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ОглавлениеIntroduction
This chapter will argue that the development of mental health policy was hugely influenced by conceptions of space and place. By the middle of the 20th century the asylum had become, in the public and sociological imagination, a Gothic institution of seclusion and abuse. This is not to suggest that there was no basis for this view. The chapter will explore the development of this representation of the asylum. The final representations of the asylum contrast dramatically with the original ones that saw the new institutions as modern and progressive. Deinstitutionalisation was to present the community in binary opposition to the asylum. Community based services would, almost by reason of their location, lead to the creation of a new form of inclusive mental health provision. This is based on an idealised notion of community. As the pressures on mental health services grew, a range of social policies that were introduced that meant that urban communities, in particular, became exclusionary rather than inclusionary.
Total institutions
Goffman is one of the most influential sociologists of the 20th century. Goffman’s work on stigma and the sociology of everyday life – the social practices that we engage in to structure and make sense of day to day social interactions – have left a rich legacy. It is interesting to note that the treatment and management of mental illness was a key area of analysis in his work. This area was representative of other stigma generating processes (Cummins, 2017a). Asylums (2017) is Goffman’s most important work in this field. It is an ethnographic account of life at the St Elizabeth’s Hospital in Washington DC. Goffman carried out his research when there were over 7,000 patients at St Elizabeth’s. The study is a landmark in ethnographic research. It also had a key role in the moves to tackle the abusive nature of the regime he described. Goffman’s portrait of the asylum was one dominated by essentially anti-therapeutic, dehumanising practices. Goffman’s work was part of the drive for reform but also had a key role in shaping the image of the asylum regime.
Before examining Asylums (2017), I will briefly outline Goffman’s broader theoretical approach to the questions raised by societal responses to mental illness. He examined these in his short essay ‘The insanity of place’ (Goffman, 1969). Goffman regarded mental illness as a challenge to normal societal rules of behaviour. It represents what he terms a form of ‘havoc’. Goffman uses the term to mean that individuals are no longer what he termed self-governing. The usual codes or systems which enable us to make sense of, or manage, our social realities are broken down. An example of this might be the impact of symptoms of bipolar disorder such as disinhibition. For Goffman, society manages havoc in one of two ways: the removal of the individuals from wider society, or the discrediting of them. Goffman outlined what he termed ‘gathering’ whereby the wider society – families, friends and institutions – attempt to deal with the havoc. As a former mental health social worker, I was involved in many gatherings in the form of Mental Health Act (MHA) assessments. I, my fellow mental health professionals and members of individuals’ families viewed Goffman’s gatherings as interventions that were seeking to ensure the safety of individuals rather than to discredit them. I also fully accept that my perspective may well be completely at odds with that of the person subject to the MHA assessment process. Alongside this, I accept that these processes include an inevitable element of discrediting and stigmatising the person subject to the assessment.
Goffman used the term ‘total institution’ to describe asylums. The term was coined by the American sociologist Everett Hughes who taught at the University of Chicago when Goffman was a postgraduate student. A total institution is one where the basic modern social arrangements whereby individuals sleep, play and work ‘in different places, with different co-participants, under different authorities, and without an overall rational plan’ (Goffman, 2017: 5–6) are broken down. Those living in total institutions are separated from the wider society. Barracks, monasteries, psychiatric hospitals, prisons and residential and nursing homes could all be regarded as total institutions or have features of total institutions. A total institution is not necessarily based on compulsory admission. This is important: people make a positive choice to enter a monastery. Not all admissions to psychiatric hospital are compulsory but the nature of the choice made is open to debate. Not all total institutions are based on a desire to exclude; they may be the result of a positive decision to reject aspects of modern society. The barriers that exist between three spheres of modern life – sleep, play and work – are broken down or disappear completely. The result is that residents/patients/inmates conduct all aspects of their lives in the same restricted physical and psychological environment. In Goffman’s psychiatric model, this environment is also a controlled one, dominated by a staff group that has power over the way that all aspects of the institution are organised and function. The regime is imposed by a system of explicit formal rules but also a second system of informal ones, overseen and imposed by the staff group. The aim of the regime is to control the havoc that led to the inmate/patient admission so that they can re-enter mainstream society.
In St Elizabeth’s, Goffman (2017) noted that the ward system was not based totally on clinical need. It had a clear disciplinary function. The ward system is an example of the way that staff exercise authority and control. For Goffman, the system was a purely behaviourist one. Behaviourism was a dominant approach in psychiatric institutions in this period. Those patients who cooperated were sent to the ‘best wards’. The most uncooperative patients were sent to the wards where the conditions were poorest. The total institution followed a clear system of rewards for good behaviour and punishment for acts seen as transgression. The rewards included improved conditions, but also access to TV and radio or cups of coffee. One of the sharpest insights that Goffman (2017) provides is into the way that individuals respond to the strictures and demands of the total institution. He recognises that within the limitations of the asylum regime, individuals attempt to – and in fact are driven to – maintain their identity. This inevitably involves some transgression of the asylum rules. Goffman highlights the way that the all-pervasive nature of the asylum regime means that behaviour in one area of a person’ s life is brought into another, providing evidence that the ‘spoiled identity’ assigned to them is a valid one. Rosenhan (1975) made a similar point when he argued that one of the most power aspects of diagnosis was that it became a prism through which all behaviour is examined and explained.
