Peter Barham, Closing the Asylum: The Mental Patient in Modern Society (London: Process Press, 2020)
Steffan Blayney, University of Sheffield
When the first edition of Peter Barham’s Closing the Asylum was published in 1992, it attempted to describe the historical underpinnings of a protracted upheaval in mental health provision which was still very much ongoing. While the dismantling of the Victorian asylum system had been the professed aim of successive British governments dating back at least to the 1959 Mental Health Act – and while the overall asylum population had been declining steadily since its peak in 1954 – still in the early 1990s deinstitutionalisation remained an unfinished project. By the time of the book’s second edition in 1997, with the majority of hospitals open a decade previously now closed, this seemed harder to argue, yet by this point characterisations of ‘care in the community’ as a failure were already becoming mainstream. This new edition, published in 2020, arrives in the wake of the 2018 Independent Review of the Mental Health Act amidst ongoing debates about the extent of coercion and legal compulsion within the mental health system.
Barham’s original text, reissued here with a new prologue and preface, situated twentieth-century debates over deinstitutionalisation within the longer history of how modern societies have dealt with the ‘problem of insanity’. This has always been a social question at least as much as it has been a medical one. In nineteenth-century Britain, and particularly after the New Poor Law of 1834, the public asylum emerged – alongside the workhouse and the prison – as a means to deal with surplus populations produced by industrialisation. Idealistically imagined by their founders as spaces of care and rehabilitation, the Victorian asylums quickly became little more than overcrowded repositories for incurables and undesirables. The segregation of the mad was given legitimacy by an emerging psychiatric profession whose own optimism about the possibility of cure quickly ceded to essentialising views of mental patients as inherently ‘broken’ or ‘flawed’ individuals, who for the most part would remain incapable of participating in society and undeserving of recognition as fully human. While such conceptualisations were never without their critics, Barham argued, the eventual movement towards asylum closure that emerged in the twentieth century failed to seriously challenge the underlying ideological structures which continued to produce madness as a social problem and the mental patient as a second-class citizen.
The resulting story of deinstitutionalisation was one in which the hopes held by many for the full liberation of hospital inmates would always be secondary to more cynical policy motives. Focusing primarily on mental health law and policy in England and Wales, and weaving historical and sociological analysis with the views of service users and campaigners, Closing the Asylum described how hopes entertained by reformers from the mid-twentieth century for progressive alternatives to the authoritarian psychiatric hospital were repeatedly frustrated or co-opted. Too often, talk of patient freedoms or more enlightened approaches to care functioned as little more than ideological cover for governments eager to cut expenditure by avoiding the costs associated with long-term custodial care. Hospitals emptied, but the services which would allow former inmates to live meaningfully independent lives fail to materialise, with new developments in psychopharmacology enabling the management of symptoms without the need for costly social or psychological therapies. For some who would formerly have been hospitalised, the institutions of the criminal justice system expanded to fill the vacuum (a growing prison population since the 1990s includes an increasing proportion of inmates identified as suffering from a mental health condition). For many more, especially those already from deprived backgrounds, newfound freedoms were undermined by persistent poverty, insufficient welfare support, and the stigma of illness leading to discrimination in housing and employment. Where the mental patient is still viewed by society as a problem to be solved rather than a full political subject, Barham demonstrated, ‘community care’ can function just as effectively as the asylum as a technology of social exclusion and marginalisation.
Another aspect of the old regime which failed to disappear along with its physical architecture was its use of force and legal compulsion. While it might have been expected that the move away from the rigid hierarchy of the asylum would lead to greater liberty for patients, evidence from the last three decades, which Barham details in the prologue to the new edition, shows that the opposite is true. The use of constraint and coercion, justified by the supposed risk posed by patients to themselves or others, has not only persisted through deinstitutionalisation but is increasing. Despite falling numbers of long-stay patients, the total number of people being detained involuntarily almost tripled between 1988 and 2015. This combined with drastic reductions in the overall number of psychiatric beds through years of austerity means that half of all psychiatric inpatients are now detained under the Mental Health Act – compared to around 10% in the 1970s. Moreover, with the arrival of Community Treatment Orders (CTOs) in 2008, mandating compulsory outpatient treatment under threat of detention, formal coercion is now no longer limited to the hospital setting. The violence of the system, it might be added, is not evenly applied: black patients are more than four times more likely to be involuntarily detained than their white counterparts, and more than ten times more likely to be subject to a CTO. Nor is the ‘shadow of coercion’ (8) which extends over the mental health system limited to those against whom the provisions of the Mental Health Act are directly mobilised. As service user activists (and some psychiatrists) have argued, in a system where patients and doctors know that the threat of compulsion is always available, it becomes difficult to see any treatment as fully voluntary.
While sharply critical of the way deinstitutionalisation has played out in practice, Barham has remained neither nostalgic for the asylum nor pessimistic about the prospects for more progressive services in the future. As he makes clear in the prologue to the new edition, ‘though the book is consistently critical and questioning of the way in which policies of community care have been implemented, it nonetheless holds steadfast to a positive view of the capabilities of the diverse range of people who are assembled under the banner of the “mentally ill”, and to the promise of community-led, above asylum-led lives for enhancing their life prospects.’ Deinstitutionalisation in this context should be seen not as an irrecoverable failure but as an unfinished ‘emancipatory project’ (28).
The ‘real questions’ that societies need to answer, as Barham maintained in 1992, have never been ‘about dismantling the mental hospitals as such, but about the prospects for manufacturing the social and political will adequate to the task of bringing back and reassimilating into society what had been thrust into the mental hospital’ (151). For Barham this means reaching a point where individuals are treated not primarily as ‘patients’, defined in law by their diagnosis, but as ‘persons’ entitled to full rights as citizens. Drawing on ideas advanced by the psychiatric survivor movement (the new edition includes a preface from the veteran campaigner Peter Campbell) he advocates a shift from managerial or paternalistic conceptions of care, underpinned by coercion, towards a focus on empowerment and autonomy for service users. This will not be achieved through legal or medical fixes, but only by reckoning with the centuries-old legacies of a system which has created the ‘mentally ill’ as a class apart.