Chapter Thirteen
The Asylum as Community or the Community as Asylum: Paradoxes and Contradictions of Mental Health Care

For several years after I first became interested in the study of madness, the primary focus of my researches was the nineteenth century. Yet my first book dealt with a far more sociologically respectable topic, contemporary mental health policy in the United States and Britain.^[1] In substantial measure, this shift occurred because the first publishers I approached were reluctant to publish the somewhat bloated manuscript that constituted my Ph.D. dissertation; and because I lacked sufficient distance from what I had written (not to mention enthusiasm for the task) to take on the job of pruning and reworking it into publishable form. Consequently, I decided to set that manuscript aside temporarily, and to begin work on a new project.

Having tried in Museums of Madness to unravel the origins of the commitment to the asylum solution, I now found myself urged by friends and colleagues to scrutinize its contemporary demise. I must confess to a certain initial skepticism about claims that so durable an institution was swiftly and certainly en route to the historical scrapheap, but the subject certainly seemed worthy of further investigation. Moreover, I already sensed that there might be some interesting parallels to be explored between contemporary assaults on the therapeutic legitimacy of the mental hospital and a hitherto neglected, almost subterranean strand of criticism of lunacy reform and its products, which had appeared and per-

sisted even at the height of Victorian optimism and complacency about the value of the asylum solution.

Very early on in my new researches, I was struck by the further parallels between the millennial expectations of the asylum's founders and the equally extravagant claims of the devotees of community care. It is difficult even a decade or two later to recapture the naive optimism of the late 1960s and early 1970s, for we live now in an era filled with denunciations of "the wholesale neglect of the mentally ill, especially the chronic patient and the deinstitutionalized":^[2] a period in which we are bombarded with exposés of scandals in the board and care and the nursing home industries, and urged to reconsider our reluctance to countenance the involuntary confinement of street people. But twenty years ago, the optimistic illusion that we had uncovered a solution to the endless difficulties associated with chronic mental disorder had not yet melted away. To the contrary, the emptying of asylums was then hailed as unambiguous evidence of social progress, part of a third "psychiatric revolution"^[3] that would finally liberate mental patients from the shackles of the past.

I completed work on Decarceration in late 1975. The book offered, unfashionably, a much bleaker assessment of the realities of deinstitutionalization, together with an account of the origins of this far-reaching change in social control styles and practices that was sharply critical of the then conventional pieties others offered on the subject. Since then, historical materials have once more absorbed the bulk of my attentions. From time to time, however, I have been drawn back to the study of contemporary realities. On one such occasion, half a dozen years ago, I wrote a piece comparing the nineteenth-century asylum as an idealized manufactured community with our idealization of twentieth-century "communities" as asylums for those afflicted with mental disorders. What follows is a revision of that essay, expanded to incorporate some discussion of developments in the 1980s.

The Asylum as Community or the Community as Asylum: Paradoxes and Contradictions of Mental Health Care

As we see wing after wing spreading, and story after story ascending, in every asylum throughout the country, we are reminded of the overgrown monastic system, which entangled so many interests and seemed so powerful that it could defy all change, but for that very reason toppled and fell by its own weight, never to be renewed. Asylum life may not come to so sudden an end, but the longer its present unnatural and oppressive system is maintained, the greater will be the revolution when it at last arrives.
—ANDREW WYNTER,
The Borderlands of Insanity

Some Persons of a Desponding Spirit are in Great Concern about that vast Number of poor People, who are Aged, Diseased, or Maimed; and I have been desired to employ my Thoughts what Course may be taken, to ease the Nation of so grievous an Incumbrance. . . . I am not in the least Pain on that Matter; because it is very well known, that they are every Day dying and rotting, by Cold and Famine, and Filth and Vermine, as fast as can reasonably be expected.
—JONATHAN SWIFT,
A Modest Proposal For Preventing the Children of Poor People in Ireland from Being a Burden to Their Parents or Country

Paradoxical as it may seem, any discussion of "community care" for the mentally ill must begin by paying serious attention to the mental hospital. The current generation of mental health reformers has shown a remarkable tendency to seize on statistics about reductions in the mental hospital census as a direct measure of the success of their endeavors. Moreover, their reiterated emphasis on the horrors endemic and inextricably part of the Victorian bins to which earlier generations consigned the mentally disturbed has helped to legitimize the notion that any change (though preferably a drastic change) must represent an improvement over what has gone before and to deflect attention away from "the demise of state responsibility for the seriously mentally ill and the current crisis of abandonment."^[1]

Though the prehistory of the asylum can be traced back to medieval religious foundations (the most widely known example in the English-

speaking world being the monastic foundation of Bethlehem, or Bedlam),^[2] its use as a major instrument of public policy has far less ancient roots. It is instead, the private, profit-making madhouses of eighteenthcentury England^[3] and, to a far greater degree, the publicly funded county asylums and state hospitals of nineteenth-century England and the United States^[4] that mark the advent of an approach to mental illness based on the physical and symbolic segregation of "lunatics"—their isolation in ever larger specialized and purpose-built institutions designed to contain and treat them. It is one of the ironies with which the history of psychiatry abounds that the emergence of the state-sponsored asylum system was itself the outcome of a vigorous campaign for reform; and that, as with the current drive to return the mentally ill to the community, their segregation in these places was urged as being vital on both humanitarian and therapeutic grounds.

