Closing The Asylum: The Mental Patient in Modern Society

By Peter Barham and Peter Campbell

Closing The Asylum: The Mental Patient in Modern Society. The Covid-19 pandemic has affected the mental health of almost everyone, but it has impacted most severely on disadvantaged groups such as people with severe mental health problems, throwing pre-existing inequalities into sharper and starker relief.  Though they had mo

• Language: English
• Publisher: Process Press Ltd
• Release date: Dec 1, 2020
• ISBN: 9781899209224

Peter Barham

Peter Barham has been engaging critically with the field of madness for more than fifty years. His work has straddled clinical & social research, historical inquiry, mental health activism and film making. His other books include: He has a Ph.D in abnormal psychology from Durham and in modern history from Cambridge. He is a chartered psychologist & a fellow of the British Psychological Society.

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PREFACE

I have been a mental health service user for more than fifty years. During that time I have had direct experience of the old asylums in full swing; the closure of the asylums and the development of a community mental health system to replace asylum-based care. I have received care and treatment in Scotland, East Anglia, South-West and North-West London. In total, I have undergone more than two dozen admissions into acute care. In some people’s eyes I could be seen as a classic revolving door patient.

Anyone with first-hand experience of the old asylums will not easily forget them. Although they were often located in beautiful countryside and had fine lawns and trees in their gardens, the buildings themselves could be grim and forbidding. I remember being in Banstead in Surrey in the late 1960s and finding myself frankly intimidated by the architecture. Inside, the atmosphere of asylums was dominated by closed doors and endless linoleum corridors. In the wards in-patients spent most of their time watching television, doing nothing at all. By mid-morning a pall of tobacco smoke hung in the dayroom air. Life was monotonous but not completely so. There was occupational therapy for the acute patients and work on the asylum estate for others. There were also entertainments - film shows and ward parties. Sometimes there were games of football or cricket at neighbouring asylums although all these events fell away as the asylums were run down. There was a definite asylum life even though it is arguable if it was real life.

It is worth remembering that the closure of the asylums was a controversial policy. By no means everyone in the mental health field wanted to see the asylums close down. In particular, relatives’ organisations were deeply suspicious, fearing their loved ones would be abandoned in a community mental health system. On the other side of the argument, among other allies, was the survivor movement (service user activists), just gaining a voice in the mid-1980s and believing the development of community care was a necessary first step towards better services and ultimately to a more equal citizenship. In the end, the latter view prevailed. But the asylums were probably closed more for the cost of keeping them open than for any deep commitment to community care on the part of government.

One novel feature of the move to community-based care was the introduction of services designed to prevent people in crisis from ending up in acute care. Nowadays in many places there are Home Treatment Teams and Crisis Resolution Teams that aim to support people through their distress in their own homes. They are a welcome and thoroughly necessary innovation. But for those of us whose crises are very severe or of a rapid onset these new services are not appropriate. For us the acute ward is likely to remain the only destination and here the picture is not so rose-coloured. In my experience, the acute ward has not changed very much in fifty years. It remains essentially a warehouse, a relatively safe place where patients can be supervised while the medication kicks in. The ward entrance is frequently locked even if the ward is ostensibly open. In-patients have to sign themselves out and in. The long-standing complaint that most nurses stay in the nursing office remains as relevant today as it did in the 1960s. Those nurses that remain in the dayroom are policing the occupants and not really interacting with them. Sometimes they are preoccupied with their mobile phones. Overall, the ward usually has a sterile feel. Nothing that is seriously therapeutic is actually taking place. It is very clear that regular medication is seen as the pre-eminent answer to the problems in-patients present.

