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Book reviews |
Green College, 43 Woodstock Road, Oxford OX2 6HG
EDITED BY SIDNEY CROWN and ALAN LEE
Edited by Peter Bartlett & David Wright. 1999. London: Athlone Press. 353 pp. £45.00 (hb), £16.99 (pb). ISBN 0-485-11541-7 (hb); ISBN 0-485-12147-6 (pb)
"Care in the community", say the editors of these 12 essays, "holds the dubious distinction of being universally supported in principle and universally condemned in practice". Furthermore, as community care has never been defined, there is no standard way of measuring its performance. Still, Bartlett & Wright have set out to investigate its history, "both as a social phenomenon and as a distinct government programme", and to do so by "challenging conventional interpretations of the centrality of psychiatric institutions".
Well, up to a point they do, since what emerges clearly is that the boundary between institution and community was always a semi-permeable one. As the editors point out, nearly half the patients admitted to asylums in the 19th century stayed no more than a year, only one in five were ever readmitted, and most had been receiving prolonged ‘community care’ before a crisis (often violence) had precipitated certification. In 1871, out of almost 70 000 ‘lunatics’ or ‘idiots’ recorded in the census, fewer than 40 000 were in institutions. In Wales, as Hirst & Michael describe here, the figures were regarded by the Lunacy Commissioners as one-third too low; many admissions to Denbigh Asylum followed the breakdown of long-standing family care which had never previously been known to the authorities. Furthermore, if a patient was not certified as ‘dangerous’, the family could insist on release from the asylum.
Mellings et al show from the records of the Exminster Asylum that the stigma and shame of certification often led families to keep a mentally ill relative in "barbarous isolation" until the household resources became depleted or the local community was outraged in some way. So the growth of institutional provision was not an "elaboration of powerful systems of social control", but a "response to ‘market demands’ for welfare benefits". Of course, every extension of public action - from clean water to universal education - demands some degree of ‘social control’, but primarily as collective action for the general good. What the evidence of this book does not provide, though, is any support for the Foucault-Scull view that "a new regime of discipline and surveillance replaced social tolerance and individual liberty" or that the asylum became "a dumping ground (for) mental and physical wrecks". Certainly, many of those admitted were in poor physical health, but the asylum provided medical and nursing care which they mostly could not have obtained outside
One of the most important ways in which the institution-community divide was bridged was through the boarding out system. Harriet Sturdy and the late William Parry-Jones show that up to the First World War, almost 25% of Scottish patients were managed in this way, and that these cases would otherwise have filled six asylums. Yet throughout the 19th century, admissions to mental hospitals there continued to rise and the building of new institutions was extensive. Boarding out, therefore, was a complement to hospital provision, rather than a replacement for it. The Scottish Lunacy Commissioners enthusiastically promoted this policy, while it was generally rejected by those in other parts of Great Britain. No explanation is offered for this difference, even though such influential figures as Bucknill and Maudsley supported the boarding out system in England.
In the 20th century, as Welshman points out, the actual phrase ‘community care’ first appears in the Wood Report on Mental Deficiency of 1929. In the 1950s, it increasingly entered the official discourse, though this remained far removed from actual provision at the local level. Partly this was because "responsibility for community care was foisted on to local authorities, the most demoralised branch of the NHS". A factor not mentioned by Welshman is the bitter opposition of the Treasury to extra funding, revealed by Charles Webster in his history of the National Health Service. Welshman complains that the Ministry of Health "did not seem willing to coerce local authorities whose services were of poor standard", but in fact, they had no power to do so.
The last chapter by Payne, shows that anti-psychiatry is still alive and kicking. She refers sarcastically to the beneficiaries of psychiatric services and to ‘schizophrenics’; would surgical or paediatric patients be described in this dismissive way? Psychiatrists simply cannot win. If they move with their patients into the community, it is "because this is the way to retain professional control"; if they stay more in hospitals, it is because they are "fearful of losing their territorial power base". Had there been more than just a single psychiatrist in the 19 contributors to this volume, a more balanced picture might have emerged.
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