During the first half of the nineteenth century, the weight of informed opinion on both sides of the Atlantic embraced an extreme therapeutic optimism. Those who led the crusade to establish state-supported mental hospitals—people like Dorothea Dix in the United States and Lord Shaftesbury in England—saw themselves as rescuing the mad from maltreatment, neglect, and inhumanity, and ushering in a golden age of kindness, scientifically guided treatment, and cure. In this respect, their self-portrait is indistinguishable from their present-day successors. But for Dix and Shaftesbury, the certain recipe for neglect and abuse was to leave the mentally disturbed to the mercies of the community. More often than not, the troublesome qualities of the insane would ensure their confinement in some nonspecialized environment—the gaol, the workhouse, or the private madhouse—whose structural deficiencies (to say nothing of the qualities of those in charge of those places) made harsh treatment all but inescapable. Even those not abandoned by their families were the unfortunate prey of ignorance, if not callous unconcern. The ministrations of the most devoted relatives, however well meaning, were all too likely to be misconceived, and thus to exacerbate rather than mitigate the underlying problem. Beyond this, "relatives and dependents" were "timid, unskilled, and frequently objects of irrita-

tion,"^[5] and the home was precisely the environment that had nurtured the disturbance in the first place.^[6]

By contrast, the asylum was portrayed as a technical, objective response to the patient's condition, an environment that provided the best possible conditions for recovery. While relieving the community of the turmoil and disorder at least latently present in madness, it provided those suffering from the condition with a sanctuary, respite from a world with which they could no longer cope. Here they would find a home where they would be known and treated as individuals, while their minds were constantly stimulated and encouraged to return to their natural state. Even the architecture and physical setting of the building could make a vital contribution to its success, by avoiding all impressions of confinement, emphasizing cheerfulness, offering an aesthetically pleasing design, and allowing a maximum of organizational flexibility.^[7] Coupled with an expertly chosen and carefully supervised staff, this milieu would secure kindly, dedicated and Unremitting care, carefully adapted to the needs and progress of the individual case.

On the one hand, therefore, nineteenth-century reformers promoted a vision of the asylum as providing a forgiving environment in which humane care on a large scale was possible and in and through which a very substantial proportion of "lunatics" could be restored to sanity. The converse of this portrait, however, was an elaborate and prolonged campaign to impress others with the gross unsuitability of the family and community as arenas for the treatment of the insane, and with the need to insulate the insane from the pressures of the world. Repeatedly, the reformers used their speeches and memorials to contrast the horrors of these alternative dispositions with idealized portraits of the asylum's beneficence. Harnessing the combined forces of humanity and science, they had protected future generations of the insane from the trials endured by poor Mary Jones, a Welsh lunatic whose family had kept her

on a foul pallet of chaff or straw . . . in a dark and offensive room over a blacksmith's forge. . . . Here she had been confined for a period of fifteen years and upward. She was seated in a bent and crouching posture on her bed of nauseous and disgusting filth. Near to her person was a cup emptied from time to time into a chamber utensil. This last vessel contained a quantity of feculent matter, the accumulation of several days. By her side were the remnants of some food of which she had partaken. . . . The stag-

nant and suffocating atmosphere, and the nauseous effluvia which infected it, were all but intolerable.^[8]

Yet if the mentally disordered in the latter half of the nineteenth century were no longer subjected to confinement of this sort, the change in their situation was hardly one the reformers had envisaged. The small, intimate institution devoted to the cure and humane care of its inmates proved to be a chimera of its planners' imaginations. By the last third of the nineteenth century, public asylums on both sides of the Atlantic had become mammoth institutions, huge custodial warehouses in which the conditions of the patients' existence departed further and further from those in the outside world, for their return to which their incarceration was still ostensibly preparing them. Even gross statistics serve as an accurate indicator of the basic character of these places. The average size of county asylums in England was little short of a thousand patients by the end of the century, and, as in the United States, there were several "hospitals of patients and employees of three thousand, four thousand, and even higher."^[9] Necessarily in such vast lunatic colonies, "all transactions, moral as well as economic, must be done wholesale," as their sheer "number renders the inmates mere automatons, acted on in this or that fashion according to the rules governing the great machine."^[10]

Thus, for active cruelty the reformers had succeeded in substituting the "monstrous evils" of "idle monotony." In what typically became "a mere house of perpetual detention," there was an "utter absence of any means of engaging the attention of the patients, interesting them in any occupations or amusements or affording them a sufficient variety of exercise outdoors."^[11] Consequently, those who bothered to examine the inside of the asylum would find "patients in the prime of life sitting or lying about, moping idly and listlessly in the debilitating atmosphere of the wards, and sinking gradually into a torpor, like that of living corpses." Men and women "who have lost even the memory of hope, sit in rows, too dull to know despair, watched by attendants; silent, grewsome [sic ] machines which eat and sleep, sleep and eat."^[12]

In the face of the growing crisis of institutional legitimacy to which these conditions ultimately gave rise, the early twentieth century witnessed a further round of reform, one designed to reinvigorate the asylum and restore it to its original curative function. David Rothman^[13] has recently dissected the American period of this second generation of reforms, those of the so-called progressive era, and shown how vast the gap between rhetoric and reality remained, how little, in fact, was changed, despite the ostensibly new emphasis on flexibility, discretion, and the carefully adapted treatment of the individual case. Indeed, the failure of this episode to produce more than cosmetic "improvements," such as the relabeling of asylums as mental hospitals, had already been documented indirectly by that explosion of sociological studies of the mental hospital as "total institution" that marked the 1950s and 1960s. (Since that body of research plays an important, yet controversial, role in the community care movement, I shall discuss it at more length shortly.)

