Closure of a large amount of mental hospitals
There are many reasons as to why such a large amount of mental hospitals closed down, but to explore the reasons why they closed, we must look at the rise of the large institutions between the 19th century and the 1980's to understand its demise, why so many were built and why, for a small time period, they were successful.
The mental hospital is defined as a hospital for the care and treatment of patients affected with acute or chronic mental illness. Between the 19th century and the 1980's, the mental hospital has been defined as the carer for mental illness. But after this 'golden age' of care for mental illness, it has become a victim of 'decareration' ever since leading to a decrease in mental hospitals and its admissions, but why?
The discharge of a patient was once known as a good thing as it symbolised the success of that hospital through 'moral treatment' (later replaced by psychiatric treatment) but even before this there was a much harsher system with the use of chains and straightjackets being the norm. As in the case of King George III who himself suffered from mental illness; patients were not seen as human beings, he was encaged, starved and beaten. The philosophy that therefore developed was the goal of a 'cure', to treat the patient in a therapeutic environment, 'To remove the patient from the midst of those circumstances under which insanity has been produced must be the first aim of treatmentâ€¦An entire change in the surroundings will sometimes of itself lead to recovery' (Bean and Mounser 1993, 4 quoting Busfield, 1986)
The mental hospital really began in Victorian times; hospitals were intentionally structured to be different from ordinary hospitals in terms of 'therapy, structure and location'. (Rogers and Pilgrim 2010, 190). As where the general hospitals in the vicinity of a highly populated area, a mental hospital would have been deliberately built in a place that is not so populated. The mental hospital (or asylum as it was once known) is seen as a conventional and humane way with dealing with the mentally ill; one of the first legal acts to recognise this was the Lunacy Act of 1845 which made local counties build asylums and gave the authority to detain "lunatics, idiots and persons of unsound mind". (Rogers and Pilgrim 2010, 190). It was enforced and regulated by the Lunacy Commission. At the time the only place for the mentally ill to go to were workhouses and private 'madhouses'. As mentioned before this moral treatment was in reaction of the harsh treatment normally given. One of the first institutions to use 'moral treatment' was the York Retreat, The York Retreat was opened in 1796 by the English Quaker community as a reaction against the harsh treatment used by other asylums. The belief at the time was that the mad were 'wild beasts'. The retreat was opened from 'The consciousness felt by a small group of citizens of an overwhelming social evil in their midst' (Rogers and Pilgrim 2010,198 quoting Jones 1960:40), although state-run asylums did not pick up this form of treatment for a while.
Andrew Scull, an American sociologist argued that the mass amount of people detained in asylums was a product of 'urbanization, industrialisation and professional forces during the first half of the 19th century' and that detainment in asylums was a way to control social 'deviance'.(Rogers and Pilgrim 2010,190) The increase in wage labour meant that services were not good enough to deal with this new form of social 'deviance' meaning that the mentally ill could not be looked after by the family or local community, and around this time the stigma of how mental illness was a loss of humanity changed to the loss of self -control among the public. Meanwhile the French sociologist Michel Foucault sees that this new found market economy promotes 'rationality, surveillance and discipline'(Rogers and Pilgrim 2010,190) But with this change of direction in the treatment of the mentally ill, many institutions began to fill up with patients rapidly overfilling local magistrates estimates, which lead to several extensions to a mental hospital. An example of this is the Conley Hatch mental hospital in London which opened in 1851 and shut down in 1993 and at its peak it held 3,500 patients.
Many institutions promoted that they had the cure for mental illness, which led to a great surge in patients. In 1998, Gittens produced research into a mental hospital in Essex and followed the lives of staff and patients in the hospital and found many contradictions about mental hospitals. He found 'In relation to women patients it is clear for example that the hospital, based as it was on men-only and women-only wards constituted a 'women-only space' and true asylum in a social context in which there was little such space in external community life' (Rogers and Pilgrim 2010, 191) He also found that there needs to be a restriction against outside forces such as social, economic and political conditions as they affect peoples abilities to deal with such material.
