The debate about care in the community was a psychiatric ‘cause celebre’ of the 1960s and 1970s. The assaults on orthodox psychiatry from the sociologists, as well as from radical psychiatrists like Thomas Szasz and R. D. Laing, made for colourful presentations, polemical writings and even some research. The term ‘de-institutionalisation’ was coined in America, while in the UK the beacon was lit by the famous ‘Water Tower’ speech of the then Minister of Health, Enoch Powel, in 1961. This has all now become another historical country, since the asylums are largely closed, specialist forms of community care have flourished (assertive outreach, early intervention, crisis teams) and getting people out of hospital is seen as the key role of those working there. There is still some sense of a mental hospital being a ‘retreat’, but the intensity of illness now found in acute units was never part of the predictions advocating community psychiatry.

Given that the notion of ‘re-institutionalisation’ is now starting to emerge, particularly via the building of more and more low-secure and medium-secure units, and in the age of risk management, what can we learn about how things progressed to the current state? This collection of 45 ‘classic’ papers, or part of them at least, is a great read, each nicely introduced and many written by the leading lights of the business. Several are selections from books and some are key texts (e.g. Stein and Test on alternatives to the hospital in 1975). However, this is essentially an American collection, with the cultural limitations of that particular society and its relatively unique system of funding mental health services. The two British contributions are from J. K. Wing (‘The functions of asylum’, 1990) and Thornicroft and Tansella (‘Components of a modern mental health service’, 2004). Classics like ‘On being sane in insane places’ (Rosenhan, 1973) are welcome in any culture, and there is a nice outline of the work of Franco Basaglia from Schaper-Hughes and colleagues (1986) that is illuminating indeed. Still, what is the average UK psychiatrist to make of articles on Medicaid cutbacks or ‘Soteria – another alternative to acute psychiatric hospitalization’, although of course the notion of a ‘non-hospital hospital’ (the crisis house) and so forth has long hovered in the less clear-thinking minds of liberationists? For example, there are useful comments on the politics of recovery and the difficulties in establishing this (even in a liberal state like Wisconsin) and that the work of specification (i.e. what is meant by recovery) is difficult to clarify. Likewise, there are considerable limitations on the true evidence available, and in the concluding discussion around community psychiatry in the future, two of the editors outline the difficulties of understanding, still, what we mean by ‘mental illness’, what is the role of the psychiatrist, how we clarify funding, and what is really meant by the community.

What is not discussed in any detail, however, the ghost in the machine, is the USA's enormous prison population (over 2 million; in the UK it is over 85 000). To what extent does this incarcerated ‘stage away’ represent the practical failure of community care, a jail-bound witness to risk overriding therapy?

This collection, therefore, is very much of the positive variety; it contains some fascinating papers and certainly enables an understanding of American social policy. But as the discussion by J. K. Wing on the meaning of the term ‘Asylum’ shows, however you cut the cake, the needs of severely and chronically disabled people continue to have a low priority.

Have today's psychiatrists anything to learn from this collection? As we fill out our care programme approach and risk management forms, try to keep our community teams together and our hospital beds safe, should we despair at the sheer hurly-burly of the enterprise? Variations across regions, countries and continents are immense, in whatever is meant by psychiatric community care, and the balance of independence and neglect is likely to move decisively towards the latter as the global recession persists. There are some useful ideas in here that may help us defend the ramparts of appropriate psychiatric care, but it is not going to be easy.