Mental Health Services and Community Care. Cummins, Ian
this, it is possible to identify key themes in the work of this diverse group of thinkers that was influential in challenging the dominant model of institutionalised care. I would identify these as follows:
•a fundamental questioning of the exercise of power of the psychiatric profession;
•a questioning of the neutrality of diagnosis;
•a concern with psychiatry’s role in the creation and perpetuation of racial and gender stereotypes;
•a belief that institutional care and compulsory treatment were inevitably abusive and dehumanising.
In the broadest terms, these are thinkers of the Left. Szasz is something of an outlier. Szasz is a small government libertarian. He sees mental illness as a way of avoiding individual social responsibility – be that in the area of criminal law or employment. Mental illness in his work is a form of malingering that is indulged by an overgenerous welfare state. His views are neatly summed up in the title of a 1995 paper ‘Idleness and lawlessness in the therapeutic state’. It would be a mistake to overlook the differences in other accounts – hence Scull’s somewhat sardonic summarising. In critical accounts, there is a sceptical approach which focuses on the social construction of mental illness. This leads to a consideration of broader social factors, such as poverty, racism, misogyny, homophobia and social inequality, rather than a focus on brain chemistry. Following on from this, the social implications of diagnosis and an analysis of the institutions that have been created to manage mental illness are at the heart of anti-psychiatry. For example, while most commentators see the development of the York Retreat as a progressive measure, Foucault (1982) essentially sees it as the exercise of power by other means. He describes the ‘moralising sadism’ of the York Retreat and its Quaker founders. In Foucault’s terms the outcomes for the inmates are the same: exclusion and subjugation. There is a nihilism at the centre of Foucault’s thinking. Stone (1982) argued that this leads Foucault to see all relationships in terms of power/subjugation, thus excluding any humanitarian impulse that might underpin to the development of these institutions. It should be acknowledged that in his exchange with Stone, Foucault disputed this interpretation of his work.
Psychiatry and anti-psychiatry
Anti-psychiatry cannot be regarded as a campaigning movement. However, it was clearly influential outside of academic circles. It needs to be considered as a key influence on the development of community care (Cummins, 2017). The key figures remained influential in debates about the nature of mental illness during their lifetimes. Laing set up therapeutic communities; Szasz campaigned against the power of psychiatry as a profession while still practising it. It would be almost impossible to overestimate the influence of Goffmann or Foucault. Both are in the most cited writers in the social sciences (Green, 2016).
Psychiatry, clearly, did not simply accept without challenge the criticisms outlined in the previous paragraph. It is interesting that three of the strongest critics of the discipline were actually psychiatrists – Laing, Szasz and Cooper, who is usually credited with coining the term ‘anti-psychiatry’. The response has come from both medicine and the humanities. The strongest arguments are that the main aim of medicine is humanitarian and altruistic: the relief of suffering (Clare, 2012; Wing, 1978) Within these accounts, there is an acceptance that certain practices would now be regarded as abusive or even amount to torture. However, the argument is that this was the state of medical knowledge at the time. The intention was therapeutic within the medical definitions of the time. This is one of the fundamental departures in Foucault’s work. In it, it is difficult to find any recognition of the possibility of a humanitarian impulse. I may be guilty here of applying modern notions of therapeutic interventions to the past where they are not applicable.
Alongside what we might term the moral defence of psychiatry – the notion that it is a branch of medicine that is concerned with the relief of suffering – we should also explore other challenges to Foucault. Scull (1991) is very critical of Foucault’s use of sources and the conclusions that he reaches arguing they are based on the analysis of a limited range of texts. In addition, Scull (1991) argues that Foucault has used a very specific period in French history to represent the totality of European developments in this field. Sedgwick (1982) has demonstrated that the link Foucault makes between the decline in the treatment of leprosy and the development of psychiatric asylums does not hold. For Foucault, prior to the ‘Great Confinement’ the mad had essentially been tolerated and allowed to live in society. Sedgwick argues that this portrayal of the mad as the lepers of modern society ignores the fact that the mad had been held in various forms of custody prior to the period Foucault is discussing. In representing asylums as a response to urbanisation, Foucault cannot account for their development in the US at a time when it was an agrarian society (Rothman, 2002). One response to this is to argue that Foucault is not making any such claims. His work is historically specific and seeks to analyse the various factors at play – at that time, in that place. This is counter to an approach that is based on or creates a metanarrative of the rise of the asylums.
For other critics, such as Rothman (2002), Foucault has, in effect, reduced the complex causes of the development of asylums to a class strategy of ‘divide and rule’. One impact of this is to simplify the complexity of the founding and management of the asylum regime. For example, it overlooks or does not accept the religious motivations of many founders – Tuke at York being a prime example. Anti-psychiatry chimed with some of the anti-authoritarian developments in the wider culture of the 1960s. This helps to explain the largely positive reception that it received. However, it is also part of its weakness. Scull (2014) demonstrates that all societies grapple with the moral and ethical questions that are generated by societal responses to mental illness. The response clearly involves social control, but we also need to see it as something more than that. There are many aspects to it because mental illness is such a diverse and complex phenomenon. Finally, the focus in Foucault’s account is on essentially state responses. This overlooks the other ways that families, wider social attitudes and public sanctions – formal and otherwise –combine to produce social order (Ignatieff, 1985).
Foucault (2003) and Goffman (2017) challenge established notions of progress. They also question the role of psychiatry, viewing it as a disciplinary process. The focus is often on the impact of the asylum regime on the incarcerated. There is a danger of overstating this. For example, the voice of the service user/patient is largely if not totally absent from Goffman (2017). The influence of these writers has led to an explosion in research and literature that explores all aspects of the asylum. The history of the asylum from below is, perhaps, more attractive than a narrative of the struggle of psychiatrists to humanise an inhumane system. However, it is important to examine all aspects of the asylum regime. The fundamental difficulty with these hugely influential accounts is that they are based on a discourse of subordination and domination. In challenging the notion of progress, there seems to be a denial of its possible existence whatsoever. Unfairly in my view, Foucault seems to be held personally responsible by many for the failings of community care. Stone (1982), for example, argues Foucault had a destructive impact on the development of mental health services, arguing the attacks on institutional care led to a collapse in the belief in care itself.
Conclusion
As noted, the progressive proponents of community care saw the abuses