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ОглавлениеCommunity care: a brief overview
Introduction
This short chapter provides a brief overview of the development of community care. It examines the way that the asylum became an obsolete institution – certainly one that had few defenders in the early 1980s. In giving a brief overview of the intellectual underpinnings of community care, the chapter introduces a series of issues – deinstitutionalisation and the penal state, community care inquiries and the asylum/community binary – which are examined in depth in subsequent chapters. Community care is a complex and highly influential shift in mental health services. As with all policies, there were a series of drivers behind the policy. I would summarise these as a combination of progressive idealism that attacked the whole notion that institutions could ever provide humane, dignified care and fiscal conservatism. Progressive idealism and fiscal conservatism are unlikely and uneasy bedfellows. The result was a policy that was imbued with service user rights but was introduced at a time of welfare retrenchment. In the UK and the US, this major shift to a community oriented vision of mental health service provision was introduced by governments committed to a small state and convinced of the supremacy of the market.
Community care is a phrase that does not appear in many, if any, contemporary mental health policy documents. It has either been discarded or is so deeply embedded that it is not worth commenting on. One of the aims of this volume is to examine the reasons behind the disappearance of community care from official discourse. The closure of the large psychiatric hospitals that had been built in the 19th century is one of the most significant social policies of the last 50 years. The process of asylum closure is usually referred to as deinstitutionalisation. Estroff (1981) identified four groups of patients who were affected by the process of deinstitutionalisation:
•long-term hospital patients who were discharged;
•patients who experienced potentially multiple psychotic episodes and hospital admissions – this group was treated as outpatients or with short, crisis-oriented admissions;
•patients who were treated on an outpatient basis;
•those patients who experienced a first serious episode of mental distress and were not admitted to hospital or who were in hospital for a relatively brief period compared to asylum admissions.
The first two groups were the focus of the first stage of the process of deinstitutionalisation. In theory, the second two groups would benefit from the establishment of community mental health centres and other changes to the provision of mental health care. Community care represents what now might seem the idealistic belief that the closure of the asylums would represent a hugely progressive shift in the care and treatment of the mentally ill. There are several narratives of community care that are examined in this volume. One of the most powerful is that community care was an inherently progressive idea based on inclusive notions of citizenship. This narrative is based on a view that sees asylums as Gothic sites of seclusion and terror. As Scull (1986) noted, this modern view of the asylum is a betrayal of its origins and would have shocked the founders of these institutions. Figures such as Tuke at the York Retreat established them as progressive and a humanitarian response to suffering. The debates about the causal factors and influence on the development of community care are explored here. What emerges is a complex, messy and often contradictory picture. Progressive idealism, fiscal conservatism and new pharmaceutical developments combined to render the asylum obsolete. The progressive drive for community care was based on the idea that the discredited asylum would be replaced with a range of properly resourced community-based resources to support citizens in acute distress. I think it is clear that this ambitious goal was never achieved. Turner and Columbo (2008) argued risk assessment has replaced an ethic of care as the main focus of service user contact. An understanding of the rise and fall of the asylums, the radical challenge to psychiatry and the subsequent failings of community care is important if we are to appreciate how to build new models of service provision.
The rise of the asylum
One way of understanding the development of community care is to see it as a response to the failings of the asylum regime. The asylum is situated physically apart from the wider community (Pilgrim and Rogers, 2014). This physical distancing, subsequently, became a metaphor for the social and civic isolation of the patients. These institutions were built on sites away from the main centres of population thus physically separating the mad from the rest of the population. Scull (1977) sees the rise of asylums as part of the Victorian response to the problems of urbanisation. In tracing the rise of the asylum, Scull (1977,1986) outlines the way that the institution was linked to and played a role in the new status of psychiatry as a distinct branch of the medical profession. Scull (1986) was particularly critical of Foucault and those who viewed asylums simply as forms of social control. He notes that there was an optimism in this period that contrasts strongly with the end of the asylum period. The new asylums were established to rescue the mad from the kinds of maltreatment and neglect with which they became synonymous. The hospital was a rational, technical response to mental illness.