One key feature of mental health services that I have regularly experienced is the use of compulsory powers. Around two-thirds of my admissions have been under sections of the Mental Health Act. Like others with a diagnosed mental disorder I have significantly reduced rights. I can be detained for periods of months. Treatments I have specifically refused can be forced on me. In effect I have become a second-class citizen with less freedom than others who do not share my diagnosis. The Mental Health Act, while protecting some of my rights, ends up disabling me. In the light of this it might be thought that mental health workers would try very hard to avoid the use of compulsion. But in fact its use has been rising in recent years. Approximately 50% of in-patients on acute wards are now detained under the Mental Health Act. Whatever the reasons for this rise, and it appears we are now living in a risk-averse culture, there does seem to be a consensus that we are currently moving in the wrong direction.

An unfortunate provision of the Mental Health Act is related to Section 136 which gives the police power to pick up mentally distressed people in a public place and take them to a place of safety for assessment. These places of safety can sometimes be police station cells. I believe it is quite wrong to detain people in solitary confinement in a police station cell at the peak of their distress. This would not be tolerated for any other group of disabled people. My own experience suggests that such treatment is often traumatic and seldom forgotten. It is an indication of a fundamental lack of sympathy for those in mental distress that this practice continues 35 years after it was introduced.

The Mental Health Act is an important element of a well-entrenched mental health system in the United Kingdom. This comprises mental health services but extends beyond them. It includes social attitudes and practices towards service users. Over a period of fifty years one would expect attitudes to have changed and this has indeed been the case. Generally, public understanding of mental health issues has improved. The media, which in the 1980s and 1990s were purveyors of predominantly negative stereotypes of the mentally-ill, nowadays convey a more balanced point of view. It is notable that many celebrities are speaking out about their own problems. The Duke and Duchess of Cambridge and the Duke and Duchess of Sussex are involving themselves in mental health campaigning. There is a sense that mental health issues are coming out of the shadows.

Too much can be made of this. First of all, openness depends partly on the type of mental health problem being talked about. Depression and anxiety are pretty much acceptable territory. Psychosis is less so and schizophrenia is still a virtual no-go area. Moreover, changes in attitude do not always mean changes in practice. Discrimination has not disappeared. People with a mental illness diagnosis are still discriminated against in employment, in housing, in insurance and other areas. The pressure to keep quiet about your history is still very real. I never succeeded at a job interview where I was open about my mental health problems until I started working as a survivor-trainer in the mental health field. Then they became an advantage.

One important element of the mental health system that did not exist at the time of my first admission was the service user/survivor movement. In those days it was not possible to become involved in developing services. Nowadays service users can involve themselves in the planning and monitoring of services, the training of mental health workers and psychiatric research. They can also campaign around controversial issues like the reform of the Mental Health Act, the misuse of psychiatric medications or the abolition of ECT. It is not clear how successful the movement has been. It certainly appears that the more radical of its proposals have not led to positive change. But at least the movement is there. Service users do have a voice if they care to use it.

A problem that affects all service users, regardless of whether they are activists or not, is credibility. The mental health system judges them as periodically or permanently incompetent. As a result it can be thought that they do not know what is in their best interests and others can act for them. When they speak out others may listen but discount what they say. When there are disagreements about treatment they are put down to the service user’s illness rather than to justifiable reasoning. This damaging lack of credibility can affect individual service users when they try to be involved in planning their own care and treatment and also has an impact on them collectively when they put forward new understandings of psychiatric phenomena like psychosis, hearing voices and hallucinations. It is one example of how the balance of power is tilted against all people with a mental illness diagnosis.

The asylums have gone now. In many places they have been transformed into high-end housing. The question remains whether the asylum mentality, the spirit that animated those institutions, has also disappeared. It has been said that you could take the worker out of the asylum but you could not take the asylum out of the worker. But now there are many mental health workers who have never known the asylum as a caring environment. Surely we have moved on to something better. It is good to be able to report that service users are now more involved in their own care and treatment. The introduction of the Care Programme Approach, advocacy and advance directives have been important developments in this respect. But this is worth repeating, the acute ward has not changed much. My experience in recent years suggests it remains custodial rather than caring and the increasing use of compulsion must have exacerbated this. What is needed is a mental health system that is sensitive to the expressed wishes of service users in whatever setting, a system that does not disempower people with a mental illness diagnosis because of the supposed nature of their problems. In short, with the asylums receding into a nostalgia-tinged past, what is needed is a genuinely service user-led mental health system.

