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These new ideas required a socio-medical organization conducive to intimate therapeu- tic encounters between individual client and therapist. Prior argues that the lack of fit between modern psychiatric theories of the mind and madness necessitated the organizational change described as ‘deinstitutionalization’. Prior perceives the ‘therapeutics of mental illness at the end of the asylum age’ as being widely dispersed. There is dual responsibility for mental health between medical and social services. The latter focus on aspects of patients’ lives, such as ‘social networks’, employment and family relationships, the former are subdivided between nursing and medical input. Medical input takes as its focus the physical characteristics of the patient, diagnosis and physical therapies such as ECT and psychotropic drugs. The object of focus, for nursing in par- ticular, centres around improving patient behaviour. However, such a focus on behaviour is not compatible with a hospital milieu since, by definition, it necessitates the patient’s contact with soci- ety, both to test the patient’s behavioural competence and to extend their behavioural repertoire.
The attendant therapeutic endeavours, which centre around such things as the ‘normalization’ of behaviour and the building of social networks, thus require a community environment rendering the hospital ‘functionless’.
Prior’s analysis avoids the assumptions inherent in the economic interest argument of Scull and the pharmacological revolution position of official accounts. However, a set of empirical ques- tions which are important in assessing the merits of the different theoretical positions that have emerged around deinstitutionalization remain unanswered. For example, although there has been an expansion of psychodynamically informed therapies and a greater focus on the social relation- ships of patients, it is a moot point whether a bio-medical hospital-centred psychiatric practice has actually been replaced with extra-hospital activities. More recently the psychological approach to care has expanded but not by the extension of psychodynamic models; cognitive-behavioural approaches are the new orthodoxy (see Chapter 8).
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provide a therapeutic culture (Quirk and Lelliott 2001). The reasons for this are multiple and similar, but not identical, to why their large predecessors failed as care environments (though they succeeded as sites of permanent or semi-permanent segregation – a form of apartheid determined by mental state):
• Because acute units retained a bio-medical emphasis they maintained the spurious illu- sion, pointed out in Goffman’s final essay in Asylums (1961) that they can act as a break- down services, like a repair garage. (A problem is brought in, fixed and then sent out mended.) In fact, the technological emphasis on medication does not provide this repair service because, despite their curative titles, psychiatric medications only control symp- toms in some people some of the time. They do not cure the conditions diagnosed by psychiatrists. Even if they did, psychiatric drugs logically should work independently of setting – after all, most community-based patients are already medicated. When admis- sion is effected to enforce poor compliance with medication, then once more the aversive aspects of coercion are experienced by patients.
• Acute units are charged with a coercive control role. The majority of patients are detained compulsorily or are aware of compulsion being invoked. This culture of compulsion is a poor starting point for active collaboration in change for patients.
• The increased risk associated with ‘co-morbidity’, especially psychotic patients who abuse substances, means that the limited bed capacity in acute units has been increas- ingly reserved for patients who are mainly there because of their assessed risk to others.
In other words, acute units implicitly serve the interests of third parties and so are not able to be ‘patient centred’.
• The presence of raised levels of risky behaviour in small mixed ward environments has led to physical and sexual assaults (on both patients and staff). On-site substance misuse has brought with it an illicit cultural network of non-patients bringing alcohol and illegal drugs into the ward environment. The control of substance misuse on site has necessarily become an organizational priority for the staff. With this comes a distrustful surveillance role in relation to patients; an anti-therapeutic process.
• Staff tend to withdraw into their own space (the nursing office) and potential therapeutic staff–patient contact diminishes. The patient experience of this milieu is one of oscillating anxiety and boredom. These emotional states are not conducive to personal change or mental health gain.
• Like the old asylums the acute units are isolated from their community context. Baruch and Treacher (1978: 223) describe this in their early case study:
staff members were effectively ‘institutionalized’ – they rarely made domiciliary vis- its to their patients and they were not involved in the communities from which their patients came, so they could never develop an understanding of the patients’ way of life or devise methods for using community resources to help the patients.
• Since these early comments from Baruch and Treacher, other studies have confirmed the problems for staff of creating a therapeutic milieu in acute units. Medication still pre- dominates and psychological interventions remain scarce (Lelliott and Quirk 2004). Staff morale remains low and patient dissatisfaction high (Norton 2004). (Indeed, consultation exercises about mental health care tend to elicit user responses, which often focus nar- rowly on complaints about inpatient regimes, even though the latter are not the only form of care now on offer in our post-institutional context.)
