The closure of mental hospitals in the late twentieth century greatly accelerated the ongoing catastrophe that is psychiatric care in this country. It was touted by policy-makers as a route to the desegregation and destigmatisation of people with serious psychological disorders. However, the result – foreseen by many at the time – has been the replacement of a flawed system of institutional care with a ‘community care’ regime that is remarkable mostly for its care-lessness and coerciveness. This is supplemented by an increasingly carceral system of secondary care for people with acute conditions. Both are grossly underfunded, despite repeated claims that mental health now enjoys parity with physical health in public funding priorities. The result is a ‘Cinderella’ service which does a huge disservice to a large (and, with Covid) rapidly growing sector of the British population.
It didn’t have to be this way. Well-planned, well-funded community psychiatric care would have been a huge improvement on most of the old ‘bins’, with their long histories of patient maltreatment and neglect (offset by some outstanding examples of good practice). But despite the emancipationist rhetoric of the asylum demolitionists, endorsed at the time by many on the left, deinstitutionalisation was mostly a cost-cutting exercise, yet another nail in the coffin of the postwar welfare settlement. The trail of broken promises has been well documented by the service-users movement, one of whose leading figures, Peter Campbell, sums it up: ‘We don’t call it “community care”… maybe community indifference, or compulsion.’ What is required, but never seriously contemplated by the psychiatric establishment or the government, is ‘a genuinely service-led mental health system’.
In 2009 I set out to discover why and how this had happened. The project was personal. In the late 1980s I had three admissions over a two-year period to one of the most notorious of the old bins: Colney Hatch Lunatic Asylum as it was in its Victorian heyday, Friern Hospital as it was then (although it was still strikingly Victorian, in look and feel, when I was there). Friern closed in 1993. In 2014 I published an account of my time there (The Last Asylum) for which I drew on interviews with former staff and patients, the hospital archive and a host of other primary and secondary sources. But one book, and its author, were my chief guides through this difficult, depressing, often enraging, story.
Peter Barham is a psychologist, historian, film-maker and mental health activist. He has written numerous books and articles on the history of madness, including the highly-praised Forgotten Lunatics of the Great War (2004). In 1992 he published Closing the Asylum: The Mental Patient in Modern Society, a landmark work that has recently been reissued with a new prologue by Barham and a preface by Peter Campbell.
Closing the Asylum is a richly-documented account of the rise, fall and afterlife of the asylum system. Much of the story has been told elsewhere, but never better. Barham is not a dispassionate chronicler. He’s worked closely for years with the service-user (‘survivor’) movement, including the Survivors’ History Group led by Andrew Roberts (who maintains an archive and a website, which is the richest source of UK survivor history). Without Roberts, Campbell, Diana Rose and other survivor activists who kindly agreed to be interviewed for my book, I could not have written it.
Closing the Asylum is full of voices from such men and women, former asylum inhabitants now negotiating life in the so-called community. When it comes to psychiatric care, Barham wrote back in 1992, ‘community’ possesses ‘null value’. It is not ‘a therapeutic site or an arena for an interrogation of the moral crisis in the relations between people with mental illness and the larger society’, but just where people end up ‘once medicine [has] cured them’. And if medicine hasn’t cured them, or at least not enough to manage with the fragmented, often very meagre, community-based support on offer, more medicine is the answer – in fact the only answer. When I investigated the situation for my book, I was told by Peter Campbell that ‘community care is built on medication.’
In the first edition of his book Barham had some harsh words for this reliance on the ‘technical fix’ of psychotropic drugs, and in this new edition he is fiercer still, not just about the drugs and their well-documented side-effects but their imposition on people via ‘Community Treatment Orders’. CTOs – which compel people to take neuroleptics under threat of detention – were introduced in 2008; within seven years there were c. 5,500 people on CTOs and the figure is probably much higher now. But these are only one feature in what Barham describes as the ‘landscape of psychiatric coercion’ in which people now find themselves.
In 1992 Barham had plenty to say about coercion and the mentality underpinning it. The asylum system was designed to contain people who, by and large, were regarded as subhuman, animalistic. This had always been true to a greater or lesser extent, but the rise of professional psychiatry from the late eighteenth century gave it a scientific gloss, as people with serious mental disorders, especially schizophrenia, became ‘psychic degenerates’, the ‘socially unfit’. In the new edition Barham draws a parallel between this dehumanisation and the ‘scientific’ racism characteristic of colonialism, ‘with their co-constitutive metaphors of savagery and madness’. Like the colonised, people with mental illnesses were brutish or childlike individuals requiring stern handling. This mentality has been strongly challenged, most recently by psychiatric service-users themselves who have become a considerable force in mental health politics. Yet coercion thrives. Compulsory drugging through CTOs has been accompanied by a huge increase in legal detention under the Mental Health Act, especially of Black people. Most of the people I met in Friern were there voluntarily, unlike prior to the 1930s when the asylums were explicitly custodial. Now the majority of in-patients in acute units are detained; institutional psychiatry has once again become carceral.
And people are poor, often very poor. As Barham writes, the shift from ‘a universalistic welfare state to a more restrictive and residulist regime’ has left individuals with long-term support requirements leading ‘lean existences’, leaner still in the wake of the pandemic. Homelessness, hunger, acute loneliness… most of the general population, including the power-brokers responsible for this dire situation, look away from this misery. People die. ‘Mad lives’, Barham writes, ‘may count for even less today than in the past.’ The mortality statistics are jaw-dropping. Today, after one year of treatment, people diagnosed with schizophrenia are ten times more likely to be dead than there were a hundred years ago. After five years of treatment, they are eleven more times likely to be dead. The gap in life-expectancy has widened over the last thirty years, with people diagnosed with schizophrenia living between 10 and 20 years less than the general population. For many thousands of people, community-care has proven literally fatal.
There are signs of change. Enthusiasts for CTOs are reconsidering their position. Service-users are being consulted, and even listened to on occasion. New rights for patients to object to the ways they are treated, including detention, are promised in a government White Paper published at the beginning of this year. All people coming under the remit of the Mental Health Act are to be ‘viewed and treated as rounded individuals’ whose ‘views and choices will be represented…through their involvement in care and treatment plans, and through enhanced opportunities to challenge treatment decisions’. The clear racial bias in coercive practices is also to come under close scrutiny. We shall see how much of this actually transpires.
The majority of people who experience mental illness, even acute illness, do so only intermittently. They (and I write as one of them, with strong memories of my asylum past) are not a species apart. They – we – are complex individuals who need, as everyone needs, reliable care in times of difficulty. If this wretched pandemic has taught us anything, it is that we are all vulnerable, needy creatures who can be struck down at any time with a disabling condition. Peter Barham has spent decades making this fundamental point on behalf of, and alongside, people with psychological disorders. The new edition of Closing the Asylum is timely, with radical implications that stretch beyond diagnosed madness to the undiagnosed, rarely-questioned craziness of the care-less neoliberal world we now inhabit.