More vividly, and for a wider audience, the same basic message was periodically reiterated in journalistic exposés of the deficiencies of the mental hospitals. Perhaps best-known of the latter genre, certainly in the United States, was Albert Deutsch's The Shame of the States . Although Deutsch was certainly no foe of institutional psychiatry, here the wheel seems once more to come full circle, with descriptions of the inmate circumstances bearing an almost eerie resemblance to the ones the original generation of reformers had proffered as irrefutable evidence of the need for an asylum system. At Byberry, for example, "the male incontinent ward was like a scene out of Dante's Inferno. Three hundred nude men stood, squatted, and sprawled in this bare room, amid shrieks, groans, and unearthly laughter. Winter or summer, these creatures were never given any clothing at all. Some lay about on the bare floor in their own excreta. The filth-covered walls were rotting away."^[14] Scenes he had witnessed elsewhere reminded him, as they did other observers, of nothing so much as the death camps they had recently viewed at Dachau, Belsen, and Buchenwald.^[15]

What is remarkable as one looks back on this 200-year "history of reform without change"^[16] is how consistently those in charge of the system, indeed society as a whole, sought to deflect attention away from the horrors of the present by resurrecting the tales of the barbarities of the past. Indeed, it is perhaps not too much to claim that one of the main ideological tasks of the history of psychiatry has been to manufacture reas-

surance of this sort, supplying us with a seemingly inexhaustible store of exemplary tales to document the inhumanities of earlier generations and the heroic struggles through which we arrived at our present (relative) state of grace and enlightenment.

The first generation of reformers seized on this splendid collective defense mechanism almost as soon as their visions began to turn sour. As early as 1845, surrounded by clear signs of the collapse of the very things they had previously urged as indispensable to the whole enterprise, they sought solace in the thought that "the worse asylum that can at this day by possibility be conceived, will still afford great protection" to the poor lunatic, when compared to his or her fate if left to the tender mercies of the community.^[17] Later in the century, defenders of the asylum system subtly shifted their ground: the standard of comparison by which the "success" of the asylums was to be judged was not the goals that the reformers had set for themselves, but rather the worst conditions the mad had been found in prior to the enactment of protective legislation.^[18] And given such a starting point, it was naturally all but impossible not to find evidence of improvement, no matter how dismal the reality one confronted.

Ironically enough, in the most recent variant of this by-now-hallowed ploy the negative referent is not the squalor and viciousness of the period before the work of Pinel and Tuke liberated the mad from their chains and secured for them the blessings of treatment in the mental hospital. Nor is it some dark episode in the asylum's history when, notwithstanding the existence of policy based on the best and most honorable intentions, things went temporarily and inexplicably wrong. Rather, the new target of reformist energy, the evil crying out for abolition, is the mental hospital itself. Instead of basking in their role as "the most blessed manifestation of true civilization the world can present,"^[19] even the most up-to-date institutions find themselves denounced as harmful and antitherapeutic, and their destruction is urged as "one of the greatest humanitarian reforms and the greatest financial economy ever achieved."^[20] Thus, over the past quarter of a century in what must surely rank as an extraordinary reversal of effort, the energy and resources once devoted to giving the illusion of reality to the chimera of the hu-

mane and curative asylum have instead been employed in the elaboration and documentation of its irredeemable flaws and deficiencies. From the late 1950s through the mid-1970s a veritable flood of social scientific research elucidated the baneful effect of confinement in an institution. The most famous and influential of these studies was undoubtedly Erving Goffman's Asylums,^[21] though that work in many ways was simply the most rhetorically persuasive presentation of a widespread scholarly consensus.

Studies of institutions as diverse as research hospitals Closely associated with major medical schools,^[22] expensive, exclusive, and well-staffed private facilities,^[23] and undermanned and underfinanced state hospitals^[24] all revealed a depressingly familiar picture. Apparently, "life in such a community tended inexorably to attenuation of the spirit, a shrinking of capacity, and slowing of the rhythms of interaction, a kind of atrophy."^[25] In the light of this research, it now appeared that, so far from sheltering the disturbed and helping to restore them to sanity, the mental hospital performed "a disabling, custodial function."^[26] Moreover, this conclusion appeared to be the more plausible in the light of the striking convergences among those working in such widely different settings, for as Belknap put it, the very "similarity of these problems strongly suggests that many of the serious problems of the state hospital are inherent in the nature of mental institutionalization rather than simply in the financial difficulties of the state hospitals."^[27]

Echoing one of the central themes of this work, major American psychiatrists, particularly those in university settings, began to express fears that "the patients are infantile . . . because we infantilize them."^[28] Instead of being a positive influence, mental hospitals threatened to amplify and even produce disturbance. Such ideas also acquired widespread currency on the other side of the Atlantic, where the work of

men like Duncan McMillan and T. P. Rees, British pioneers of the concept of the open hospital, was held to provide unambiguous support for the notion "that much of the aggressive, disturbed, suicidal, and regressive behavior of the mentally ill is not necessarily or inherently a part of the illness as such but is very largely an artificial by-product of the way of life imposed on them [by hospitalization]."^[29] Another British psychiatrist, Russell Barton, even ventured to give this iatrogenic phenomenon the status of a new psychiatric label of its own—"institutional neurosis."^[30]

Seen in the context of this general intellectual climate, many of the details of Goffman's arguments in Asylums are not in the least original. The importance of his essays lay rather in the skill with which he deployed and then extended conventional wisdom and in the adroitness with which he made use of limited evidence of often dubious validity to advance some extremely general claims. Though the reader is hard-put to recall the fact, Goffman's primary data source is a relatively brief period of field observation in a single hospital, St. Elizabeth's in Washington, D.C., a data base that in other hands would have produced still another ethnography of a particular institution. In this case, however, the outcome is a general delineation of an organizational type to which all mental hospitals belong—along with prisons, monasteries, military schools, old-age homes, and concentration camps. Replete with vivid "references to mortifications that disrupt, defile, assault, or contaminate the self,"^[31] Goffman's account of these "total institutions" provides a powerful indictment of such places as engines of degradation and oppression, a finely rendered "symbolic presentation of organizational tyranny, and a closed universe symbolizing the thwarting of human possibilities."^[32]

Oddly enough, given his interactionist sensibilities, the central feature of the portrait Goffman sketches is an inevitable and powerful structural determinism. By its very nature, the mental hospital (not unlike Dickens' Marshalsea) manufactures the human materials that justify its existence. The crucial factor in forming mental patients is their institution rather than their illness. And their reactions and adjustments, pathological as they might seem to an outsider, are the product of the ill effects of their environment (with all its peculiar routines and deprivations) rather than the natural outcome of an unfolding intra-individual pathology.