As mentioned, its primary ideals were to treat patients with 'moral treatment' yet this was forgotten about early on in its life, with the exaggerated numbers which local magistrates didn't expect and such serious illnesses, political bodies were urging to keep costs down. Legal acts such as The Mental Treatment Act 1930 which allowed voluntary admissions to mental hospitals, it was also the act that got rid of the term asylum, and many mental hospitals found that it was not necessary to keep voluntary patients institutionalised. This led to a slight decrease in patients but it wasn't until the 1950's that its fall became apparent. Goffman (Rogers and Pilgrim 2010, 192) found that there were four types of institutions because of this:
Nursing homes, where the 'incapable' are cared for
Sanatoriums for those who have who have an unwanted threat to the community.
Prisons, where the welfare of the inmate is not of paramount importance
Monasteries and convents for those who volunteer to be away from the world
In 1948 the NHS was created, this led to all mental institutions being free for everyone, psychiatrists wanted this to broaden their field of study. The Mental Health Act of 1959 aimed to provide informal treatment for mentally ill patients with the possibility of detaining a patient against his/her will
One of the starting points of the crisis was in 1961, Enoch Powell, the minster of Health at the time, believed that mental hospitals were 'doomed institutions', so in 1961 he drafted The Hospital Plan where he planned to build thousands more hospitals and abolish certain mental institutes. The discharge of patients had become the policy of the demise of the asylum, subsequently the 'Community care blue book' was published which offered an alternative system to the mental hospital; where mentally ill patients would see a specialist for an appointment just like a regular doctor, the patient could then carry on with their lives and live at home. The patient could live a fairly regular life and would stop the segregation from normal society; it would entail the patient receiving treatment in a non-asylum setting such as in a district general hospital psychiatric unit. However it is argued that it is society that made the patient mentally ill in the first place, within the institutions there is a guaranteed market for experts' services where specialists could hone their skills, yet the asylum grew out of a need to establish a social order. The asylum had many problems as Goffman points out, he believes in 'the mortification of self' when being admitted to a mental hospital, with self being defined as 'being constructed by the pattern of social control which exists in an institution'.(Rogers and Pilgrim 2010,192) The persons past identity is completely stripped, their movement is restricted, hospital issue clothes are given and any personal belongings are taken away, they are then obliged to disown their former selves through confessions with the staff, there is no such thing as privacy and freedom of choice is extremely limited with all activities on a schedule.
Wing's (1962) research shows that feelings of withdrawal and apathy in patients was caused by their length of stay in a ward and the lack of a stimulating environment, good medical leadership is not enough to reduce these feelings in patients, as he says 'it is unlikely that the functions of am energetic reformer can be built in to the social structure of an institution'. As John Connolly points out 'once confined, the very confinement is admitted as the strongest of all proofs that man must be mad'. by 1990 the average asylum held 961 compared to in 1930 which held 1221. Once the asylum had reached its peak size, it realised that the patient was losing their individuality through being guided by the institutions rules; this resulted in a problematized re-entry into society. Originally the asylums were urged to be built by humanitarians, today the opposite is true, community care is now seen to be therapeutic and humanitarian, their return to the community legitimised community care as it deflected attention away from 'the demise of state responsibility for the seriously mentally ill and the current crisis of abandonment'. (Bean and Mounser 1993, 8) During the time where many large institutions were on the brink of collapse Martin (1985) conducted research into what they were failing, he found that many of the failures were with the nursing staff whom participated in inhumane, brutal and threatening behaviour and committed mass negligence on their patients. He asked two questions. 'How do trained carers become to behave contrary to professional standards? And how have hospitals been arranged in such a way that abuse and neglect have not been prevented?' To answer he found 6 points:
Large institutions were situated outside mass populated areas meaning they were cut off from the community
Wards were isolated from each other, and were almost their own little world
Un trained and un experienced staff were left to deal will large amounts of unruly patients,
The worst wards were the ones rarely visited by a specialist, leaving the junior staff to do the work leading to a lack of leadership
There was a lack of staff development through staff training courses etc
There was a huge lack of privacy for the patients
(Rogers and Pilgrim 2010, 194) These factors led scholars to doubt that the large asylums could be put right and doubted that they could be reformed. They believe that there is a huge 'corruption of care.