Asylums (Goffman, 2017) is, or should be, on the reading list for every mental health module on social work, sociology and social policy courses. The strength of the work is that it examines how response to mental illness becomes a form of social control. Scull (1986) also highlights this as the fundamental weakness of Goffman’s analysis. It does not allow for any therapeutic motivations. The cultural influence of Asylums can be seen in a number of representations of mental illness – most notably in Ken Kesey’s (1962) novel One Flew over the Cuckoo’s Nest (and Milos Forman’s 1975 multi Oscar winning film adaptation of the book). The character of McMurphy and Jack Nicholson’s portrayal of him in the film became iconic representations of the main themes of the anti-psychiatry movement (Cummins, 2017b). The character – serving a prison sentence for statutory rape – is presented as a rebel against the abuses of the regimes but also the wider conformity of post war US consumer society. In his analysis, Goffman excluded the possibility that the asylum could be viewed as an attempt to respond to human suffering. This is clearly not an attempt to defend abusive practices. It is to suggest that Asylums fails to place these institutions in a clear historical context. There is a streak of nihilism that runs through his work that is echoed in Foucault.
The current view of the asylum is largely dominated by its representation as a Gothic institution. Tuan (1979) described them as key markers in ‘landscapes of fear’. Ironically, many of the design features, outlined in the next section, that were seen as therapeutic at the time add to this image. In 1954 there were still 154,000 patients in British mental hospitals. The criticisms of these institutions grew in the 1950s and 1960s. Barton (1959) identified the negative effects that institutionalisation could have on patients, comparing the behaviour of patients on long-stay wards to similar behaviour that he had seen of prisoners in concentration camps. Scott (1973) argued that the hospital itself made individuals passive. This meant that they would be unable to cope with life outside the institution. This followed earlier work by Wing (1962), which had shown how the process of social withdrawal developed among long-stay patients. Overall the picture is one of a physically, socially and culturally isolated institutions cut off from the main stream of health care and the wider society. Martin (1985) described the systemic faults in the institutional provision as the ‘corruption of care’. As discussed in Chapter 3, scandals about the abuse of patients and subsequent public exposure of them became one of the powerful drivers of moves to reform.
Asylum
The term asylum originally meant a place of refuge, safety and protection. This is reflected in its usage in modern international law. Asylum is the protection granted by one state to citizens who have fled another state because of political oppression or fear of persecution. It is the right of a state to grant asylum – it can be refused. In more recent times, asylum seeker has been consistently used in the tabloid press as a term of abuse (Tyler, 2013). Scull (1986) notes that the modern treatment and management of mental illness involved an expansion of state institutions. These institutions were accompanied by the rise of specialists – alienists, the forerunner of the modern psychiatrist – who were able apply their specialist knowledge and skills to the identification, assessment and subsequent treatment of groups or individuals.
The publicly funded asylum did not emerge in England until the 19th century. Prior to this period, there was a system of private madhouses where the wealthy were able to place disturbed relatives. These madhouses were often small and not subject to regulation. Abuse was common and a series of scandals led to a Parliamentary Inquiry and eventually An Act for Regulating Private Madhouses (1774). There were a series of scandals and debates about the treatment of the mentally ill in this period. William Tuke opened the York Retreat in 1796. The funds for the Retreat were raised by the local Quaker community in response to the appalling treatment of Hannah Mills, who died in the York Lunatic Asylum. The system of moral treatment that Tuke helped to develop was based in Quaker informed principles of treating individuals with respect and dignity. The 1828 County Asylums Act saw the establishment of a more formal admissions process but also an inspection regime that provided annual reports to Parliament. In 1845, the Lunatic Asylums Act placed a duty on counties to establish a pauper asylum. This led to a huge expansion in the number of asylums that became such important features of the physical and cultural landscape.
This illustrates that there was a clear humanitarian impulse in the development of the asylum system (Scull, 1986). The later crisis in asylums obscures or marginalises this (Cummins, 2017a). The geographical position and architecture of the asylums were cited by its 20th century critics as evidence of an ideology that sought to banish or exclude the mentally ill and other undesirables from the wider society (Foucault, 2003; Goffman, 2017). This was not the case at the time. Many asylums such as the one in York were called Retreats for the very specific reason that they were just that – a place to escape the pressures of the modern world. One of Scull’s (1986) main criticisms of Goffman (2017) is that he fails to acknowledge that this at any point. As outlined, Goffman (2017) saw the institution as creating the difficulties that the patients face. There is hardly any consideration of the issues that led to their admission. This is, of course, not to deny that abuses took place or that the impact of admission. It is simply to acknowledge the complexity of these processes.