Michel Foucault is one of the most influential and widely cited writers in the humanities and social sciences. His work and the responses to it have opened new areas of debate. Foucault’s work is complex and often appears contradictory. The key themes that he explored include: the nature of power; the development of modern institutions, such as prisons and psychiatric hospitals; and modern modes of social regulation. Foucault argues that these shifts in what he terms ‘technologies of power’ cannot be necessarily seen as progressive. They reflect changes in the dynamics of societal power. His work on two key institutions of modernity – the asylum and the prison – has at its core a concern with the exercise of power (Foucault, 2003). His work is a challenge to the traditional notion that the development of these institutions can be read as a process of reform. Foucault sees these institutions as new technologies of power. The task is to examine the shifts in social, cultural and political beliefs that underpin these reforms.
Foucault’s work is, unlike that of other critics of the asylum regime, historical. He explores the birth of these modern institutions. His influence was and is such that it was taken to be a criticism of contemporary systems (Cummins, 2017). Foucault outlines the way that the focus of punishment and treatment moves from the body of prisoners or patients to their minds. He argues that this is a more pervasive form of social control. In this analysis, power and the power to punish are much more dispersed throughout the social system. It therefore operates on several levels. Foucault terms this ideology of discipline ‘savior’. Expressions of this ideology can be found among all groups including those termed deviants and it operates as a mechanism of repression both of the self and others. A subject is created by a series of what he terms ‘dividing practices’ (Foucault, 1982). These ‘dividing practices’ are the application of a branch of knowledge such as psychiatry or criminology. The application of such knowledge, for Foucault creates new groups or cases or in as he puts it ‘specifications of individuals’. The implications of being placed in such a category are potentially profound. These include being institutionalised and being denied the rights of citizenship. Foucault argues that the ‘Great Confinement’ saw the development of institutionalisation as the response to the poor, mad or offenders. In Discipline and Punish (2012), Foucault outlines the development of the ‘disciplinary gaze’. This is the process by which individuals become cases subject to a system of classification and control. In his writings, Foucault draws attention to the symbolism of the institutions. Bentham’s panoptican becomes not just an architectural design but an embodiment of new society, whose institutions form a ‘carceral archipelago’ for the management of deviant populations, be they criminals or the insane (Foucault, 2003).
It would be a mistake to assume that there were not attempts to respond to the radical perspectives of Foucault and others. The liberal view of the asylum highlights that they represent progress on the previous system. The motives of reformers are fundamentally humanitarian and focusing on the relief of the pain and suffering of their fellow citizens (Jones, 1960). This is an approach that does not see these institutions solely in terms of exercising functions of social control. Individuals such as Tuke, the founder of the York Retreat, are represented as challenging the more hostile views of wider society. By contrast, Foucault (2003) never seems to acknowledge that there is a possibility that some reforms might have been the result of humanitarian concerns. This liberal progressive view of the development of asylums is based on several key premises. It sees mental illness as just that illness and as such a feature of the human condition. Those involved in its treatment and management are motivated by social values to relieve suffering (Ignatieff, 1985). There is, therefore, a key role for the medical profession. This is seen as a logical outcome and allows for the application of rational, morally neutral medical knowledge to the symptoms of mental illness. This creates a narrative of reform involving the improvement of services by the application of new knowledge (Rothman, 2002)
Anti-psychiatry
Anti-psychiatry is a term for a series of critical perspectives on psychiatry that appeared in the 1960s and 1970s. Key thinkers including Goffman (2017), Foucault (2003), Scull (1977), Laing (1959,1967) Fanon (2008) and Szasz (1963,1971) produced a series of highly influential works that questioned the fundamental position of psychiatry. It should be emphasised that this was never a grouping or an intellectual school. They had little if anything in common.
