An early attempt to humanize the large impersonal isolated institutions was to introduce a more personal democratic approach to care. Therapeutic communities (TCs) – small units or wards designed to make the social environment the main therapeutic tool – were pioneered in Britain during the Second World War by psychotherapeutically orientated psychiatrists. The number of soldier patients suffering from the stress of warfare meant that the individual model of therapy became untenable because of scarce staff resources. These army psychiatrists were encouraged to experiment with a variety of group methods to increase staff cost-effectiveness. The twofold objectives looked for in therapeutic communities were identified by Main (1946) as the need to resocialize patients who had become dependent as a result of traditional hospital practices, and the use of the hospital environment as a therapeutic agent through establishing social participation.
The latter was considered to be particularly valuable in treating people with neurotic conditions.
Later in civilian life, the TC approach was adapted more often to treat people with a diagnosis of personality disorder (Warren and Dolan 2001). The modification of the institution to form a TC has been reviewed sociologically by Manning (1989). These reviews focus on examples, such as the Henderson Hospital in Surrey, where the whole institution was involved. In other places a TC approach implemented piecemeal in a larger custodial setting tended to peter out. For example, the rapid turn-over of acute psychiatric units, with their ‘revolving door’ patients and bio-medical treatment regime, have tolerated the TC model poorly.
Inherent to the TC ideal was the belief that the social structure of the ward, group atmosphere and ward morale were important elements in the therapeutic endeavour of psychiatry. Central to these objectives was the need for rapid change in the organization of the hospital in order to make it more flexible and egalitarian. Attempts were made to break down the traditionally rigid and hierarchical role divisions between staff and patients, and decisions on the running of the TC were to be decided through group discussion. The latter measure was designed to promote communica- tion between staff and patients.
Therapeutic communities developed rapidly during the 1960s, but soon after they became marginalized. Thus, their success in changing mainstream psychiatric theory and practice has been modest. The main weaknesses seem to stem from their organizational form. Perrow (1965) has pointed to the shortcomings of TCs as viable organizations. In particular he points to the fail- ure to change fundamentally the social structure of the organization, which he traces to the failure of the TCs’ ‘technology’ (or the means used for reaching the set goals).
THe orGANIzATIoN of MeNTAl HeAlTH work 93
The wider organization (the mental hospital), of which TCs formed only a small part, con- tinued to operate custodial practices and the bureaucratic and professional structures remained relatively impervious to change. This limitation was clearly recognized in Italy, where TCs were seen as only a preliminary step towards the total dismantling of the asylum system, which came to be viewed as unreformable (Basaglia 1964).
The ‘technology’ for reaching the set goals of therapeutic communities was not enough to change a custodial culture and existing structures. In other words, the group work and social envi- ronment were not effective in changing sets of superordinate institutional relationships. Only one of Perrow’s three conditions of organizational functioning was present and so the effectiveness and viability of TCs were undermined by the total institution. Certainly, the success of the TC, as an ideology or therapy, was limited in persuading British psychiatry to move away from a medical model, as indicated in an interview with Maxwell Jones, a pioneer of TCs, in 1984: ‘For orthodox psychiatry it [the therapeutic community ideal] has provided a name to be wheeled out whenever it wants to defend Britain’s reputation as the country which pioneered social psychiatry and to be conveniently forgotten otherwise’ (The Guardian, August 1984).
A radical alternative to trying to humanize the institution was the run-down and ultimate clo- sure of large mental hospitals. In the later part of the twentieth century many countries followed a policy of hospital run-down and closure, often referred to as ‘deinstitutionalization’. The latter is also used interchangeably in some policy texts with the terms ‘decarceration’ or ‘desegregation’.
In 1954 there were 154,000 residents in British mental hospitals; by 1982 this had fallen to 100,000.
In other countries the degree of deinstitutionalization has been even greater. For example, in Italy between 1968 and 1978 the asylum population fell from 100,000 to 50,000.
The various clinical and research critiques of institutional life may not have been influential in changing policy. Scull comments that the work of social scientists on the disabling and custodial function of the asylum was not accompanied by evidence of greater public tolerance towards emo- tional deviance. In some cases, as in the work of John Martin discussed earlier, social scientists were probably more witnesses to the crisis of the institution than participants in crisis resolution or policy reform.
The reasons thought to be responsible for deinstitutionalization are multiple and contested, and implicate a complex set of inter-relationships between the medical profession, public morality, the State and political economy. A number of different accounts have been offered for deinstitu- tionalization policies, which we will consider in turn.
The ‘pharmacological revolution’
The ‘pharmacological revolution’ is a frequently cited explanation for hospital run-down. Simply put, it suggests that advances in medical treatment of mental illness permitted patients to be dis- charged from institutions en masse. According to this view of change, the introduction of major tranquillizers in particular enabled the alleviation of symptoms in psychotic patients, allowing large numbers of asylum residents to move into the community. Its explanatory power is still expressed in recent respectable psychiatric textbooks. For example:
The introduction of chlorpromazine in 1952 made it easier to manage disturbed behaviour, and therefore easier to open wards that had been locked, to engage patients in social activities, and to discharge some of them into the community . . .
(Gelder et al. 2001: 769) This account of deinstitutionalization generates both theoretical and empirical difficulties. For example, it cannot explain why community care policies were applied to a range of care groups, such as people with learning disabilities and older people, who are not psychotic. They are not, therefore, the supposed target of ‘antipsychotic’ medication. However, in later years at times the
94 A SoCIoloGy of MeNTAl HeAlTH AND IllNeSS
true role of these drugs as tranquillizers to suppress difficult behaviour showed through in their (mis)use with non-psychiatric patients, such as agitated older people and difficult-to-manage peo- ple with learning disabilities.