The asylum was planned for a very specific purpose. It is a representation of an ideological response to the problem of madness (Franklin, 2002). The same is equally true of the modern notions of community, which form the basis of community care. The asylums built following the 1845 County Asylum Act were often designed by famous architects such as Sir George Gilbert Scott, a leading figure in the Victorian Revival. In his early career, he designed hundreds of workhouses. His most famous designs include the Albert Memorial and the main building of the University of Glasgow. Charles Fowler, who designed Covent Garden Market, was responsible for an asylum in Devon. The asylums were thus important civic statements. The great architect critic Sir Nikolaus Pevsner praised a number of asylum designs for the scope and ambition of their design. The Victorian Society and other conservation groups have campaigned for the listing of asylums because of their architectural heritage.
The asylums of the Victorian period were located outside of urban settings. This distance from the urban environment and the large grounds that often surrounded them was a key feature of moral treatment. Fresh air and other aspects of the rural idyll were seen as having recuperative properties. The asylums were built on rural slightly elevated sites to avoid the dangers of miasma – foul smelling vapours that were the result of poor sanitation. Until the development of germ theory, it was believed that miasma spread disease (Franklin, 2002). The early asylums were small with a couple of hundred patients. The 1845 Act led to the building of bigger institutions. The other important design features included separate wards for men and women as well as different wards for patients suffering from different conditions. Wards were built facing south with access to a court where patients were able to experience fresh air and sunshine – key elements of the therapy (Franklin, 2002). The corridor plan of these asylums was based on the sanitary principles proposed by Florence Nightingale. The asylum designs often included a house for the medical superintendent, workshops, recreation hall, a ballroom, a farm, a brewery, a chapel and a mortuary. The effect was the creation of a small self-contained community.
In examining a range of perspectives on the development of asylums, it is important not to paint an unrealistic picture or ignore the abuses that occurred or the damage that was done to individuals. Parr et al (2003) in their discussion of the Craig Dunain Hospital near Inverness show that the patients’ narratives of the institution are much more complex and contradictory than is sometimes allowed for. The authors note that the institution had a negative reputation with outside observers. However, the memories of the staff and patients were much more nuanced and complex. The former patients highlighted the lack of personal space and the accompanying indignities. For example, there was no real privacy so patients received injections or had consultations with their doctors in what amounted to public spaces on the ward. At the same time, the former patients spoke about the friendships that they had developed. The grounds of the asylum were particularly fondly remembered as a place where patients were able to enjoy a measure of personal freedom – smoke cigarettes, have intimate relationships and so on. The asylum in this approach is viewed as a much more complex and ambiguous set of social and physical relationships than is allowed for Goffman’s total institution narrative. As one former resident put it ‘That awful place was home’ (Parr, 2003). In Parr et al’s (2003) study the former patients of Craig Dunain are very critical of the new functionalist mental health facility that replaced it – describing it as soulless.
The asylum may have physically disappeared from the landscape, but it remains a potent cultural reference point. There are any number of computer games and apps such as ‘Adventure Escape: Asylum’ which are based on the Gothic image of the asylum. In this game, for example, the marketing plays to a number of tropes that occur across the horror genre:
Anna wakes up one day in an asylum with hazy memories of her past. Soon, it’s clear that something has gone very, very wrong at the Byers Institute. In fact, there is a killer on the loose. (Google Play, no date)
In addition, there are several modern novels that explore the experience of asylums. These include Lehane’s (2003) tribute to B movies and pulp fiction Shutter Island, where a detective is called to a hospital for the criminally insane to investigate the disappearance of a patient. In Maggie O’Farrell’s (2006) Costa award winning novel The Vanishing Act of Esme Lennox, the title character has spent her adult life in an Edinburgh asylum. The novel explores the reasons why her family sought to have her institutionalised.
The process of deinstitutionalisation created the question: what should be done with the sites of the asylums? One of the ironies was that the geographical position of the asylum meant that they were now prime sites for development. Cummins (2018) notes that the site of the former asylum in Gorizia that was closed as part of Basaglia’s reforms of the Italian system became a public park. In the UK of the 1980s and 1990s, the focus was much more on private provision – housing and shopping developments. The heritage status of some sites led to the retention of the buildings as part of prestige developments (Chaplin and Peters, 2003), with the substantial grounds being a bonus. These luxury housing developments use a language of sanctuary that has echoes of the asylum narrative. The development is a private space that offers an escape from the pressures of the city but convenient access to it. This is, of course, required as the buyers will need to work in lucratively paid jobs to afford such an exclusive property. Chaplin and Peters (2003) note that the advertising for such developments uses terms such as ‘seclusion’ that had generally negative overtones when the space was an asylum. The authors found that there were few explicit references to the fact that these developments were on the sites of former asylums. The stigma attached to the asylum lingers on, even after the institution itself has physically disappeared. However, as Chaplin and Peters conclude, ‘paradoxically, asylum can now be bought in an ideal self-contained community, with security to keep society out’ (Chaplin and Peters, 2003: 228).
