Outside the Walls of the Asylum: The History of Care in the Community 1750-2000ed. Peter Bartlett and David Wright
The Athlone Press, London, 1999
ISBN-13: 978-0-48-512147-6; 260 pages
Pamela DaleUniversity of Exeter
This collection of essays represents an ambitious attempt to investigate the history of community care in Britain and Ireland from 1750 to the present. Community care is examined as both a social phenomenon and a distinct government programme. Exciting original research is used to illuminate ongoing historical debates and contextualise current concerns about the future direction of community care. Outside the walls of the asylum aims to break out of the straightjacket of asyl um history but rather than down play the importance of the rise and fall of asylum care the essays seek to explore the boundaries between different forms of care and how these have shifted over time.
The essays aim to break new ground while recasting familiar debates about the public/private, institution/community, formal and informal care. Class and gender are highlighted as explanations of how insanity was constructed differently according to time and place with reference to social, economic, political, legal, cultural and intellectual factors. With so much to consider the reader is grateful for the comprehensive and well balanced introduction provided by Bartlett and Wright. The workshops that generated the collection of essays, and close editorship, have given the seeming disparate essays a feeling of cohesion and common purpose that is reinforced by the holistic overview by Bartlett and Wright that foregrounds the common interest in breaking down the walls of the asylum.
Bartlett and Wright correctly identify the institutional focus within the historiography of madness but note that despite the many factors driving researchers into hospital archives there is increasing awareness that care outside of the asylum was also important. This collection of essays fills an important gap in the literature and will surely prompt further research into the historical as well as modern complexities of non-institutional care. A recurring theme in these essays is that there neither is nor was a simple inverse relationship between the asylum and community provision. However, Mathew Thomson's suggestion that institutional and community care were intimately linked both strategically and ideologically has been tested and generally confirmed. Naïve assumptions about a golden age of tolerance and care before the birth of the asylum continue to be swept away and yet family care is demonstrated to be more robust to the challenge of capitalism than Scull suggested. In fact, throughout the period, families emerg e as key negotiators in deciding the care of their relatives rather than passive clients of the state. Although Anne Borsay's recent IHR review of 'Insanity, Institutions and Society: A social history of Madness in Comparative Perspective' (1999 edited by Melling and Forsythe) and the author's response shows how contentious this conclusion may prove to be. Provision for pauper lunatics was designed and implemented with little reference to the main clients of the service but welfare service it was, opening possibilities for bargaining resistance and collusion between families and the groups providing and financing care.
Walsh and Melling et al outline circumstances in which the family might be empowered. They highlight a situation where peculiar local circumstances, related to the attitude of authority figures and financial considerations, may have enabled the family to retain considerable power in the decision making proients and communities in their planning and delivery. This is a different type of state crisis to the one outlined by Scull but issues of legitimacy and locality are crucial to understanding the relationships between institutional and community care, the statutory and the voluntary, the public and the private. The volatility of social and political life in Northern Ireland dramatises the ethnic, religious, class and gender tensions and alliances that clearly lay behind the development of both asylums and community alternatives at different times.
Sarah Payne and Jim Campbell examine the tensions inherent in community care as it was delivered in the 1970s, 1980s and 1990s. This was a period when community care was central to mental health policy and the numbers of inpatient beds declined dramatically. Although debate original ly centred on the best way to deliver community care there is now concern about resource allocation, risk management and the failure to fully unite public support behind the initiative.
Whilst both Payne and Campbell highlight apparent benefits for service users concerns about the neglect of the most vulnerable, who pose some kind of danger to themselves and to others persist. Women as carers re-emerge as a feminist concern but in reality the younger mentally ill often have to function as their own carers with little community involvement and the obvious risks of homelessness. Control has re-emerged in policy debates with young men being seen as a particularly dangerous group. Forensic psychiatric teams operating at interface between the criminal justice and mental health systems have assumed importance in meeting the needs of the vulnerable and setting the limits to community care.