If these ‘non-therapeutic’ acute units are the back-stop for non-hospital services, what are the latter? Community care is constituted by a variety of activities and services. The main
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initiatives evident since the early 1990s include psychiatric services in primary health care set- tings, the expanded use of community psychiatric nurses, the development of community mental health centres, the provision of domiciliary services, the development of residential and day care facilities, an increased emphasis of voluntary services and informal care by relatives and friends, and the relocation of mental health responsibilities from the secondary care sector to primary care.
There was a rapid development of certain community resources as the asylums were run down. For example, between 1977 and 1987 Community Mental Health Centres (CMHCs) in Britain expanded from 1 to 54 (Sayce 1989). Psychiatric services delivered via primary care were another area of expansion. However, it would be misleading to exaggerate the extent of re-provision from hospital-based services to the community. Mental health provision in Britain is no longer largely hospital-based. In the USA, where a longer period has elapsed since the Community Mental Health Act 1963 than since the British National Health Service (NHS) and Community Care Act of 1990, the old, large State asylums have simply been replaced by a network of smaller, private inpatient facilities. Even in the USA, Community Mental Health Centres were forced under fiscal pressure to shift to a custodial role (Samson 1992).
Samson insists that the USA has never had proper community care but that instead a vari- ety of economic and professional pressures have ensured a policy of re-institutionalization. Con- sequently, he argues that those who attack the ‘failure’ of community care policies are actually attacking a straw man, given that what has actually happened is deinstitutionalization followed by re-institutionalization.
In Britain, the theory of community living has often been replaced by the practice of deinsti- tutionalization. The political objective of community care was first mentioned in the Mental Treat- ment Act 1930 and, by the 1970s, there was a bipartisan political goal of transferring people out of institutions. Yet, it was only in 1985 that the first British mental hospital actually closed.
By the late 1980s, 85 per cent of resources spent on mental health by the State were still bound up with hospitals (Sayce 1989). Data supplied by the Department of Health in 1992 showed both numerical losses and gains to hospital-based psychiatry. Although the number of psychiatric beds decreased from 193,000 in 1959 to 108,000 in 1985, by 1985 there had been a rise in the number of small psychiatric hospital facilities from 303 to 492. And even though hospital resident numbers dropped by 24 per cent between 1980 and 1990, psychiatric facilities still contained 36 per cent of all hospital beds by the latter year. In 1990 there were more than 50,000 psychiatric inpatients in England alone, at any one time. Moreover, despite a steady decline in the number of people occu- pying hospital beds since the 1960s, short-stay admissions rose dramatically, creating ‘revolving- door’ hospital care, rather than fully fledged care in the community.
By 2000 there were just over 100,000 admissions to English psychiatric units, and there was a continuation of this decline in the first decade of the twenty-first century. However, an indication of the rapid throughput was that only 3.2 per cent stayed for longer than 90 days. Less than 1 per cent stayed for more than 1 year (Thompson et al. 2004). At the same time, these quick turnover units nearly always operate at 100 per cent bed occupancy. They are unable to provide either the stable place of residence offered by the old asylums or the continuity span required for a therapeu- tic community approach to be effective.
Despite the growth in the popularity of CMHCs as ideals at a local level (Sayce (1989) found that even in localities where there were no centres, policy-makers thought they should have one), they have remained on the margins of community care and almost disappeared in the twenty-first century. They were often established in the face of opposition from conservative forces within the psychiatric profession (Goldie et al. 1989) and were not included in official government plans for replacing asylum beds, as they were, for example, in Italy. As new services they were sub- jected to greater scrutiny and evaluations than hospital-based services. New day places to replace
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hospital beds were not only slow in coming (between 1975 and 1985 only 9000 new places were made available (Audit Commission 1986)), they were overwhelmingly placed on hospital sites.
Similarly, although there was a decrease in the number of inpatients, as outpatients they still attended hospital premises for their appointments. Domiciliary services – the visiting of people in their own homes by mental health professionals – today constitutes only a tiny proportion of this total.
A health economic review of spending on mental health services (Sainsbury 2003) indicated a strong inertia about resources being bound up with hospital-based activity. Government spending was increased after 2000, in order to expand mental health services, but the report concluded that this intention was unlikely to be successful. Although mental health is designated as a priority in health policy, proportionally the growth in expenditure on it, compared to other forms of State spending, has been slower. As a result, in proportional terms, the share allocated by the local State to mental health services continued to fall. Also there was slow progress in the timetable to implement the National Service Framework for Mental Health (Department of Health/Home Office 1999).