As I suggested earlier, there are serious weaknesses in the evidentiary base on which these extraordinary far-reaching claims rest. There is, for

example, not even a token attempt in Goffman's work to confront the issue of what explains inmates' presence in the mental hospital in the first place. We are instead supposed to rest content with an unsubstantiated claim that they are the victims of "contingencies," somehow "betrayed" into the institution by their nearest and dearest (for reasons that remain entirely obscure). The "blame" for their situation, then, lies not at all in their own conduct or mental state, but rather in a conspiracy of others to secure their exclusion from society. Likewise, questions of the social location of madness and of the kind of existence to which hospitalization is an alternative are simply passed over in silence. And perhaps most notably of all, there is not even an attempt to generate valid and reliable evidence essential to any credible assessment of the respective contribution of intrapsychic and environmental influences to what he calls the "moral career of the mental patient." As Craig McEwen puts it, "Goffman's analysis has persuaded readers as much by its literary power as by the weight of its evidence"; indeed it relies for its persuasiveness on our willingness to take "literary metaphor as established fact."^[33]

Yet there is no shortage of people (and policymakers) willing to make precisely that leap of faith. In the process, the chilling equation of the mental hospital and the concentration camp, originally the hyperbole of muckraking journalists, has now acquired the mantle of academic respectability. Ideologically, this is a development of profound significance, for it has effectively legitimized "community treatment," not by a careful demonstration of its merits (which would require systematic attention to its practical implementation), but by rendering the alternative simply unthinkable. Who, in the circumstances, would even attempt to dispute the claim that "the worst home is better than the best mental hospital"?^[34]

It was this climate of opinion that over more than two decades, from the mid-1950s onward, allowed the portrayal of the simple decline in mental hospital censuses and in length of stay in the hospitals as an unambiguous reform and improvement. Measured in this crude yet easily quantifiable way, the "success" of community care in both England and America is easily shown, though the speed and extent of the changes has varied between the two societies. From the earliest years of the statefunded mental hospital system in the nineteenth century a pattern was established in both societies of consistent and almost uninterrupted increase in in-patient population. This remorseless increase was such that in the United States during the first half of the twentieth century, "the public mental hospital population had quadrupled . . . , whereas the gen-

eral population had only doubled."^[35] In England, the timing of the rise was somewhat different, with the most spectacular increases coming in the last half of the nineteenth century, but even here the hospital census all but tripled between 1890 and 1950.

This pattern of uninterrupted growth was abruptly reversed in the mid-1950s. First in England, then in the United States, the in-patient census began to fall. As Table 1 shows, the population of English mental hospitals had decreased from little short of 150,000 in 1954 to some 75,000 in 1980. In the United States, the decline began two years later, and from a maximum of approximately 560,000 had fallen to only 171,500 some twenty years later, and to 132,000 by 1980 (Table 2). Allowing for population growth, of course, the break with historical trends was even more dramatic than these data would indicate. In the United States, for example, had the size of the hospital population relative to the total population remained constant (and historically the tendency was for it to rise faster than the general population), by 1975 the mental hospitals would have contained some three-quarters of a million people.

As comparison of Tables 1 and 2 reveals, once the in-patient census began to decline, it did so each and every year in both countries. This common experience is the more remarkable given that both societies were also experiencing a simuhaneous and sharp increase in admissions to mental hospitals. Between 1955 and 1968, admissions to mental hospitals in England and Wales rose from 78,586 per year to 170,527; and although admissions dipped to 169,864 in 1970, this was still more than twice the number admitted in 1955. The rise in admissions has been equally steady and of similar magnitude in the United States. Whereas approximately 185,000 were admitted to mental hospitals in 1956, by 1970 the figure was 393,000 (although, once more, there was a slight decline after this). Statistically speaking, therefore, the decline in mental hospital populations reflects a policy of greatly accelerated discharge. In the United States, for example, whereas, in 1950, the average stay in a state mental hospital was over twenty years, by 1975, it was no more than seven months.

Still, if deinstitutionalization has shared certain features in the two societies, even the gross statistics in Tables 1 and 2 suggest that there have also been important divergences. In both England and the United States, during the first ten years of declines in their hospital populations the dips were consistent but relatively small. But while the English in-patient population continued a mostly steady 2 or 3 percent per annum de-

crease, its American counterpart began to decline much more rapidly. The major source of the difference lies in the treatment of the senile and the mentally ill elderly. In England, persons over 65 do not constitute a disproportionate fraction of those discharged from mental hospitals.^[36] Beginning in the latter 1960s, however, the contrary is true in the United States. Between 1969 and 1974 alone, the number of patients over 65 in state and county mental hospitals nationwide fell by 56 percent, from 135,322 to 59,685.^[37] In individual states, the decline was steeper yet. In 1968, a memorandum from the New York state commissioner of mental hygiene ordered the implementation of more restrictive admissions of the elderly, leading to a fall in hospital cases from 78,020 to 34,000 by

1973, a decrease of 64 percent in five years. As Table 3 (page 320) shows, other states were even more "successful" than this.

