• the crisis of the asylum;
• responses to the crisis;
• community care and re-institutionalization
• primary care, open settings, ehealth and psychological therapies.
The rise of the asylum and its legacy
The structure and organization of the large nineteenth-century mental hospital did not fit the ideal type of the general hospital. Its architectural design and daily functions were organizationally incongruent in terms of therapy, structure and location. For example, while the general hospital
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was geographically located for easy access, many of the large Victorian asylums were deliberately built away from centres of populations. The lack of fit between institutional forms inspired by thinking in the nineteenth century and the ‘new’ twentieth-century norms regarding health care delivery led to a crisis within these organizations. This crisis formed the focus of a critique of the institution, which emanated from a number of sources.
The segregation of lunatics into large institutions took place over the final three centuries of the second millennium in Europe and North America. Psychiatric historians do not agree on the precise timing of this shift or on the exact explanation for its occurrence (Foucault 1965; Rothman 1971; Grob 1973; Scull 1979). Tracing the creation of large institutions can help us understand their demise but this involves the examination of competing historical claims.
A conventional and conservative account suggests that the asylum is viewed as part and par- cel of medical progress and an increasingly humane way of dealing with ‘mentally ill’ people. For instance, Jones (1960) stresses the humanitarianism behind the reform movement leading to the Lunatics Act 1845. This Act compelled county authorities to establish asylums and enforced their regulation via a centralized Lunacy Commission and a system of medical records. Much of Jones’s account centres around the official reports of Metropolitan Commissioners between 1828 and 1845 and the role of government-appointed bodies (such as Parliamentary Select Committees), which drew public attention to the poor state of workhouses and private madhouses. The establishment of early institutions modelled on the moral treatment regime of the York Retreat is described as arising from ‘the consciousness felt by a small group of citizens of an overwhelming social evil in their midst’ (Jones 1960: 40). In fact, moral treatment failed to transfer from the early charity hospitals like the Retreat to the state-run asylums, although its image dominated the rhetoric of asylum reformers (Donnelly 1983). Jones (1960: 149) sees the implementation of the 1845 Act in a humanitarian light: ‘Ashley and his colleagues had roused the conscience of mid-Victorian society, and had set a new standard of public morality by which the care of the helpless and degraded classes of the community was to be seen as a social responsibility’.
Critical historians reject this more conventional account of events. The incarceration of mad people in asylums is seen as inextricably linked to the wider-scale containment of social devi- ancy: the poor in workhouses and criminals in prisons. The accounts of alternative histories vary.
Scull (1979), a Marxist, suggested that mass confinement (of which the asylum system consti- tuted an integral part) was a product of urbanization, industrialization and professional forces during the first half of the nineteenth century. The development of capitalism, with its demand for wage labour, meant that the existing means of poor relief was ill-equipped to deal with social devi- ance produced by the new market economy. Thus, the old outdoor system of relief in operation since the Elizabethan Poor Law was replaced by mass incarceration in institutions.
From the beginning of the nineteenth century a gradual process of segregation took place.
Poor, able-bodied people (that is, those fit to work) were sent to workhouses, which were orien- tated towards instilling ‘proper work habits’. These people were separated from those that could not work, which included those deemed insane and in need of incarceration in asylums. At the same time, ideas about madness were changing. It became recognized as a loss of self-control and not, as previously, a loss of humanity. These changing values were influenced by the exposure of the brutal treatment of those in madhouses. This encouraged the abandonment of mechanical restraints and it endorsed regimes such as the York Retreat.
These new social values permitted a greater willingness to accept a medical view of madness, the ascendance of which Scull attributes to the entrepreneurial leanings of medical practitioners, who were at the same time making efforts to professionalize and expand. Lucrative pickings were to be had by the profession trying to capture the madhouses previously run by laymen. Rather than having to attract patients to them, the asylum provided them with a ready-made and captive clientele.
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Unlike Jones or Scull, Foucault (1965) does not concern himself with the specifics of the his- tory of institutions. He views the Hôpital Générale at the end of the seventeenth century (where at one time 1 per cent of Paris’s population who were ‘incapable’ of productive work was incar- cerated) as symbolizing a new concept of madness. The spirit of capitalism, which Foucault traces from the Enlightenment onwards, promotes rationality, surveillance and discipline. Reason becomes separated from unreason. This separation out of unreason, whereby madness comes to be seen as the lack of the faculty of ‘logos’, is symbolized in the replacement of lepers by lunatics.