Leary (2011) outlines what he calls ‘ruin pornography’, by this he means the stylish and artistic photographs and media representations of once great industrial cities. He terms this trend Detroitism, as the city has gone from being a metonym for post war growth to one for deindustrialisation. As he points out, it is possible to buy art house coffee table books of ruined and neglected buildings that were once the heartbeat of US post war industrial economic boom. What these photographs cannot capture is the dynamism of a booming economy or what that meant for working class people. The stylised photographs and images obviously cannot capture the reality of these areas as working environments – the heat, the noise and the physical effort required to keep up with industrial processes are all missing. In a rather similar vein, there is a thriving interest in neglected and abandoned asylums. These photographs are used, in a similar way, to capture the essence of the former institutions. These haunting photographs of abandoned wards, strange equipment used in treatments and images of neglected patients all add to the Gothic reputation of the asylum. ‘Asylumism’ thus acts as a metonym for the management and treatment of mental illness before the advent of community care. In doing so, it collapses the end of the asylum as an institution into its whole history.
Van der Velde (2016) published Abandoned Asylums – a series of photographs that promises readers ‘an unrestricted visual journey inside America’s abandoned state hospitals, asylums and psychiatric facilities, the institutions where countless stories and personal dramas played out behind locked doors and out of public sight’. It also promises images of hospitals that treated the famous and infamous, including Marilyn Monroe and Charles Manson. The abandoned and decaying institutions act as magnets for so-called ‘urban explorers’, such as Keïtaï, who enter abandoned sites and post photographs of what they find. Alongside a series of photographs, the following is an entry from Keïtaï’s blog about a visit to the former West Park Asylum in Epsom Surrey.
We were able to see more of the place; the padded cell, the main hall, the post office and the children’s creche. The padded cell was our main goal like many others who venture there. It was smaller then [sic] I expected and harder too. (Keïtaï, 2011)
This is not the only approach to the complex history of the asylum. For example, ‘The lives they left behind: Suitcases from a state hospital attic’ (Community Consortium, 2015) is an exhibition based on a suitcases found in an abandoned building when the Willard Psychiatric Center in New York’s Finger Lakes closed in 1995. The exhibition paints a complex portrait of the individual lives of the patients before they entered the asylum. This approach forces the reader to ask fundamental questions such as ‘why were these individuals admitted to the institution, how were they treated and why were patients for such long periods?’ Raymond Depardon produced a series of superb photographs of the Gorizia asylum where Basaglia (Foot, 2015) enacted his reforms. These photographs document the need for the reform, as Depardon in discussing how he came to take the photographs states:
I often went back to the old hospital in Trieste, the place called the ‘manicomio’, the ‘lunatic asylum’. One day, I followed this group coming out of the canteen. What was it about the patients that struck me: the way they looked, the clothes they wore, the way they walked? I was drawn to them. I found myself in a very old ‘reparto;’ the door of the ward closed behind me, there wasn’t a nurse in sight. With the noise and the decrepitude of the place, I confess that for a moment I took fright. I started taking photographs, very quietly. (Raymond Depardon, quoted in Howard, 2018)
The development of mental health policy is a history of space and place, seclusion and exclusion. In examining this history, it is vital to consider the symbolic value that is placed on particular spaces and places. Bedlam comes to be representative of institutionalised care. In the US, conscientious objectors in the Second World War were sent to work as hospital orderlies in asylums. Parsons (2018) highlights that these individuals were appalled by what they saw and became committed to reform. This initially involved fighting racial segregation. Conscientious objectors working at the Philadelphia State Hospital at Byberry took their concerns to two journalists Alfred Deutsch and Albert Maisel. This resulted, in 1946, in the publication of an expose in Life magazine, which reached millions of US citizens – the modern equivalent of a prime time documentary or viral video. The expose compared the hospital to prisons. The article also included a photograph, entitled Despair, of an emaciated, naked patient (Parsons, 2018). For readers, who the previous year had seen newsreels of the liberation of Belsen, the link was an obvious one. Later, in 1960s Italy, Basaglia, who was heavily influenced by the work of the Holocaust survivor Primo Levy, made a similar link between the camp and the asylum (Foot, 2015). This was a link that Levy did not think stood up to scrutiny (Cummins, 2018).