As I shall discuss at greater length later, this pattern of accelerated discharge both reflects and depends on some broad differences in the practical implementation of deinstitutionalization in England and the United States. I have pointed out that one major ideological defense of the decanting of patients from mental hospitals has been the essentially negative one that life in a state-run "total institution" was so irredeemably awful that the mere absence of its detorming, dehumanizing pressures must be an improvement. Some of the deinstitutionalization's supporters have been content with this claim to be guided by a belated recognition of "the limits of benevolence"^[38] and have argued that this round of reform rests on a prudent recognition of the need to concentrate on avoiding harm rather than doing good.^[39] In most quarters, however, the movement back to the community has involved the invocation

of millennial claims not very different from those that accompanied its predecessors in the history of psychiatric reform. In Paul Rock's apt phrase, most of the advocates of community treatment have sought to picture the community as a kind of "secular Lourdes providing inexpensive redemption"^[40] to the lame, the halt, the morally unfit, and the mentally maimed.

Gliding silently over the reality of the increasingly segmented, isolated, and atomized existence characteristic of late capitalist societies, those active in promoting the community approach to serious forms of mental disorder argued that the very locus of treatment could prove therapeutic. By not segregating the mentally ill from the rest of us, the community approach would help to keep them integrated with their neighbors, and even where those linkages had already been strained or fractured, would more readily permit a reestablishment of social ties with "normal" society. Instead of the passive and dependent behavior nourished by institutional existence, community care would restore independence and initiative. Possibly with some assistance from an outpatient clinic located at a general hospital or, in the United States, from one of the new community mental health centers, patients would find their needs provided for with minimal disturbance to their existing living arrangements and in ways that preserved and protected their basic social capacities.

To an extraordinary extent, however, expectations like these rested upon a priori reasoning rather than empirical demonstration; and, as Kirk and Thierren have pointed out, the notion that they even remotely correspond with actual outcomes is simply a myth, "reflecting more the intentions and hopes of community mental health than the uncomfortable realities."^[41]

In the midst of all the excitement about the replacement of the mental hospital and the breathless proclamations about the virtues of the community, few people noticed the degree to which the new programs remained castles in the air, figments of their planners' imaginations. Nor did many appear to realize, for some considerable time, that despite all the rhetoric on both sides of the Atlantic about "better services for the mentally handicapped" (the title of an official statement of British policy),^[42] the reality was the much darker one of retrenchment or even elimination of state-supported programs for victims of severe and chronic forms of mental disorder. As Peter Sedgwick put it, with pardonable sarcasm, "The reduction in the register of patients . . . has been

achieved through the creation of rhetoric of 'community care facilities' whose influence over policy in hospital admission and discharge has been particularly remarkable when one considers that they do not, in the actual world, exist."^[43]

Sooner or later, however, any audience becomes disenchanted with a shell game in which there is no pea. For almost a quarter century, there was a remarkable dearth of "major research projects of academic respectability that [showed] either the extent of the need or the extent of the failure" of mental health policy.^[44] But more recently, the implementation of community care has finally begun to attract more critical attention, much of it journalistic, but some of it (belatedly) from scholarly sources.^[45] In consequence, it is now generally conceded that, on both sides of the Atlantic, a policy of deinstitutionalization was implemented with little or no prior consideration of such basic issues as where the patients who were released would end up; who would provide the services they needed; and who would pay for those services.^[46] What is perhaps more surprising, the massive reassignment of patients has continued in the face of continuing lack of attention to these matters, with the predictable consequences I shall discuss shortly.

Given the general emphasis on the therapeutic value of reintegration into the community, and leaving to one side the fact that "the belief in the value of reintegration has been devoid of any systematic analysis of what constitutes a relevant community,"^[47] one might have "expected that, by now, a substantial body of research would have been built up to demonstrate the advantages that accrue when the educational, occupational, domestic, and protective functions of mental hospitals are taken over by alternative agencies. In fact, such studies [as exist] . . . have been,

in the main, descriptive rather than experimental, and are rarely epidemiological in nature, so that it is difficult to know how far the results can be generalized."^[48] For example, the study of Pasamanick and his associates^[49] which is often cited as demonstrating the feasibility of maintaining schizophrenics in the community, deals only with those who are members of intact families, who, as we know, form only a very small percentage of long-term mental patients. Moreover, a subsequent follow-up study with even these patients produced much less favorable findings, possibly the result of the failure of the authorities to maintain adequate funding for the program.^[50] On the other side of the equation, we also lack thoughtful and careful analysis, based on a sufficiently representative sample of ex-patients, of the social and economic costs of maintaining such people in the community—defining cost in the broadest sense and moving beyond a narrow concern with fiscal costs to the state to incorporate a consideration of human as well as monetary costs to the patients, their families, and the community at large.

Ex-patients, and those who would formerly have been sent to mental hospitals (for many jurisdictions have sharply cut back the criteria justifying commitment), are to be found, of course, in a wide variety of settings, and attempting to generalize about their situations is necessarily a hazardous business. The problem is intensified by "the paucity of followup studies whose data can be generalized and compared and that trace the movement of discharged patients through the labyrinth of psychiatric facilities and living conditions after their release."^[51] And it is, of course, still more acute when one is discussing more than one country. Among state mental health bureaucrats, ignorance about the fate of their former charges is often so great that they may not even know where the discharged patients are to be found.^[52] A recent American study, for example, discovered with disconcerting regularity that "information on what happened to former mental hospital patients and residents in institutions for the retarded was generally not available. Follow-up of released patients was generally haphazard, fragmented, or nonexistent."^[53]