Despite this, it is possible to identify key themes in the work of this diverse group of thinkers that was influential in challenging the dominant model of institutionalised care. I would identify these as follows:
•a fundamental questioning of the exercise of power of the psychiatric profession;
•a questioning of the neutrality of diagnosis;
•a concern with psychiatry’s role in the creation and perpetuation of racial and gender stereotypes;
•a belief that institutional care and compulsory treatment were inevitably abusive and dehumanising.
In the broadest terms, these are thinkers of the Left. Szasz is something of an outlier. Szasz is a small government libertarian. He sees mental illness as a way of avoiding individual social responsibility – be that in the area of criminal law or employment. Mental illness in his work is a form of malingering that is indulged by an overgenerous welfare state. His views are neatly summed up in the title of a 1995 paper ‘Idleness and lawlessness in the therapeutic state’. It would be a mistake to overlook the differences in other accounts – hence Scull’s somewhat sardonic summarising. In critical accounts, there is a sceptical approach which focuses on the social construction of mental illness. This leads to a consideration of broader social factors, such as poverty, racism, misogyny, homophobia and social inequality, rather than a focus on brain chemistry. Following on from this, the social implications of diagnosis and an analysis of the institutions that have been created to manage mental illness are at the heart of anti-psychiatry. For example, while most commentators see the development of the York Retreat as a progressive measure, Foucault (1982) essentially sees it as the exercise of power by other means. He describes the ‘moralising sadism’ of the York Retreat and its Quaker founders. In Foucault’s terms the outcomes for the inmates are the same: exclusion and subjugation. There is a nihilism at the centre of Foucault’s thinking. Stone (1982) argued that this leads Foucault to see all relationships in terms of power/subjugation, thus excluding any humanitarian impulse that might underpin to the development of these institutions. It should be acknowledged that in his exchange with Stone, Foucault disputed this interpretation of his work.
Psychiatry and anti-psychiatry
Anti-psychiatry cannot be regarded as a campaigning movement. However, it was clearly influential outside of academic circles. It needs to be considered as a key influence on the development of community care (Cummins, 2017). The key figures remained influential in debates about the nature of mental illness during their lifetimes. Laing set up therapeutic communities; Szasz campaigned against the power of psychiatry as a profession while still practising it. It would be almost impossible to overestimate the influence of Goffmann or Foucault. Both are in the most cited writers in the social sciences (Green, 2016).
Psychiatry, clearly, did not simply accept without challenge the criticisms outlined in the previous paragraph. It is interesting that three of the strongest critics of the discipline were actually psychiatrists – Laing, Szasz and Cooper, who is usually credited with coining the term ‘anti-psychiatry’. The response has come from both medicine and the humanities. The strongest arguments are that the main aim of medicine is humanitarian and altruistic: the relief of suffering (Clare, 2012; Wing, 1978) Within these accounts, there is an acceptance that certain practices would now be regarded as abusive or even amount to torture. However, the argument is that this was the state of medical knowledge at the time. The intention was therapeutic within the medical definitions of the time. This is one of the fundamental departures in Foucault’s work. In it, it is difficult to find any recognition of the possibility of a humanitarian impulse. I may be guilty here of applying modern notions of therapeutic interventions to the past where they are not applicable.
Alongside what we might term the moral defence of psychiatry – the notion that it is a branch of medicine that is concerned with the relief of suffering – we should also explore other challenges to Foucault. Scull (1991) is very critical of Foucault’s use of sources and the conclusions that he reaches arguing they are based on the analysis of a limited range of texts. In addition, Scull (1991) argues that Foucault has used a very specific period in French history to represent the totality of European developments in this field. Sedgwick (1982) has demonstrated that the link Foucault makes between the decline in the treatment of leprosy and the development of psychiatric asylums does not hold. For Foucault, prior to the ‘Great Confinement’ the mad had essentially been tolerated and allowed to live in society. Sedgwick argues that this portrayal of the mad as the lepers of modern society ignores the fact that the mad had been held in various forms of custody prior to the period Foucault is discussing. In representing asylums as a response to urbanisation, Foucault cannot account for their development in the US at a time when it was an agrarian society (Rothman, 2002). One response to this is to argue that Foucault is not making any such claims. His work is historically specific and seeks to analyse the various factors at play – at that time, in that place. This is counter to an approach that is based on or creates a metanarrative of the rise of the asylums.