The French historian Pierre Nora considers public memory and sites of commemoration, He noted that there is a ‘rapid slippage of the present into a historical past that is gone for good’ (Nora, 1989: 7). He argued that we respond to this by focusing on memories of physical spaces. Thus, the modern world becomes obsessed with a socially constructed version of history that can replace previous collective memories (Nora, 1989). He coined the term lieux de mémoire for sites of remembrance. Nora (1989) sees memory and history as being in opposition with each other. He states: ‘History’s goal and ambition is not to exact but to annihilate what has in reality taken place’ (Nora, 1989: 9). He uses the battlefields of Verdun. The site has become a national monument to the Fallen. In creating the memorials, the horror and carnage has been removed. In its place, there is a grandeur and solemnity totally at odds with the battle that the site commemorates. One possible way to approach asylums is to see them as lieux de mémoire where the memories are still contested.
Community
As previously outlined, the asylum was an institution set apart both physically and psychology from the wider society. This exclusion also reflected the way that psychiatry was a discipline apart from others in medicine. One of the drivers of community care was to tackle this social isolation of the psychiatric patient. There was an implicit assumption that the ills of institutionalisation would be overcome by community based services. Community is one of Raymond Williams’ Keywords (2014). Keywords (Williams, 2014) is an exploration of the changing meanings of the words and terms that are used in discussions of culture and cultural ideas. It consists of 110 short essays on terms including bourgeois, culture and hegemony. He published a revised version in 1983, and added 21 new words.
In 2018, MacCabe and Yanacek edited a new collection – Keywords for Today. Community is one of their keywords. Williams had suggested that community is a word that is never used in a negative fashion. They do not consider its use in the phrase community care, which clearly developed negative connotations, in a very relatively short period in the late 1980s and early 1990s. Community is long established in the English language. It originally meant the common people as opposed to those of rank, the people of a local area or the quality of holding something in common (MacCabe and Yanacek, 2018). The authors note that, as society became more complex, community was the word used for alternative approaches to group living, for example, a religious community. This use made its way into the history of mental health – for example Laing’s establishment of therapeutic communities (Cummins, 2017a). These communities were self-contained and in a sense self-governing. They were attempts to live an alternative, healthier life. The use of community has spread. It is used in a broader political sense – for example the emergence of the term gay community in the 1980s – to represent a grouping of individuals with a shared social identity or shared political and cultural interests. It should be noted that this use of the term is fraught with difficulties. It assumes that there is a commonality of interests which might not necessarily be the case. The notion of community politics is used to denote a more informal, localised approach to campaigning. This is presented as a purer form of political activity. Here community stands in opposition or contrast to the tainted world of machine politics. In one of those ironies of usage, in recent times, there has been the emergence of ‘gated communities’ – as previously noted, a number on the site of former asylums. The use of community plays to notion of inclusion and a nostalgic vision of what life used to be while they are gated to ensure that unwanted elements are kept out.
Community, then, is a term that carries within it elements of nostalgia but also positive notions of making better social connections between individuals and groups. There remains a sense of flexibility in the use of the term community. It can be used as a cipher for a range of values. In the political and policy sphere, it is used as a marker to claim that there is something of an ethical core to proposals. For Bauman (2001) community acts as a counter to a more individualised present or Rose’s (1996) ‘death of the social’. Thus, community is presented as the solution to a whole range of social and other problems. However, we cannot find the mechanisms that will help to recreate it (Bauman, 2001). These trends seem to have become more entrenched since the development of social media. Social media creates communities of a different sort to the organic forms that are the basis of these debates.
Arendt (1959) argues that some form of commonality is central to our physical survival. Individualism and autonomy are core values of our increasingly dislocated community. However, there are contradictions here as we cannot survive without care from others – as infants but also at other times in our lives (Fineman, 2004). The notion of community is a powerful one. In his analysis of nationalism, Anderson (2006) argued that a nation is ‘an imagined political community’ – this is true of all nations. Politicians and elites can make calls based on the idea that though citizens will never meet most of the members of the imagined community, they share interests or an identity. There are periods where this is most keenly felt, for example, major events such as the Olympic Games. This notion of an imagined community can also be applied at a more regional or micro level. Community is an elusive ideal – it is constructed from memory. An idea that is projected into both the past – as it never existed in the way that it is remembered – and the future where it can never exist in the way that it is imagined.
The multiplicity of meanings attached to community allow it to be used with little analytical work (Crow and Allan, 1995). In the late 1970s and early 1980s, as policies of deindustrialisation began to take effect, there was an increasing interest in the notion of community. Community was seen as providing a bulwark against the impact of New Right economic and social policies. Even though many on the Left were attracted to these notions, the use of the term across the political spectrum meant that it was problematic. In particular, the term seems to imply some sense of greater localised, democratic involvement in decision making, but this was often not the case. Policies were often constructed and shaped by the needs of the wider state. The result was that the responsibility for hugely significant social problems was localised limiting the role of state actors and policies in their creation. Brown (2015) notes the way that neoliberal politics pushes the nexus of social problems and their solutions further and further away from the site of their creation. Calls to communities are part of this process. Issues such as class and inequality become marginalised. The language of community is a potentially powerful depoliticising force.