One thing is certain: the overwhelming majority of them are not being serviced by the new community mental health centers. The existence of several hundred of these federally sponsored centers in the United States has fostered the comforting notion, particularly among overseas observers,^[54] that those discharged from state hospitals have simply been transferred to a setting that provides a more modern and effective way of delivering treatment. Such assumptions are quite natural. (After all, the patients are allegedly being discharged to receive "community treatment," and the community mental health centers are one of the few places where community treatment is conceivably being dispensed.) Nevertheless, they are also quite mistaken. Even if one disregards the centers' uneven geographical distribution and their current fiscal problems, it remains the case that neither their ideology nor their most common services are "directed at the needs of those who have traditionally resided in state psychiatric institutions."^[55] From the outset, those running the new centers have displayed a pronounced preference for treating "'good patients' [rather] than chronic schizophrenics, alcoholics or senile psychotics"^[56] —in other words, precisely a desire not to treat the patients being discharged from state institutions. Unsurprisingly, therefore, studies show "no large consistent relationship between the opening of centers and changes in state hospitals resident rates."^[57] Indeed, National Institute of Mental Health data demonstrate that "public mental hospitals accounted for fewer referrals to community mental health centers [less than 4 percent] than any other referral source reported, except for the clergy."^[58] Partly as a consequence, community health centers "have no direct bearing on the bulk of publicly funded mental health care in the public sector."^[59]

Nevertheless, some of those discharged from mental hospitals have unambiguously benefited from the shift in social policy. Victims of an earlier tendency toward what the Wolperts have called "overhospitalization,"^[60] they have experienced few problems obtaining employment and housing, maintaining social ties, and so forth, blending all but impercep-

tibly into the general population. Such benign outcomes are, however, far from constituting the norm.

Rather as one might expect, among those with more noticeable continuing impairment, ex-patients placed with their families seem on the whole to have fared best. Even here, there have been costs, sometimes serious costs. John Wing has recently expressed "surprise" that, in view of the greatly increased likelihood of someone with schizophrenia living at home instead of in a hospital, so little research is being done on the problems experienced by their relatives.^[61] His own work, and that of his associates, has provided us with much of what little data we do possess on this subject and demonstrates that "the burden on relatives and the community was rarely negligible, and in some cases it was intolerable."^[62] A good deal of the distress and misery has remained hidden because of families' reticence about complaining—a natural tendency, but one that has helped sustain a false optimism about the effects of the shifts to community treatment. As George Brown puts it, "relatives are not in a strong position to complain—they are not experts, they may be ashamed to talk about their problems and they have come to the conclusion that no help can be offered which will substantially reduce their difficulties."^[63] (Such conclusions may have a strong factual basis, in view of the widespread inadequacies or even absence of after-care facilities and the reluctance, often refusal, of the authorities to countenance rehospitalization.) The new policy has thus unquestionably seen "a considerable burden being placed on the health, leisure, and finances of the families [involved]."^[64] The evidence may not be sufficient yet to warrant Arnhoff's claim that "the consequences of indiscriminate community treatment may often have profound iatrogenic effects. . . . We may be producing more psychological and social disturbance than we correct."^[65] But at the very least, we must recognize that "if . . . state policy is to shift more responsibility on to 'the family,' then the physical and psychological burdens on individuals will increase disproportionately."^[66]

Their public silence and lack of protest notwithstanding, more research into these families' situations is clearly essential. Yet even without that additional research, we know that one consequence of the new policies is all but certain: "community care," in this form at least, means tying down women in traditional servicing roles for their disabled kinfolk. To put it another way, in the absence of "genuine, socially funded resources of community care, [attempts] to loosen the tyranny of the mental institution [proceed at the price of] re-enforcing an archaic sexual division of labour."^[67]

Yet whatever the difficulties encountered by these ex-patients and their families, they pale by comparison with the experiences of the greater number of ex-patients who have no families or whose families simply refuse to accept responsibility for them. Particularly in the United States the precipitous decline in mental hospital populations from the mid-1960s onwards has been matched by an equally dramatic upsurge in the numbers of psychiatrically impaired residents of nursing homes. This trend is particularly marked among, but not confined to, the aged mentally ill. Table 3 suggests how rapid and complete the elimination of the elderly from American state hospitals has been. That the majority of them have simply been transferred from one institutional setting to another is suggested by the fact that between 1963 and 1969 the number of nursing home inmates with mental disorders virtually doubled,^[68] and evidence from the National Center for Health Statistics shows a further 48 percent increase through mid-1974, from 607,400 to 899,500.^[69] Data from the National Institute of Mental Health show that by the mid1970s, nursing homes had become the "largest single place of care for the mentally ill," absorbing 29.3 percent of the direct costs associated with coping with them.^[70] More than 50 percent of these nursing home residents were placed in facilities with more than a hundred beds, and more than 15 percent in "homes" with more than 200 beds.^[71]

These numbers alone might cause one to suspect that "the return of patients to the community has, in many ways, extended the philosophy of custodialism to the community rather than ending it at the gates of the hospital."^[72] But there is a growing volume of more direct evidence that demonstrates the "ghettoization of the returning ex-patients along with other dependent groups in the population; the growing succession of inner city land use to institutions providing services to the dependent

and needy . . . the forced immobility of the chronically disabled within deteriorated urban neighborhoods . . . areas where land use deterioration has proceeded to such a point that the land market is substantially unaffected by the introduction of community services and their clients."^[73] The 1977 General Accounting Office study of deinstitutionalization reported "a general tendency to place formerly institutionalized persons in those nursing homes where the quality of care was poorer and safety standards not complied with as rigidly as in other nursing homes. . . . Generally speaking, the more mental patients there were in a facility, the worse the conditions."^[74] Despite their titles, these places frequently provided neither nursing nor a home. In the words of an Oregon Task Force, "a typical day for a mentally ill person in a nursing home was sleeping, eating, watching television, smoking cigarettes, sitting in groups in the largest room, or looking out the window [sic ]; there was no evidence of an organized plan to meet their needs."^[75] To make matters worse, state agencies typically provide few or no follow-up services, and little in the way of effective supervision or inspection. In the absence of such controls and lacking the bureaucratic encrustations of state enterprises, nursing home operators have found ways to pare down on even the miserable subsistence existence characteristic of state institutions.