For other critics, such as Rothman (2002), Foucault has, in effect, reduced the complex causes of the development of asylums to a class strategy of ‘divide and rule’. One impact of this is to simplify the complexity of the founding and management of the asylum regime. For example, it overlooks or does not accept the religious motivations of many founders – Tuke at York being a prime example. Anti-psychiatry chimed with some of the anti-authoritarian developments in the wider culture of the 1960s. This helps to explain the largely positive reception that it received. However, it is also part of its weakness. Scull (2014) demonstrates that all societies grapple with the moral and ethical questions that are generated by societal responses to mental illness. The response clearly involves social control, but we also need to see it as something more than that. There are many aspects to it because mental illness is such a diverse and complex phenomenon. Finally, the focus in Foucault’s account is on essentially state responses. This overlooks the other ways that families, wider social attitudes and public sanctions – formal and otherwise –combine to produce social order (Ignatieff, 1985).
Foucault (2003) and Goffman (2017) challenge established notions of progress. They also question the role of psychiatry, viewing it as a disciplinary process. The focus is often on the impact of the asylum regime on the incarcerated. There is a danger of overstating this. For example, the voice of the service user/patient is largely if not totally absent from Goffman (2017). The influence of these writers has led to an explosion in research and literature that explores all aspects of the asylum. The history of the asylum from below is, perhaps, more attractive than a narrative of the struggle of psychiatrists to humanise an inhumane system. However, it is important to examine all aspects of the asylum regime. The fundamental difficulty with these hugely influential accounts is that they are based on a discourse of subordination and domination. In challenging the notion of progress, there seems to be a denial of its possible existence whatsoever. Unfairly in my view, Foucault seems to be held personally responsible by many for the failings of community care. Stone (1982), for example, argues Foucault had a destructive impact on the development of mental health services, arguing the attacks on institutional care led to a collapse in the belief in care itself.
Conclusion
As noted, the progressive proponents of community care saw the abuses of the asylum system as a fundamental human rights issue. Institutionalised forms of treatment were inherently abusive as they denied people the full rights of citizenship and subjected them to inhumane and degrading treatment. For fiscal conservatives, the asylums were part of an increasingly unaffordable welfare state. In later chapters, I explore how the progressive vision of community care disappeared. By 1998, and the arrival of the first New Labour administration, community care had officially ‘failed’. One is tempted to respond that it had never really been tried. The sweeping statement that it had failed ignores the fact that there were and are people who would previously been institutionalised, who have not been and are living independently. However, the grander vision of a series of community mental health and crisis centres that would replace the large glooming presence of the asylum has never materialised.
The assumption that there is a binary of the asylum/community and that they are always in opposition is something of an illusion. The idea that all the problems raised by the asylum regime could be solved by a return to the community ignored more fundamental questions about the nature of mental health services. The impulse behind community care was to improve the standards of mental health provision. The overwhelming majority of writers accept that there will be a need for a period of recovery that involves a therapeutic setting of one sort or another. The York Retreat and others like it were just that – a retreat from the pressures of the world. Even a writer as radical as Laing accepted this and set up therapeutic communities as a result. This is not to deny that is that prolonged periods of hospital care can in themselves be damaging and that services need to exist to intervene at an early stage to provide support to those suffering from any form of mental distress. This is a public health model of service provision that ideally develops tiers that will meet individual and community need. Community care from the late 1980s onwards appears as a policy with few vocal supporters. This is partly due to the media coverage of high-profile cases (Cummins, 2010, 2012). One should, perhaps, not be too shocked that the tabloid media, which did so much to contribute to the stigma that users of mental health services face, reported these cases in such a lurid fashion. These reports undermined wider support for the policy. The response has been a call for more coercive legislation, one which ultimately led to the introduction of Community Treatment Orders.