The main expansion of the policy of community care was, somewhat ironically, undertaken by a government whose leader, Thatcher, famously declared that there was no such thing as society. Hall (1979) was one of the first to identify the implications of the shifting political and economic trends of the 1970s. In his seminal essay ‘The Great Moving Right Show’, Hall (1979) saw that the mixture of economic liberalism and social conservativism that Thatcher represented was a new and influential political force. The essay was published in January 1979 before Thatcher’s election victory in May of that year. The post war social democratic settlement was unravelling at that point – most clearly in the winter of discontent (Lopez, 2014). Thatcherism was able to pose as representative of the interests ‘ordinary’ British citizen against the vested interests of the social democratic welfare state – radical trade unions, teachers and social workers, and so on.
These processes also entail the Othering of groups such as BAME communities, the poor, welfare claimants and offenders. Hall was right in his view that Thatcherism marked a break from the post war consensus. Thatcher developed a political image that was the antithesis of consensus, attacking what she saw as the nation’s enemies within and without. Thatcher’s uses of the symbols of Nation and Empire are excellent examples of Anderson’s (2006) ‘imagined community’ as well as the fact these communities are inevitably exclusionary.
In the city: geographies of exclusion
Members of the Chicago school were the first to develop a spatial theorisation of the city (Soja,1996). Spatial factors play a key role in the creation and maintenance of social and community relationships (Simmel, 2004). The city represents modernity, progress (Park, 1967) and creativity but also a sense of dislocation and danger. At the same time establishes social order (Tonnies, 1955). Any analysis of the deregulated, gentrified city created by modern forms of capitalism has to consider Davis’ (1998) City of Quartz. Davis’ (1998) study of Los Angeles (LA) focuses on the way that urban spaces are sorted and segregated. Urban spaces are the key battle ground where capital establishes and maintains its dominance. Public space is essentially privatised. The poor are excluded so that the middle classes and elites can take advantage of the new leisure culture of city centres. Davis (1998: 224) argues ‘Police battle the criminalised poor for valorized spaces’. Value comes from the fact that these are spaces dedicated to consumption and recreation. They therefore need to be protected. The subtitle of City of Quartz is ‘excavating the future’. The LA model of development and regeneration is one that has been followed across late capitalist societies.
Neoliberal forms of governance saw huge changes to the management of urban environments. This shift was based on a whole series of financial policies, such as free trade zones, deregulation and changes to planning law, that has been characterised as a process of ‘creative destruction’ (Brenner and Theodore, 2002). Alongside these financial policies a set of social policies including zero tolerance initiatives, clampdowns on anti-social behaviour and increased use of CCTV have attempted to manage the city centres and make them attractive to capital and consumers (Harvey, 1990). In these new urban environments, public space is more limited and other environments, for example shopping malls, are subject to greater forms of surveillance or private policing. These environments are replicated across cities so that they become predictable and somewhat sanitised (Sibley, 1995). Sibley (1995) argues that an integral part of these new developments is ‘boundary erection’. These boundaries are physical but also economic and psychological. They are based on conceptions of abjection and hostility. The new boundaries of the modern urban environment are increasingly moral ones (Sibley, 1995: 39–43) The exclusions are based on factors that include class, race and disability. The ultimate division is, perhaps, between consumers and the ultimate deviant in neoliberalism – the non-consumer. In these processes, the value of property is seen as higher than the value of people (Sibley, 1995). If asylums can be viewed as rural, then community care is a policy most closely associated with urban environments. Wacquant (2008) sees the city as a location or means of sorting populations into desirable/undesirable. This is done on the basis of class and race. However, mental health status also became a factor in these processes (Moon, 2000; Cummins, 2010a).
The period of community care coincided with the initial stages of what came to be termed neoliberalism. These policies led to increased inequality, which has produced social and economic segregation (Savage, 2015). These developments have social, psychological and economic impacts (Wilkinson and Pickett, 2010). There are huge differences between the physical and mental health of the richest and poorest in society. The early development of these increasing divisions can be traced back to the 1980s. These differences are starkest in the most unequal societies. More equal societies with progressive welfare and health systems mitigate these potentially adverse outcomes (Marmot, 2015). There was a brief period under the first New Labour government where increased investment in social welfare halted some of these developments. However, they have been intensified during the austerity since 2010 (Cummins, 2018). In many ways, the progressive arguments for community care in the mental health sector assumed continued broader investment in social welfare provisions. There was an implicit view that a shift from spending money on institutionalised psychiatry to community mental health services would not only take place but also lead to better outcomes for service users.