This book is a very welcome re-issue and I was pleased to be asked to write a Preface to it. Peter Barham is a friend and colleague of mine and we often meet for a takeaway curry and to discuss our writing projects. I was delighted to hear that a new edition of Closing the Asylum was being planned as I have always felt the previous editions were important tools in understanding what has been happening in the mental health system in the last forty years.

My enthusiasm was increased when I read the new Prologue Peter has written for this edition. It was around about then that Peter put the proposal to me that I should write a Preface and of course I agreed.

Closing the Asylum is an important book. The issues it illuminates remain central and relevant today. A new Prologue brings the text up to date and provides a crucial focus on the dilemma of compulsion in psychiatry. It underlines the fact that the challenges the mental patient pose have not vanished simply because the asylums have closed. Most importantly, the book shows that they continue to be a vulnerable and devalued group in modern society. Closing the Asylum is notable for being so sensitive to the true predicament of people caught up in the mental health system. It is a very necessary contribution to current mental health debates.

Peter Campbell

PROLOGUE TO THE NEW EDITION

I first embarked upon this book almost thirty years ago, though the second edition appeared in the late 1990s. I was pleased when Robert M.Young, the founder of Process Press, proposed to me that the press should reissue it, mainly because I feel that while much has changed, both in British society and in mental health, in the intervening period, many of the paradoxes, dilemmas, uncertainties, and ironies of the post-asylum landscape that I identify in the book are still very much alive and relevant to current debates. It may be helpful if, in this prologue I try briefly to set the book in the context of its emergence and also draw attention to some features of the current scene that are less prominent in the book, notably the dramatic increase in the recourse to coercion and constraint in the delivery of mental health care in the community. When referring to the proposals for Community Treatment Orders that were already being debated in the 1990s, I say that it ‘appears unlikely that they will be implemented’. Well, I obviously made the wrong call there for they were indeed introduced in England and Wales in 2008. And yet, ten years later, the controversy around them, far from abating, has if anything increased, and research has now questioned their effectiveness and value. So, as I shall discuss, having taken off with determination in one direction, the debate has now circled back to re-engage with some of the same questions and concerns, practical and ethical, that I try to identify here.

‘COMMUNITY CARE HAS FAILED’

Starting in the early 1990s already community care was being widely derided as an idealistic, foolhardy, ill-judged, irresponsible, and even cynical, endeavour. It was a deceitful foil for cost-cutting measures that involved the ‘release’ (as though the penitentiary and the psychiatric hospital were indistinguishable) of mental patients into the community whose propensity for violence was, apparently, perfectly obvious to everyone apart from the misguided elite (politicians and doctors mostly) who had the power to make the critical decisions concerning them. An association between mental illness and violence was widely assumed and if a person with a psychiatric diagnosis committed any kind of act that could be characterised as violent it added fuel to a combustible stereotype, even more so if a person from the black and minority ethnic (BME) communities was involved. Amidst headlines such as ‘Freed mental patients kill two a month’ (Daily Mail, 13 October 1997) and ‘Abandoned to wreak havoc’ (Daily Mirror, 24 February 1994), a succession of cases involving former mental patients were flagged by the media, notably Christopher Clunis’s murder of Jonathan Zito, a complete stranger, on the platform of a tube station. The ‘tube murder case’ was widely deployed as a symbol of the failings of community care policies. In a climate increasingly governed by the politics of fear, the incoming Labour government announced sterner and more restrictive, verging on draconian, measures. ‘Community care has failed’, declared Health Minister Frank Dobson. Throughout much of 1998 newspapers were blasted by headlines such as: ‘Care in the Community is Dead’; and ‘Dobson Acts to Sweep the Mentally Ill off the Streets’. ‘A sad and sorry episode in the history of British social theory is drawing to a close’, declared an editorial in the Daily Telegraph in January 1998. ‘The policy known as care in the community which plucked the mentally ill out of huge Victorian asylums and sent them to live, often alone, in towns and villages is to be reversed'. Opined The Independent, the policy ‘was based on lofty and widely held ideas... Whatever the theoretical benefits of care in the community, in practice it was a disaster... hundreds of thousands of vulnerable and disturbed patients were simply turfed out to fend for themselves... public anxiety and the needs of the mentally ill have meant that a rethink is necessary’ (editorial, 30 July 1998).¹

