new mechanisms of control.

The danger of the production of the "mental patient" and its subjectivation as dangerous, murderous, and requiring control isn't simply that it isn't true. The danger lies in the fact that at a time of austerity and increasing repression, of total policing and total pathologisation, the choice of new freedom or new controls might begin to slide away. My fear is that with these stories that seek to criminalise those experiencing mental distress will lead directly to calls for a return to the Asylum. If that happens then the question of freedom is out of the window. The criminalised mental patient must be imprisoned- and so those who are among the most at risk are again identified as the sacrificial scapegoat. The state flexes its muscles and sweeps the suffering masses into another jail. I'm not sure what action can be taken against The Sun and The Telegraph and all the other outlets for this dangerous bullshit. Perhaps more than a mad pride there needs to be a weaponisation of madness, or at least of its display? Either way, solidarity with people with mental distress is crucial- especially with those who might fear coming forward for whatever scraps of help psychiatry currently manages to provide. And anger. But that's never in short supply.