From the late 1990s onwards, in the UK and across Europe, there has been an ongoing moral panic (Cohen, 2011) about the ‘ghettoisation’ of socially deprived urban areas. The term ghetto – in modern usage – suggests an area of poor housing, poverty, substance misuse problems, high crime and gang violence. It also has racist overtones.
More recently in the UK, governments of all political persuasions have been concerned with the issue of ‘sink’ estates. Slater (2018) demonstrates that the term ‘sink estate’, which is often presented as an academic or sociological term, was invented by journalists. Its use was then extended by free market think tanks before becoming a form of policy doxa. It was used as a shorthand for areas that allegedly create a range of social problems such as poverty, worklessness and welfare dependency. Slater (2009) argues that the ghetto is a social and psychological space with its boundaries created by ethnicity. Although these spaces were originally the result of discrimination, they also generate forms of community organisation.
Wacquant (2008a, 2008b, 2009a, 2009b) suggests that modern, urban, spatially concentrated forms of poverty have made it more difficult to sustain social and community institutions. Fordism had been associated with a range of previously strong civic institutions, ranging from political to social and from trade unions to sports and youth clubs. Changing patterns of employment and the increase in precarity have been a key factor here. It is very important to note that Wacquant is not suggesting that such social systems do not exist. For example, his Body and Soul (2000) examines the experience of young black men who use a gym in Chicago and considers the function of these informal structures in some detail. In a similar vein, McKenzie’s (2015) portrait of life on a Nottingham estate – Getting By – focuses not only on the economic and social pressures facing the residents but also the ways in which they overcome them.
Wacquant (2007) terms this ‘territorial stigmatization’ – the processes whereby areas are characterised by:
… forms of poverty that are neither residual, nor cyclical or transitional, but inscribed in the future of contemporary societies insofar as they are fed by the ongoing fragmentation of the wage labour relationship, the functional disconnection of dispossessed neighbourhoods from the national and global economies, and the reconfiguration of the welfare state in the polarizing city. (Wacquant, 2007: 66–7)
Media representations of community care as a failing policy focused on either the neglect of patients or an increased risk to the public. The longer the policy was in the public eye, the more the media focus was on the alleged increased risk that former psychiatric patients posed to their fellow citizens. There is a similar arc here to the asylum narratives outlined earlier. The failings of the policy in its later iterations acts as a prism through which the whole prism is viewed. This obscures not only positive aspects of earlier periods but also means that the narratives of those who might have spent their lives in institutions but did not are never examined or are lost. By 1984, there were 71,000 inpatients, roughly half the number when Powell made his Water Tower speech in 1961. Leff and Triemann (2000) argue that the first wave of community care was largely seen as a positive move. This period saw the resettlement of long-stay patients. These patients were, on the whole, better supported by mental health services. One key aspect of this was the fact that resettlement often involved the use of specific funding for that purpose. Later, community care services had to compete with others for access to increasingly squeezed funds.
As with deinstitutionalisation in the US, community care rather rapidly became associated with street homelessness or people living in very poor accommodation. Scull (1986), in criticising the impact of deinstitutionalisation, identifies what he terms a modern trade in lunacy. He notes that the irony of a policy developed to deal with the abuses of the asylum regime leading to concerns about vulnerable people being exploited by unscrupulous private landlords. Similar concerns in the early 19th century had been a driving force in the establishment of the original asylums. In 1976, John Pilger, then a campaigning journalist for the Daily Mirror, wrote an expose of the way that psychiatric patients were being discharged to bed and breakfast (B&B) accommodation with no support or follow up. Pilger report is based in Birmingham, which he describes as a ‘city of lost souls’. The article reports that former patients are living in crowded, often insanitary conditions. They are often not allowed in the accommodation during the day so spend their time wandering about the city centre as there is little in the way of constructive activity. The social workers that Pilger interviewed for the article suggest that Birmingham, possibly because of its size and the number of B&Bs acts as something of a magnet. They give accounts of psychiatric institutions outside of the city discharging patients with a one-way ticket to Birmingham. When reading the Ritchie Inquiry (Ritchie et al, 1994) and its account of Christopher Clunis’s contact with mental health services, which took place 15 years after Pilger’s article, one is struck by how often Clunis is living in homeless accommodation – a clearly totally unsuitable environment and one that could not possibly hope to meet his needs.