The latter became the new ‘race apart’, and their confinement followed.
Critical histories therefore challenge self-congratulatory versions of history, which tend to mask the interests of powerful sections of society, such as the psychiatric profession and the cen- tral capitalist State. However, Rothman (1983) suggests that there are problems with critical, as well as conservative, histories because in both accounts ‘conception triumphs over data’. Accord- ing to Rothman, a focus on ideology, whether it is humanitarianism (Jones), capitalism (Scull) or surveillance (Foucault), can divert the historian’s attention from the complex empirical reality of specific individual cases. For example Scull’s emphasis on the economic, Rothman claims, is overstated. The early American system of asylums appeared in the absence of a market economy.
Ideas about madness, he suggests, can be influenced by idiosyncratic factors other than those associated with a capitalist mode of production (for example, ideals related to localized political activity and religious doctrine).
Sociologists in the 1960s were party to critical arguments about the dehumanizing effects of the asylum when the direction of mental health policy was clearly focused around whether or not to proceed with mass hospital closure. With the passage of time, when hospital closure and reset- tlement have become the norm, more recent sociologically informed commentary suggests that the history of the asylum is a contradictory one, particularly when seen in the context of the rise in new forms of surveillance, ways of dealing with psychiatric patients, and in a society which is arguably no more tolerant of psychiatric patients than previous generations.
Gittins’s (1998) socio-historical analysis of a large psychiatric hospital in Essex, based on the biographical narratives of staff and patients who lived or worked in the hospital, suggests contradictions and paradoxes about the way the asylums were. In relation to women patients it is clear, for example, that the hospital, based as it was on men-only or women-only wards, con- stituted a ‘women-only space’ and true asylum in a social context in which there was little such space in external community life. Moreover, the hardships and restriction of asylum life need to be balanced against the external social, economic and political conditions during the heyday of the asylum, such as extreme poverty, unemployment and wars which affected people’s abilities to cope with difficult material and personal situations. The ambiguous history of the asylum is cap- tured by Gittins (1998), who argues that the asylum had some advantages of stability and patient protection, though its drawbacks were also not in doubt.
These different histories and interpretations point to the way in which accounts of psychi- atric organizations are themselves socially constructed and influenced by the particular point in time in which they are written. We turn now to the processes underlying the dismantling of the asylum system. Again, competing explanations influenced by different perspectives and read- ing of events provides a complex and contested picture of the causes of hospital rundown and closure.
The asylum system was problematic from its inception. The ideals of ‘moral treatment’ were abandoned almost immediately. The system rapidly became overwhelmed by the numbers admit- ted with chronic conditions. Political pressures were encountered to keep costs down. Although the dominance of the institution began to wane from the 1930s onwards, with a gradual reduction in the number of asylum residents, it was not until the late 1950s and early 1960s that it was faced with a sustained analysis and critique. These criticisms will now be examined.
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Ronald Laing, David Cooper, Franco Basaglia and Thomas Szasz were psychiatrists who challenged traditional professional theory and practice. (Collectively they were dubbed ‘anti- psychiatrists’, although only Cooper conceded the label.) They wanted to develop services for patients based on voluntary psychological approaches, and consequently they attacked current coercive, biological and institutional psychiatry. Goffman (1961), in his seminal work, Asylums, considered the mental hospital to be a ‘total institution’. This he defined as a place of residence with a large number of people isolated from wider society, for lengthy periods of time, which runs according to an enclosed and formalized administrative regime. Goffman described four types of total institutions:
1 those which care for the incapable and ‘harmless’ (such as nursing homes and hospices);
2 those which provide for those who are perceived as an unwanted threat to the community (for example, sanatoriums for people who suffer from TB);
3 those which cater for the dangerous people where the welfare of the inmate is not para- mount (for example prisons and prisoner of war camps);
4 those that are designed for people who voluntarily decide to retreat from the world, for instance for religious purposes (monasteries and convents).
The old asylums were examples of the second type of total institution. Secure psychiatric provi- sion (medium-security units and high-security hospitals such as Ashworth and Broadmoor) are remaining examples. Model (or Weber’s ‘ideal type’ of) total institutions possess a number of char- acteristics. All aspects of life are conducted in the same place. Activities always take place in the presence of others and are strictly timetabled and geared towards fulfilling the official aims of the institution rather than the needs of individuals. A strict demarcation exists between ‘inmates’ and staff.