Ultimately every single patient will leave a mental institute whether they are ready to return into society or not and the goal is to cease contact with the hospital afterwards, scholars believe that the hospital, now in a community based system, has less of an importance it once had and is only one institution among others. The community based system is where the patient makes their first and last contact with treatment, they will enter the hospital for a short time and continue their treatment in the community as their treatment does not require hospital admission. This process is known as deinstitutionalisation as patients will not be treated by hospital based treatment and instead will be by community based psychiatrists. However this is not new, in the old system the patient may have made his/her first contact with a G.P and then sent to a mental hospital for treatment, although this has not changed there are now community psychiatric teams to send the patient to the hospital and to treat them inside and outside the hospital, The old system had a sole focus on the hospital, today 'it no longer directs, controls nor dictates the pace of treatment or care' (Rogers and Pilgrim 2010, 196)
There is a whole array of reasons discussed as to the demise of mental hospitals, one reason is the 'pharmalogical revolution' which suggests that the advances in medical treatments, such as tranquilizers' let patients be discharged in mass numbers, 'the introduction of chlorpromazine in 1952 made it easier to manage disturbed behaviour, and therefore easier to open wards that had been locked, to engage patients in social activities, and to discharge some of them into the community' Rogers and Pilgrim 2010,197 quoting Gelder et al 2001,769)
Scull blames 'economic determinism' and 'decareceation' for this massive decline in the use of mental hospitals, he believes that it was 'state sponsored policy of closing down asylums', with the emergence of the welfare state, segrative control mechanisms became too expensive. Inflation contributed by unpaid patient labour and cost of employees, ex-patients also required care which had considerable costs, community care was the cheaper option. Another reason would be the shift of focus from chronic conditions to acute conditions such as depression and anxiety which has been described as the common cold for mental health specialists, these acute conditions were once treated by mental hospitals but it has shifted to the GP and is easily treated by them meaning that the majority of people with mental heath problems never seek specialist treatment. Additionally, as mentioned before community care played a significant role in the downfall of asylums, many specialists found that a change of scenery was very beneficial to the patient, even patients with long-term chronic illnesses can return to society and live in community residences with good results making the mental hospital useful for a short period yet quickly and easily disposed of at point of departure; no longer serving any purpose nor use to the ex-patient. However many studies have found that many psychiatric wards are non-therapeutic and that they share the same problems as they did in the Victorian era, mainly because , according to Goffman, they act as a repair garage; a problem is brought in, fixed and then sent out. Only medication is given, total care is not. A study conducted by Braginsky, Braginsky and Ring (1973) found that the minor patients all wanted to go home, while the more serious cases had no interest in leaving and instead maximised their comforts in the hospital as they'd rather stay in the hospital than become a victim of poverty outside
The focus has also shifted to the cause and solution of mental health, epidemiology (the study of patterns of health and illness in public health) and treatment were separated in the era of the mental hospital, today they are much closer, the hospital has disappeared leaving the attention to the inequalities in mental health prevention and 'positive mental health'
To conclude, the mental hospital has made leaps and bounds in the field of mental health with its aim to understand mental health scientifically and tried to cure mental illness, even though that was deemed impossible. Its failure was mainly due to costs and the shift of attention to other fields of treatment. Yet two types of institution has been created due to this, community mental health centres and district general hospital units both modern in their treatment. Although there are still many similarities, high risk patients are still held against their will. Overall the care is much more professional, information is available over the internet, telephone or even the television, but more importantly there is a focus on the patient's life and freedom, many may argue that the government still no longer offers a complete care system, but it's a start.
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