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.
Introduction
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