The asylum was thus not replaced by a well-resourced system of community mental centres, crisis accommodation, supported and independent living schemes and employment, which would enable people with mental health problems to complete the journey from ‘patient to citizen’ (Sayce, 2000) As the asylum closed, a fragmented, dislocated informal network of bedsits, housing projects, day centres or, increasingly, prisons and the criminal justice system replaced it (Moon, 2000; and Wolff, 2005). For many, as Parr et al (2003) demonstrated the friendship and communal living aspects that existed in asylums were lost. Knowles (2000) in her study of the way that former patients negotiated the public spaces, shopping malls and urban environment of Montreal shows that rather becoming integrated into the wider community, this group was isolated and shunned in similar ways to asylum patients. A series of powerful black and white photographs captures the ways that the ‘mad’ exist alongside but are ignored by the wider society. Knowles (2000) highlights the ways in which the responsibility for the care of the ‘mad’ has moved from public to private institutions. She goes on to suggest that the restructuring of mental health services acted as a model for other ‘problematic populations’. As Cross (2010) suggests, pre-existing social representations of the ‘other’ are very powerful in their ability to create a new identity for social categories. In this case, the representation of the mad from the asylum era has followed those people into the community. The homeless mentally ill (black) man became a TV and film drama cliché of gritty urban realism. The representation has changed – the mad are not now dishevelled creatures chained to walls – they are the homeless of the modern city living on the streets with all their belongings in shopping carts. Their presence on the margins is accepted as a feature of modern urban life. In his discussion of asylum seekers, Bauman (2007) argues that in a world of ‘imagined communities’ they are the ‘unimaginable’. Similar processes can be identified here; the mad became one of the constituents of what Bauman termed ‘internally excluded’. The media debates about community care led not to calls for investment in community mental health services but changes to legislation and a demand for the return of institutionalised care (Cummins, 2010b).
Conclusion
Mental health and responses to it take place within specific locations – temporal and spatial. The geographical locus of treatment provides an insight into the theoretical underpinnings of treatment but also wider social attitudes. Two idealised notions or representations of the asylum and the community came to play a dominant role in broader understandings of mental health policy. The asylum/community binary contains within it a series of other binaries: past/future; rural/urban; inclusion/exclusion; abuse/dignity; institutionalisation/independence; tradition/modernity; and deterioration/progress. The development of asylums involved the institutionalisation of populations who were regarded in some way as deviant (Castel, 1988, 1989). Asylums were located on the outskirts of cities or in rural settings, partly for therapeutic reasons but also as acts of exclusion. The asylum dominated the landscape in a physical but also a metaphorical sense. The closure of the asylums represented not just the transfer of the location of services but a switch in the modality of service provision (Joseph and Kearns, 1996). The seclusion of the asylum setting and their architecture ironically made them attractive to property developers in the 1980s. Those sites that were abandoned became part of the Gothic myth of the asylum.
Community care was seen as an antithesis to the dehumanising regime of the total institution that Goffman (2014) and others outlined. Community was used in a very problematic way that overlooked some of the philosophical difficulties with the concept. The community was assumed to be an entity rather than an abstraction but also a welcoming one. This proved to be naive, perhaps even wildly optimistic. As community care was being introduced, a series of economic and social policies placed tremendous pressure on the poorest urban communities. The asylum disappeared and its place was a rather hidden world of B&Bs and often poor supported housing projects or homelessness. These moves were at odds with a narrative of independence and civic rights that was to be found in policy documents. Moon (2000: 241) argues that the ‘concealed others’ of the asylum regime were replaced with the ‘visible others’ of the new system. The asylum was a site of social hygiene. Community care became associated with the ‘street’ as a public space of potential danger. These concerns were increased by the series of homicides that are examined in Chapter 3. It led to calls for more the provision of more secure psychiatric beds.
Young (1999) discussed what he termed the ‘narrative of modernity’. He saw the Fordist regime of production as leading to a stable pattern of employment supported by a universalist welfare regime. These systems helped to generate a series of social and community bounds. The moves from asylum to community should be viewed as part of wider shifts in society. The asylum came to be seen as an abusive system that denied citizens with mental health problems fundamental rights. The inclusive nature of the Fordist regime was illusory – inclusion for some means exclusion and marginalisation for others (Foucault, 2003). The excluded groups such as women, the poor, people from minority communities and the mentally ill were seen as ‘other’ – not full citizens in both the legal and moral sense (Nye 2003; Yar and Penna, 2004) The historical narrative of modernity includes an emphasis on the development of individualism and the progressive implementation of Enlightenment ideals. This view was challenged from the 1960s by a number of social movements which included mental health service user groups. Wider democratic developments obscured the treatment and continued exclusion from civil society of marginalised groups (O’Brien and Penna, 1998).
The policy of community care became a domestic policy crisis for the beleaguered Major government (Cummins, 2010a). One of the key ways in which the modern state claims legitimacy is by ensuring public and individual safety. Thus governments must respond to a series of threats such as a possible terrorist attack. These threats are increasingly internal or domestic ones. The ‘madman’ of tabloid legend became one of these perceived threats to the legitimacy of the ‘personal security state’. The option of building new asylums was never seriously considered. This would have required a huge fiscal commitment from the state. A new much looser network of private mental health care provision developed. This was largely hidden from the wider society. Local people might be aware of a small supported housing project but these were usually terraced houses rather than purpose built accommodation. It is a sad reality that the abuse, neglect and marginalisation that took place under the old regime did not end when the asylum gates were closed.