More importantly, a number of studies demonstrate that an increased pattern of discharges occurred prior to the widespread use of major tranquillizers. Nor did the introduction of psycho- tropic drugs appear to accelerate the rate of discharges. The pattern of the fall remained consistent with that preceding their widespread use. In a few countries inpatient numbers actually rose after the introduction of chlorpromazine (see Table 6.1).
The notion that medical intervention was principally responsible for ‘decarceration’ may have been deduced from a reading of the official statistics produced on mental hospital inmates of the time. However, Scull (1977: 83) points out that a reading of these sources of data may have led to erroneous interpretations being made, since they mask ‘earlier changes at the local level and obscure the degree to which the fall in overall numbers, when it did come, represents a continua- tion rather than a departure from pre-existing trends’.
Thus, according to Scull, while psychotropic medication has helped manage deviance follow- ing deinstitutionalization (through the control rather than permanent alleviation of symptoms), it was not responsible for the genesis of this policy. The retention of the unfounded claim of a
‘pharmacological revolution’ in later texts, such as Gelder and colleagues’, points up professional interest work in the preferred depiction of mental health policy history.
Other analyses of data sources indicate that organizational factors and social policy initiatives are responsible for changes in the location of psychiatric practice. Table 6.1 shows the growth in the number of psychiatric beds in a number of European countries following the Second World War, which ran counter to run-down in the UK and the USA. While the type of increased bed use varied from one country to another (in some it was short-term beds, in others new specialist facili- ties) the point is that inpatient care increased during a time when the major tranquillizers were widely and increasingly utilized.
‘Economic determinism’
This is an alternative explanation for ‘decarceration’, by Scull (1977). He uses the term to describe the ‘state-sponsored policy of closing down asylums’ (1977: 1), which he relates to changes in Table 6.1 Post-war growth of psychiatric beds in europe
Country Year No. psychiatric beds
Belgium 1951 19,841
1970 26,553
Austria 1950 9,868
1975 14,314
Italy 1954 88,241
1961 113,040
Spain 1949 25,571
1974 42,493
federal German republic 1953 86,640
1975 112,791
Source: Adapted from world Health organization Statistics Annuals
THe orGANIzATIoN of MeNTAl HeAlTH work 95
social control mechanisms. Scull contends that, with the emergence of the welfare state, segrega- tive control mechanisms became too costly and difficult to justify. The cost inflation of mental hospitals prior to, and after, the Second World War was brought about by the elimination of unpaid patient labour and increased cost of employees as a result of the unionization of labour. The latter had the effect of contributing to the doubling of unit costs (because of the cost of a shorter work- ing day and holiday entitlement).
Thus the maintenance of ex-patients on welfare payments and the ‘neglecting’ of community care becomes a more viable State policy. The reality of community habitation for ex-inmates, according to Scull, has been an unmitigated disaster for the majority. The inhumanity of the asy- lum has simply been replaced by the negligence of the community.
A problem with Scull’s account is that it is more applicable to the 1980s, when fiscal savings were undoubtedly the driver for changes in social policy in relation to a range of patients with long-term conditions. The fiscal crisis of the State thesis fits less readily, though, with the imme- diate post-war period when he claims deinstitutionalization started. However, although the time frame is wrong, there is certainly evidence that the driver of fiscal savings eventually found its time, at least as a partial explanation for hospital run-down.
Changes in the organization of medicine: a shift to acute problems and primary care
The history of the large hospitals was bound up with the warehousing of chronic madness. How- ever, during the twentieth century the ambit of psychiatry changed in a number of ways. By the end of that century mental health services also dealt with a range of other problems, such as neurosis, personality disorder and substance misuse. The shift had been occurring since the First World War when male neurosis (in the form of shellshock) entered centre stage. Also, a profes- sional norm developed within psychiatry about the need to treat acute psychosis (with two-thirds of patients being deemed to recover permanently or have their symptoms eliminated until another acute episode).
The rhetoric of the ‘pharmacological revolution’ described earlier boosted this change in pro- fessional attention. Specious curative descriptions began to emerge in medicine such as ‘antipsy- chotic’ and ‘antidepressant’ medication. There was a focus on acute, not chronic, problems and the development of acute psychiatric units in DGHs, with a limited number of beds (Baruch and Treacher 1978). This move aligned psychiatry with other medical specialties. In other words the desegregation was primarily of psychiatrists, to boost their medical respectability.
At the same time, it was becoming evident that conditions such as ‘depression’ (the ‘common cold of psychiatry at once familiar and mysterious’ (Seligman 1975)) and ‘anxiety’ could be con- tained in primary care. The great majority of patients with these ‘common mental disorders’ either did not seek help or were treated only by GPs, an arrangement still applicable today (Goldberg and Huxley 1980). Thus the remaining picture is that the bulk of people deemed to have mental health problems never access specialist services.
This change in the character of the medical framing of emotional deviance has been empha- sized by some social constructivist analysts such as Prior (1991), who avoids both economic and technological determinism. Rather than attempting to identify causal mechanisms, his aim is to describe the object, ideology and organizational arrangements which constitute contemporary psychiatry. Prior argues that the target of psychiatric practice changes over time. Each new object is accompanied by a different type of clinical practice and organizational setting. For example, the nineteenth-century view of madness took, as its focus, the brain and forms of degeneracy, which demanded exclusion and control in the asylum. In contrast, the concepts of ‘psyche’ and
‘the unconscious’ in Freudian theory centred around the concept of ‘mind’. The rising popularity of psychoanalytically informed ideas also started to cloud the distinction between normal and patho- logical behaviour which, according to Ramon (1985), helped destigmatize mental illness.
96 A SoCIoloGy of MeNTAl HeAlTH AND IllNeSS
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).