Action was now promised: Health Secretary Frank Dobson ‘will announce shortly that the controversial care in the community policy is to be reversed and the Mental Health Act rewritten. Money will be allocated to build new institutions around the country to house schizophrenics and other patients’ (Independent on Sunday, 15 November 1998). From much of the press coverage the public could reasonably conclude that all these tragedies could be averted if only people with a diagnosis of schizophrenia were to take their medication and comply with treatment. Much of this coverage was, however, highly selective and slanted. The no less tragic case of the death of a patient as a result of neuroleptic drugs, for instance, was hailed with a resounding silence. When the unfortunate Munir Majotti died in hospital in York after being injected five times within 40 minutes with the maximum recommended dose for a powerful neuroleptic, there was, alas, no lament in the press over his untimely end or an outcry over the deficiencies in the care he received. As an influential review of media influences on mental health policy in this period concluded, ‘policy measures introduced in response to public concerns about risk and dangerousness have further stigmatized people with serious mental health problems’. Under such circumstances, ‘the vulnerable mental health service user is unlikely to receive appropriate care’.²

THE LANDSCAPE OF PSYCHIATRIC COERCION

Psychiatrist George Szmukler, Emeritus Professor of Psychiatry and Society at King’s College London, titles his remarkable new book Men In White Coats: Treatment Under Coercion in order to evoke a disquieting metaphoric truth about the contemporary landscape of psychiatric coercion.³ Today, we inhabit a radically split, or bifurcated, mental health culture in which opposing tendencies, some of them contemporary, others the relics or hang-overs from eras that one might have supposed long surpassed, nonetheless co-exist. Sometimes they go their own way, apparently oblivious of each other, but sometimes they collide.

The Mental Health Act 2007 introduced for the first time the right to Independent Mental Health Advocacy for service users in order to support them in understanding and exercising their legal rights. An Independent Mental Health Advocate, who worked for a year at the Maudsley Hospital supporting inmates to understand and exercise their rights, recounted how his clients’ legitimate objections to the drugs they were put on were routinely ignored: ‘As soon as the patient disagrees with the medication, they are coerced into taking it. If they question the diagnosis, that is seen as part of their illness and is used to justify forced treatment. As soon as you disagree with the professionals, you’re in trouble basically’. And then the white coats move in: ‘The patient is forcibly taken by six people, held down, and injected... I’ve seen people crying and shaking, in absolute distress, following being restrained... But from what I’ve seen, professionals don’t seem to appreciate the impact of what they’re doing. They just see it as, this is the medication that is best for the person, the person doesn’t agree because they don’t understand their illness, so we’re going to use force. There is no attempt at negotiation’.⁴

COERCION AND COMMUNITY CARE

It is in the much-intensified recourse to involuntary detention that the forces of containment have most obviously been manifest. The number of people detained involuntarily in mental hospitals in England and Wales rose from 21,897 in 1988 to 58,399 in 2015. Nearly 50% of in-patients are now detained on an order under the Mental Health Act. George Szmukler recalls that when he was a trainee psychiatrist in the late 1970s it was less than 10%. Tania Gergel and George Szmukler invite us to ponder the irony that ‘while community care may have been envisioned as a step towards greater liberty within psychiatry, use of coercion in many countries is currently increasing’.⁵ In addition, when Community Treatment Orders (CTOs) were introduced in England and Wales in 2008 the government had predicted a take-up of not more than a few hundred a year, but in actuality by the spring of 2015 there were as many as 5461 people on a CTO, and there are no signs that their use is likely to abate.