Moon (2000) highlights the geographical paradox at the heart of the development of community care services: the closure of the asylums has not resolved the marginalisation of those experiencing mental health problems. The asylums were distant institutions geographically and metaphorically (Philo 1987; Scull 1989). The notion of community care was based on an inclusive vision. In tracing the history of community care, this volume seeks to examine why that vision never materialised. Far from being a welcoming, supportive environment, communities, particularly in urban areas, have reproduced the worst aspects of the asylum (Wolff, 2005). Those with the most complex needs are often found living in the poorest neighbourhoods, in poor quality residential care homes, on the streets or increasingly in the prison system (Moon, 2000; Singleton et al, 1998). The overall picture is a very bleak one, so bleak in fact that the asylum system appears to have some advantages in that it was, at least, a community. For a variety of reasons – economic, social and political – the community has not proved up to the task of providing humane and effective services for those with the most complex needs.
Mental health services have always struggled to gain an appropriate level of funding – particularly in comparison with other areas of medicine. This is partly a reflection of the stigma attached to the area. The period that is mostly examined in this volume (1983–97) was one that saw a broader restructuring of the welfare state. These pressures meant community care was never properly funded (Scull, 1986). One of the main conclusions of a series of inquiries into failures in community care services (Ritchie, 1994; Blom-Cooper et al, 1995) was that resources were stretched to breaking point. It is interesting to note that these inquiries called for more investment in mental health services but focused on the need for more secure provision. In addition, there were calls for changes in mental health legislation. When examining these issues, it is impossible to separate mental health services from the wider discourses of risk and risk management that came to dominate social work, in particular, as well as other public services (Cummins, 2018a).
The critics of the asylum regime from a human rights perspective were clearly not arguing that they should be replaced by prisons, police custody, homelessness and poor quality bed and breakfast accommodation. The treatment of mental illness is fundamentally a moral issue that involves questions about the rights of the individual and the wider society (Eastman and Starling, 2006). Such questions did not disappear because of the advent of community care. The powers of compulsory admission have remained largely unchanged. The reform of the Mental Health Act (MHA) in 2007 saw the introduction of Community Treatment Orders legislation. This could be taken as the symbolic ending of a policy commitment to community care. These debates are the result of the nature and impact of mental illness. It is only, perhaps, on the more extreme wings of libertarian thought (Szasz 1963, 1971) that there is a total rejection of the therapeutic state having powers to intervene when individuals, because of their mental health, are seen as putting themselves or others at risk in some way. One of the many paradoxes of community care is that the rights of the mentally ill are on a much stronger footing than they have ever been. In the US, challenges to the legal processes of detention were one of the key drivers of deinstitutionalisation (Harcourt, 2005). In the UK, greater legal protections exist that mean people can challenge, for example, employers if they experience discrimination as a result of their mental health problems. In cases of compulsory detention, a new legal framework was introduced to ensure compatibility with the provisions of the HRA (Human Rights Act) of 1998. The 2018 review of the MHA was carried after May identified the parlous state of mental health services as one of the ‘grave injustices’ that existed in the country. There is wider public discussion and acknowledgement of the impact of mental illness. Stigma and fear remain but the physical segregation in asylums has gone. In addition, psychiatry, mental health social work, nursing and other disciplines have a wider range of interventions to alleviate distress to offer. However, the policies and legislation which will impact on those in greatest need do not reflect these progressive themes. These paradoxes will be explored in the forthcoming chapters.