The tag 'dangerous' has historically been applied to madmen and the special management problems they have presented at different times is discussed in some detail by Oonagh Walsh and Melling et al. The small minority of cases attracting the label dangerous have historically been amongst the most difficult to place since their care and control is often contentious. All the essays dealing with this subject highlight a merry-go-round of placements in workhouses, prisons and asylums with no consensus on the most appropriate institution being achieved and community care being vulnerable to family and community fears. This is the type of penal-welfare system outlined by Garland and its ongoing institutional focus seems re-enforced by recent plans to develop more medium secure units across Britain. The institutional focus of care for this most vulnerable group seems to stem from the failure of community support, from families, professional and the wider public.
While Sarah Payne is rightly critical of sensational media coverage that she blames for a backlash against the idea of community care, it is also true that the press can mobilise public support in favour of improved civil liberties and better care. Suzuki uses ideas of mob justice, so important in the work of EP Thompson, to show how in the nineteenth century crowds would gather to frustrate cases of wrongful confinement. However he notes that the readiness for outsiders to intervene varies according to time and place. It is certainly no longer the case that crowds gather but public opinion is still a powerful determinant of the treatment of the mentally disordered and the resources available for their care. However, the importance of economic factors and the professional attitudes of doctors and officials in shaping a popular consensus must not be forgotten.
Walsh and Melling et al suggest that even within the nineteenth century penal-welfare system there were negotiations of power between the authorities and patients and families. Tensions between local and central authorities, asylum superintendents and poor law officials provided scope for families to impose some of their own demands. Bucknill, at the Devon Asylum, did not welcome the admission of criminal lunatics despite the professional prestige attached to criminal work. The County Magistrates also resisted the admission of these cases. The costs of maintenance, the care/ control problems and the need to secure Home Office approval for discharging these cases all seem important factors behind this local resistance to approved policy that ultimately led to enhanced state provision. In Ireland the asylums were not able to refuse cases and feared becoming a dumping ground for the unwanted populations of prisons and workhouses. Walsh argues that, the curative function of the institution was important for the doctors and officials connected with it but for the general public and hard-pressed relatives it was often a moot point whether or not asylum cured dangerous cases or simply removed them from society. Committal of Irish lunatics very easy and open to abuse by relatives but this was not the whole picture. The pattern of admissions, discharges and re-admissions suggests to Walsh that relatives saw the institution as a resource that could solve their problems by offering respite care even where prospects for cure seemed remote.
By contrast Hilary Marland emphasises the importance of 'curing' puerperal mania, as these cases became the object of professional competition between midwives, obstetricians, and alienists in the nineteenth century. Marland highlights the necessity of securing patient co-operation to effect a quick cure thus allowing the women patients far more power over their own treatment than is the case in Showalter's work. Although contemporary ideas about women's bodies and women's minds are still seen as crucially important to the management of puerperal insanity it is the husband's authority that is usurped by the doctor. However, the transformation of the home into a closely regulated asylum raises difficult questions about the true boundaries of the asylum. The social control arguments being reinforced by the powerful links between puerperal insanity, poverty and illegitimacy especially towards the end of the century when hereditary arguments assumed greater prominence. Zedner's work on women, crime and custody in Victorian England has been criticised for over representing women in her discussion on the construction of the weak minded criminal. However, although men were more likely to be detected as being mentally disordered in prison this reinforces rather than refutes the view that mental health and mental disabilities were and are constructed and managed on the basis of gender. Marland's work suggests that this did not necessarily disadvantage women, a claim possibly supported by the fact that women formed a majority of the patients boarded out in mid to late nineteenth century Scotland. However the freedom, or otherwise, enjoyed by these women must be contrasted with the admittedly inferior resources allocated to their care and the lack of interest they seem to have attracted from asylum based medical men.
To conclude, Outside the walls of the asylum brings together an important collection of work on the history of community care in Britain and Ireland from 1750 to the present. It highlights broad continuities across time and space without postulating a simple evolutionary model. The essays draw on and integrate the two main themes in the history of psychiatry, one centred on the institution, the other on developments within the family. In the Foucauldian tradition parallels are drawn between the shifting boundary of asylums and community care and the development of the other great confining institutions of prison and workhouse. However intentions and outcomes are properly separated and while the attitudes and actions of the powerful, doctors, officials and magistrates, are examined the rights, duties, obligations, preferences and resources of the patient and their family are also considered. This has led to a new emphasis on the importance of local factors in the treatment of the insane that will surely prove a stimulus to further research.