Until 1930 all patients in public mental asylums were detained against their will, but in recent years the ‘coercive shadow’ that has always hung over public psychiatry especially, has expanded and intensified, spurred very largely by the huge reduction in the availability of in-patient beds - down from 150,000 in the mid-1950s to 67,000 in 1987 and to just over 19,000 in 2016 - in a society that has in the meantime become increasingly risk-averse. As a result, the void left by the erasure of the old mental hospital regimes has been filled, or compensated for, by a new coercive and fear-driven zealotry. Nowadays, a patient must frequently be sectioned in order to secure a bed.

The ‘shadow of coercion’ refers especially to the psychiatric patient’s ineluctable awareness of the coercive taint that permeates the psychiatric treatment context. As the veteran activist Peter Campbell, founder of ‘Survivors Speak Out’, observes: ‘That an individual can be compelled to receive psychiatric treatment affects each in-patient regardless of whether his stay is formal or informal. It is hardly possible to be unaware that you are being cared for within a legal framework that allows for treatment against your will’. Similarly, two survivor advocates and researchers, Jasna Russo and Jan Wallcraft, underline the ‘coercive potential of psychiatric treatment itself’ for in a system based on the option of using force ‘the question of whether a person is legally coerced or not may become a side issue on an experiential level’.⁶

WASTE PRODUCTS OF CIVILIZATION

In Britain in the early nineteenth century, the revolution of laissez-faire capitalism brought about the eclipse of customary forms of social protection, or moral economy, hastening the establishment, and soon the expansion, of a system of public lunatic asylums for a surplus population who would otherwise have been without protection. Starting already with the eighteenth century Enlightenment, there has been a predisposition in the West to equate humanity with reason and to strip madness of significance. The product of a Victorian culture of domination and subordination, psychiatry (as the profession later styled itself) treated the great majority of its subjects (those, at least, who languished in public asylums) as if they were a colonised people. Perceiving them as a failed cadre in the cultural politics of the imperial race, psychological medicine obligingly spawned a condemnatory rhetoric about the mad, masquerading as science.

‘Sanity is self-control and insanity is the want of it’, asserted Sir Thomas Clouston, the hugely influential medical superintendent of the Royal Edinburgh Asylum, in 1896, who regarded his patients as unruly children in need of discipline, summing up his approach as ‘discipline, order, a life under medical rule’.⁷Alienists, as psychiatrists were formerly known, made it their corporate mission to deliver the message to the suffering inmates that their membership of the ordinary human community had been permanently suspended. With the ascendancy of Social Darwinist ideologies, the type of person classified as a lunatic, at ‘home’ or on the colonial periphery, became emblematic of an inferior type of being, as a throw-back, or regression, to a more primitive stage of human development, or as a waste product of civilization. Towards the end of the nineteenth century especially, the mad poor were not only confined physically but also bonded to a perverse outlook in which mental suffering was frequently conflated with moral turpitude. ‘Lunatics’, opined the distinguished psychiatrist Daniel Hack Tuke in 1878, are ‘an infirm type of humanity’ and on admission to the asylum, ‘ No good is plainly inscribed on their foreheads’.⁸ Through to the present-day, psychiatric modernity has viewed madness essentially in defect or deficit terms as a transgression, or an offence, against civilization. The ‘twentieth century collars madness’, stated Michel Foucault the French philosopher and anatomist of psychiatric modernity, in an early interview, ‘reducing it to a natural phenomenon bound up with the truth of the world’.⁹