Another factor indicating that mental health services continue to have a ‘Cinderella’ status relates to the range of peculiar costs or budgetary pressures experienced by them. These include debt repayment, staff shortages (which lead to expensive short-term agency payments) and the increasing prescribing costs associated with the introduction of new and expensive psychotropic medications.
A look at the breakdown of spending on mental health services reveals socio-political priori- ties. For example, Table 6.2 indicates that there is a socio-political emphasis on social control (the combined items on acute facilities, secure provision and mentally disordered offenders). These Table 6.2 Service expenditure 2002/03
Per cent
Community mental health terms 17.2
Access and crisis services 6.6
Clinical services including acute inpatient care 24.6
Secure and high-dependency provision 12.3
Continuing care 12.2
Services for mentally disordered offenders 1.1
other community and hospital professional teams/specialists 1.6
Psychological therapy services 4.6
Home support services 2.1
Day services 5.3
Support services 1.5
Services for carers 0.3
Accommodation 10.3
Mental health promotion 0.1
Direct payments 0.1
Total direct costs 100.0
Source: Sainsbury (2003)
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items account for nearly 40 per cent of government spending on mental health services. This can be compared with the amount spent on mental health promotion – a mere 0.1 per cent. Psychologi- cal therapy services only received 4.6 per cent of spending (suggesting a bio-medical inertia in the mental health care system). Other non-hospital-based services, which are meant to signal a service reconfiguration towards community-based interventions, lagged behind the political rhetoric of the chapter on mental health in the NHS Plan (Department of Health 2000). Between them the items on new assertive outreach, crisis resolution, early intervention and services for carers accounted for less than 7 per cent of spending.
A final consideration about the problem of re-institutionalization and the inertia of hospital- oriented State funding is the interaction of political interests which have impeded shifts to ordinary living and fuller citizenship for people with mental health problems. The old asylums were a total solution for the social problems associated with mental abnormality. In particular, they provided three main functions:
• semi-permanent or permanent accommodation;
• treatment;
• social control.
All of these functions occurred concurrently in one institution. Whatever disadvantages the old asylum system had for their inmates (by creating a form of disabling apartheid) as well as advan- tages (see comments from Gittins (1998) earlier), the socio-political benefit for others was that a group of non-conformist, troublesome, worrisome and economically inefficient people was seg- regated. Mental abnormality was swept away or ‘warehoused’ out of the sight and mind of the majority of free citizens. The consequences of demolishing these warehouses were thus obvious.
The three functions would still be required by society for both economic efficiency and the mainte- nance of a moral order, but now they would have to be reconfigured or reconstructed.
This political challenge had tempted cautious politicians to hold on to revised forms of institu- tional care and encouraged them with new forms of legal measures to ensure the coercive control of community-based patients (see Chapter 10). In addition, the new context of acute units acted to provide the psychiatric profession with an opportunity to retain its traditional preferred link between power and beds. Moreover, the shift to DGH inpatient units was also an opportunity to increase the professional standing of a low-status medical specialty. Families troubled by patients in their midst would also look to new forms of safe residential disposal. Thus, a confluence of interests emerged in the final quarter of the twentieth century to retain a hospital focus to men- tal health work, despite the run-down of the asylum system. However, this has placed unrealistic expectations upon DGH units.
The interest groups just described have become immediately aggrieved about the inefficiency of the units compared to the old asylums, as the shift in scale means that the new units cannot rep- licate all the functions of the old hospitals. This has led to diverse demands in response; some of these centred on requests for more beds (from psychiatrists and patient-relative pressure groups) or calls for a halt to the run-down of the old asylums. There were also demands for greater com- munity support to reduce the need for admission (from user groups).
It can be seen then that the prioritizing of control, professional preferences to treat in inpa- tient settings and the continued need for people with mental health problems to be accommo- dated together place pressure upon smaller-scale hospital facilities. This pressure created such political anxiety in the mid-1990s that in the short term Britain ministers opted to slow asylum run-down and keep high investment levels in beds. In response, critics argued that the three func- tions noted above should be dealt with as separate policy questions: accommodation implies social housing not hospitalization; treatment needs to be cost-effective and its appropriate siting
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clarified; and risk management should be dealt with rationally, not prejudicially (Pilgrim and Rogers 1997).
The macro policy context together with the micro behaviour of professionals making and dealing with mental health referrals determine the pace and success of community care. A com- parison of community-based care for those patients with a diagnosis of schizophrenia in Verona and South Manchester indicated that the organization of services in the former resulted in shorter hospital stays as a result of better integration between hospital and community services (Gater et al. 1995).