Mental Health Services and Community Care. Cummins, Ian
city centre as there is little in the way of constructive activity. The social workers that Pilger interviewed for the article suggest that Birmingham, possibly because of its size and the number of B&Bs acts as something of a magnet. They give accounts of psychiatric institutions outside of the city discharging patients with a one-way ticket to Birmingham. When reading the Ritchie Inquiry (Ritchie et al, 1994) and its account of Christopher Clunis’s contact with mental health services, which took place 15 years after Pilger’s article, one is struck by how often Clunis is living in homeless accommodation – a clearly totally unsuitable environment and one that could not possibly hope to meet his needs.
The asylum was thus not replaced by a well-resourced system of community mental centres, crisis accommodation, supported and independent living schemes and employment, which would enable people with mental health problems to complete the journey from ‘patient to citizen’ (Sayce, 2000) As the asylum closed, a fragmented, dislocated informal network of bedsits, housing projects, day centres or, increasingly, prisons and the criminal justice system replaced it (Moon, 2000; and Wolff, 2005). For many, as Parr et al (2003) demonstrated the friendship and communal living aspects that existed in asylums were lost. Knowles (2000) in her study of the way that former patients negotiated the public spaces, shopping malls and urban environment of Montreal shows that rather becoming integrated into the wider community, this group was isolated and shunned in similar ways to asylum patients. A series of powerful black and white photographs captures the ways that the ‘mad’ exist alongside but are ignored by the wider society. Knowles (2000) highlights the ways in which the responsibility for the care of the ‘mad’ has moved from public to private institutions. She goes on to suggest that the restructuring of mental health services acted as a model for other ‘problematic populations’. As Cross (2010) suggests, pre-existing social representations of the ‘other’ are very powerful in their ability to create a new identity for social categories. In this case, the representation of the mad from the asylum era has followed those people into the community. The homeless mentally ill (black) man became a TV and film drama cliché of gritty urban realism. The representation has changed – the mad are not now dishevelled creatures chained to walls – they are the homeless of the modern city living on the streets with all their belongings in shopping carts. Their presence on the margins is accepted as a feature of modern urban life. In his discussion of asylum seekers, Bauman (2007) argues that in a world of ‘imagined communities’ they are the ‘unimaginable’. Similar processes can be identified here; the mad became one of the constituents of what Bauman termed ‘internally excluded’. The media debates about community care led not to calls for investment in community mental health services but changes to legislation and a demand for the return of institutionalised care (Cummins, 2010b).
Conclusion
Mental health and responses to it take place within specific locations – temporal and spatial. The geographical locus of treatment provides an insight into the theoretical underpinnings of treatment but also wider social attitudes. Two idealised notions or representations of the asylum and the community came to play a dominant role in broader understandings of mental health policy. The asylum/community binary contains within it a series of other binaries: past/future; rural/urban; inclusion/exclusion; abuse/dignity; institutionalisation/independence; tradition/modernity; and deterioration/progress. The development of asylums involved the institutionalisation of populations who were regarded in some way as deviant (Castel, 1988, 1989). Asylums were located on the outskirts of cities or in rural settings, partly for therapeutic reasons but also as acts of exclusion. The asylum dominated the landscape in a physical but also a metaphorical sense. The closure of the asylums represented not just the transfer of the location of services but a switch in the modality of service provision (Joseph and Kearns, 1996). The seclusion of the asylum setting and their architecture ironically made them attractive to property developers in the 1980s. Those sites that were abandoned became part of the Gothic myth of the asylum.
Community care was seen as an antithesis to the dehumanising regime of the total institution that Goffman (2014) and others outlined. Community was used in a very problematic way that overlooked some of the philosophical difficulties with the concept. The community was assumed to be an entity rather than an abstraction but also a welcoming one. This proved to be naive, perhaps even wildly optimistic. As community care was being introduced, a series of economic and social policies placed tremendous pressure on the poorest urban communities. The asylum disappeared and its place was a rather hidden world of B&Bs and often poor supported housing projects or homelessness. These moves were at odds with a narrative of independence and civic rights that was to be found in policy documents. Moon (2000: 241) argues that the ‘concealed others’ of the asylum regime were replaced with the ‘visible others’ of the new system. The asylum was a site of social hygiene. Community care became associated with the ‘street’ as a public space of potential danger. These concerns were increased by the series of homicides that are examined in Chapter 3. It led to calls for more the provision of more secure psychiatric beds.
Young (1999) discussed what he termed the ‘narrative of modernity’. He saw the Fordist regime of production as leading to a stable pattern of employment supported by a universalist welfare regime. These systems helped to generate a series of social and community bounds. The moves from asylum to community should be viewed as part of wider shifts in society. The asylum came to be seen as an abusive system that denied citizens with mental health problems fundamental rights. The inclusive nature of the Fordist regime was illusory – inclusion for some means exclusion and marginalisation for others (Foucault, 2003). The excluded groups such as women, the poor, people from minority communities and the mentally ill were seen as ‘other’ – not full citizens in both the legal and moral sense (Nye 2003; Yar and Penna, 2004) The historical narrative of modernity includes an emphasis on the development of individualism and the progressive implementation of Enlightenment ideals. This view was challenged from the 1960s by a number of social movements which included mental health service user groups. Wider democratic developments obscured the treatment and continued exclusion from civil society of marginalised groups (O’Brien and Penna, 1998).
The policy of community care became a domestic policy crisis for the beleaguered Major government (Cummins, 2010a). One of the key ways in which the modern state claims legitimacy is by ensuring public and individual safety. Thus governments must respond to a series of threats such as a possible terrorist attack. These threats are increasingly internal or domestic ones. The ‘madman’ of tabloid legend became one of these perceived threats to the legitimacy of the ‘personal security state’. The option of building new asylums was never seriously considered. This would have required a huge fiscal commitment from the state. A new much looser network of private mental health care provision developed. This was largely hidden from the wider society. Local people might be aware of a small supported housing project but these were usually terraced houses rather than purpose built accommodation. It is a sad reality that the abuse, neglect and marginalisation that took place under the old regime did not end when the asylum gates were closed.