PSYCHIATRY AND COLONIAL RELATIONS

In an accomplished and finely-honed analysis, critical psychologist China Mills interrogates the ‘uncomfortable question of whether psychiatry (and the disciplines of the psy) can be both a tool of more traditional colonialism and a form of colonialism itself’. Though we should not collapse colonialism and psychiatrisation together, it is at the same time very relevant to trace the interlacing histories of colonialism and psychiatry and especially their co-constitutive metaphors of savagery and madness. Thus, for instance, ‘the dog-eared textbooks of psychology and psychiatry are full of parallels drawn between colonised peoples (savages, primitive peoples) and people with mental illness.’ ‘What if psychiatry itself mobilises a colonial relation’, Mills asks, ‘alienating people from their own understandings of distress & violently interpellating them into a fixed identity as mentally ill? Even when applied within the countries it originates from, ‘psychiatry has been criticised as being a form of colonisation,... labelling people as irrational and thus in need of care in their best interests, and subjecting people to forced treatment and involuntary detention’. Psychiatric and colonial discourse both ‘construct subjects who are understood as degenerate in order to justify intervention’; and ‘produce forms of governmentality that appropriate and dominate the subject peoples they constitute and fix as others’. In order ‘to better understand the continued coloniality of psychiatry’, Mills invites us to ‘read psychiatry as enacting a colonial relation’ and as a mechanism to enable a ‘perpetuated coloniality’.¹⁰

AN END TO SEGREGATION?

As historians have shown, it was in the nineteenth century that the movement accelerated and intensified to segregate those deemed to suffer from mental disturbance from society, both physically and categorically. It is exactly this segregated universe that, on an optimistic reading, policies of deinstitutionalization were intended to dismantle, demolishing not just buildings but also oppressive and isolating categories, in the name of a more inclusive and welcoming ethos of mental health understanding and care. As writer and mental health activist Alastair Kemp remarks, in a variation on Michel Foucault’s history of madness, the forces of ‘recovery’ and the forces of containment have always been in tension in the history of mental health, in a dialectical movement in which, one then the other, temporarily succeeds in gaining ascendancy.¹¹

The emancipatory struggles of former mental patients have continued apace in recent decades, enacting a radical sense of ‘recovery’ as an emancipatory process through which users and survivors recover their own powers of self-determination, and the control over their personal and collective histories. And, as a result, the psychiatric survivors movement has come to assume a more robust presence in the mental health landscape and in the wider society. In a recent historical study of the mental health service user movement in Scotland, Mark Gallagher describes how, by the early 1980s, in an edgy act of self-definition that both played to, and mocked, the Thatcherite ideology of self-help and independent living, user groups were no longer identifying as ‘mental patients’ but instead were referring to themselves as ‘consumers’ of mental health services, and challenging the passive ‘sick role’ of ‘being the good obedient patient’ to which state-sanctioned medicine still expected psychiatric patients to adhere. In sociologist Talcott Parsons’ classic formulation of the ‘sick role’, the sick were ‘deprived of the possibility of forming a solidary collectivity’ or a subculture of the sick. In actuality, from the mid-twentieth century onwards, diverse groups among the disabled and sick were starting to organize and form collective identities, and former mental patients were just the latest recruits to an increasingly non-deferential medical culture. ‘What we mean by self-help’, asserted one such Glaswegian ex-mental patient action group, ‘is organizing ourselves to get what we need, and doing so on our terms, and not allowing ourselves to be patronized or led by the nose under any circumstances’.¹² In 1975 the moral philosopher Alasdair MacIntyre invited ‘patients to become active moral agents in an area where they have been passive: patients have to become agents.’¹³And within just a few years, as Gallagher remarks:

‘psychiatric patients in Glasgow, the city where Alasdair MacIntyre was born, were realizing in practice what he had advanced in thought. These psychiatric patients and ex-patients were no longer prepared to passively submit, as powerless and isolated individuals, to the