Of course, many discharged mental patients of all ages end up in other, perhaps still less salubrious settings—board-and-care homes and so-called welfare hotels. In Philadelphia, for example, a Temple University study revealed that some 15,000 ex-patients were living in approximately 1,500 boarding homes in the city. In New Jersey, a whole new industry has sprung up, utilizing the huge, cheap, run-down Victorian hotels in formerly fashionable beach resorts as accommodation for several thousand more discharged mental patients. In New York, there have been repeated media exposés of the massive concentrations of ex-

inmates in the squalid single-room occupancy welfare hotels of the upper west side of Manhattan and in the Long Island communities surrounding Pilgrim and Central Islip state hospitals. Many of the boarding homes in the latter area, in a pattern which is becoming all too familiar, were opened by those formerly employed by the state hospitals.^[76] In Michigan, the pattern is depressingly similar:

Many of the foster care homes serving the mentally disabled were in innercity areas with high crime rates, abandoned buildings, sub-standard housing, poor economic conditions, and little or no recreational opportunities. Of a total of 378 community placement residences in Detroit serving the mentally disabled, 165 were located in the inner-city, with 101 on one street. State officials attributed this to the availability of large homes at relatively low prices . . . and to restrictive zoning which limits after-care homes to the older, run-down sections of the city. Although the number of mentally disabled in these facilities was not known, it has been estimated to be several thousand. The only service being provided many released mentally ill patients was medication.^[77]

Such developments have not occurred without implicit and explicit state sponsorship and encouragement. In New York State, the scandals associated with the connections between the board-and-care industry and the political establishment eventually forced a full-scale inquiry and subsequent prosecutions.^[78] Pennsylvania, with remarkable foresight, repealed its provisions for inspecting boarding homes the same year (1967) it began "a massive deinstitutionalization program aimed at moving patients out of mental hospitals into community programs."^[79] Hawaii faced a massive shortage of beds in licensed boarding homes when it adopted a policy of accelerated discharge. The problem was resolved, with unusual bureaucratic flexibility, through "the proliferation, with the explicit encouragement of the state mental health division, of unlicensed boarding homes for the placement of ex-hospitalized patients."^[80] Nebraska at first shied away from such a laissez-faire approach, deciding apparently that some form of state oversight was called for. Accordingly, in a splendidly original variant on the ancient practice of treating the mad like cattle, the state placed licensing and inspection of the boardand-care homes in the hands of its state Department of Agriculture. Subsequent citizen complaints about the resulting conditions led to the

withdrawal of licenses, but not the patients, "from an estimated 320 of these homes, leaving them without state supervision or regulation."^[81] Missouri simply noted the existence of some "755 unlicensed facilities in [the] State housing more than 10,000 patients"^[82] and continued to dispense the state funds on which their operators depended. And still other states, like Maryland and Oregon, opted for perhaps the safest course of all—no follow-up of those they released, and hence a blissful official ignorance about their subsequent fate.^[83]

Such systematic academic research as has been done on conditions in board-and-care facilities (and again the research is noticeable mainly by its absence) confirms the picture. Lamb and Goertzel concluded that "it is only an illusion that patients who were placed in board and care homes are 'in the community.' . . . These facilities are for the most part like small long-term state hospital wards isolated from the community. One is overcome by the depressing atmosphere, not because of the physical appearance of the boarding home, but because of the passivity, isolation, and inactivity of the residents."^[84] Kirk and Thierren use remarkably similar language to describe their findings in Hawaii: "Many ex-patients are placed in 'ward-like' environments where they are supervised by exstate hospital staff, and they participate in a state hospital routine, albeit now 'in the community.' But many of these former patients do not even have the limited involvement provided by a day hospital. They spend the majority of their time in a boarding home which promotes dependency, passivity, isolation and inactivity."^[85]

In the United States over the past quarter century, with the wholesale assistance of federal funds—Supplemental Security Income (SSI), Medicaid, Medicare, and so forth—mental patients have been transformed into a commodity from which various professionals and entrepreneurs extract a profit. The consequence has been the emergence of a new "trade in lunacy"^[86] that in many ways bears a remarkable resemblance to the private madhouses that were employed to deal with the mentally disordered and distracted in eighteenth-century England. In that earlier period, anyone could enter this business, and there was no regulation of conduct, with the result that gross exploitation and maltreatment of patients were commonplace. As critics at the time pointed out, in such "trading speculations [operated] with a view to pecuniary profit . . . the extent of the profit must depend on the amount that can be saved out of

the sum paid for the board of each individual."^[87] Proprietors must therefore "have a strong tendency to consider the interests of the patients and their own at direct variance."^[88] Given free entry into the business and the difficulties associated with the inspection and supervision of a multitude of operations, the least scrupulous were likely to be the most successful, and appalling results were all but structurally guaranteed. So it proved: It was precisely the abuses to which this system was prone that led to a campaign for reform and to the establishment of England's state mental hospitals.^[89]

Again the cycle is repeating itself. We now live in a period, also hailed as an era of reform, when anyone can open a boarding home for mentally ill patients discharged from the state system. Once more the mentally disturbed are at the mercy of speculators who have every incentive to warehouse their charges as cheaply as possible, since the volume of profit is inversely proportional to the amount expended on the inmates.^[90]

At the beginning of this chapter, I alluded to the case of Mary Jones, one of a number of "exemplary tales"^[91] the nineteenth-century reformers used to point out the horrors of the nonasylum treatment of the insane. Contrary to their expectations, horrors of a virtually identical sort continued to be generated by the mental hospitals they succeeded in establishing.^[92] Recent investigations suggest that they continue unabated in the new community settings. I must confess that beyond a certain point I have difficulty calibrating human misery, but certainly the condition of a

Mrs. Bond, an ex-patient found in an Illinois nursing home seems to differ little if at all from that of her Welsh counterpart of the midnineteenth century. As the Senate Committee on Aging reported:

Mrs. Bond was covered with decubiti (bed sores) from the waist down, that decubiti on the hips were the size of grapefruit and bones could be seen; that the meatus and the labia were so stuck together with mucous and filth that tincture of green soap had to be used before a Foley Catheter could be inserted; that her toes were a solid mass of dirt which stuck together and not until they had been soaked in TID for three (3) days did the toes come apart; that body odor was most offensive; edema of feet, legs, and left hand.^[93]

On a less lurid level, we possess a handful of studies that systematically compare the social functioning and clinical condition of hospitalized chronic patients with those of their counterparts in quasi-institutional community settings. "From both American and Canadian studies we have reports that fewer of the [hospitalized] patients were incontinent, fewer took no part in bathing, more were able to bathe without help, fewer took no responsibility for their own grooming, more dressed without assistance, fewer failed to dress and remain in hospital gowns, and more had money available and were capable of making occasional purchases."^[94] More dramatically, a number of studies appear to demonstrate a close correlation between the relocation of chronic patients and sharp increases in their mortality rates.^[95]

Intended as a cheap alternative to the state hospital, the ramshackle network of board-and-care homes and welfare hotels stand as an indictment of contemporary American mental "health" policy. They constitute perhaps the most extreme example of what has become the new orthodoxy, an "almost unanimous abdication from the task of proposing and securing any provision for a humane and continuous form of care

for those mental patients who need something rather more than shortterm therapy for an acute phase of their illness."^[96] Here, ecologically separated and isolated from the rest of us, the most useless and unwanted segments of our society can be left to decompose quietly and, save for the occasional media exposé, all but invisibly.

In view of the depths of the misery and maltreatment associated with recent American mental health policy, Kathleen Jones' claim that "so far the United States has made a much better job of the business of deinstitutionalization"^[97] would, if accurate, constitute an even more damning indictment of British practice than she perhaps intended. Apparently what led her to make this unfortunate assertion was the combination of a relatively intimate knowledge of the failures of British policies with a rather naive acceptance at face value of the claims made by American advocates of deinstitutionalization. And certainly at the level of rhetoric, Americans have by and large been the more active and shameless. Practically, however, the British experience has not (yet?) been quite as awful.

In part the British record is better because deinstitutionalization has simply not been as rapid or far-reaching as in America. In general, the shift away from the mental hospital in both societies has been powerfully influenced by fiscal considerations, the savings realizable by substituting neglect for even minimal custodial care.^[98] In the United States, however, these pressures have been magnified by the fragmentation of the political structure. Care of the mentally ill has traditionally been a responsibility of the states, but deinstitutionalization has been promoted by the states' ability to transfer most of the costs of community support to the federal level. (The causal linkage is particularly plain in the case of the mass discharges of the elderly beginning in the late 1960s.)^[99] In the absence of this additional incentive, the rush to empty mental hospitals has been somewhat less headlong in Britain.

Ex-patients there have also for the most part been spared the excesses associated with the new trade in lunacy.^[100] The chains of private boardand-care homes and the dilapidated welfare hotels, now so large a part of American mental health "services," have few precise British equiva-

lents.^[101] In part, this situation probably reflects the somewhat lower numbers of chronic patients discharged. Undoubtedly too, it also mirrors the more entrepreneurial character of American capitalism and the greater legitimacy accorded to the process of the privatization of state and welfare services^[102] in a society still wedded to the myth of "free enterprise."

All these qualifications notwithstanding, the British experience with community care remains dismal and depressing in its own right. As Peter Sedgwick points out,

In Britain no less than in the United States, "community care" and "the replacement of the mental hospital" were slogans which masked the growing depletion of real services for mental patients; the accumulating numbers of impaired, retarded and demented males in the prisons and common lodging houses; the scarcity not only of local authority residential provisions for the mentally disabled but of day care centers and skilled social work resources; the jettisoning of mental patients in their thousands into the isolated helpless environment of their families of origin, who appealed in vain for hospital admission (even for a temporary period of respite), for counselling or support, and even for basic information and advice.^[103]

Kathleen Jones is not unaware of these catastrophic failures masquerading under the official guise of a "revolution" in psychiatric care. It is her awareness of the failures that prompts her bitter comparison of British policy with an idealized, indeed mythological portrait of American practices. For her, much of the blame can be apportioned to administrative lapses. In particular, the reorganization of the British National Health Service in 1973, which eliminated any distinctive organization for the mental health services, left "no administrative focus, no forum for policy debate, and no impetus to personal development. The result is that the British services are now fragmented and to a large extent the personnel are demoralized."^[104]

But while poor morale and administrative chaos have certainly contributed to worsening the situation, they are scarcely the major sources of the current difficulties. More centrally important is the absence of the

necessary infrastructure of services and financial supports without which talk about community care is simply a sham. During 1973–74, for example, while 300 million pounds was spent on the mentally ill still receiving institutional treatment, a mere 6.5 million pounds was spent on residential and day care services for those "in the community." Local authority spending on residential facilities for the mentally ill was a derisory 0.04 percent of their total expenditure.^[105] Three years later, 116 out of 170 local authorities did not provide a single residential place for the elderly mentally infirm.^[106] And more recently still, the intensifying fiscal crisis of the Thatcher-Reaganite years has simply reinforced the existing conservative hostility to social welfare services and made the prospect of providing even minimal levels of supportive services still more remote.^[107]

It should be starkly apparent, though, that our collective reluctance to make a serious and sustained effort to provide a humane and caring environment for those manifesting grave and persistent mental disturbance has far deeper roots than the callousness of our contemporary political leadership. The personal disorganization and defective social skills of the sufferers themselves preclude their forming an effective pressure group in their own behalf. In any event, "the stigma attaching still to their various disabilities and illnesses usually prevents most of them from asserting a group identity in public, for purposes of demonstration or financial appeal,"^[108] while their social marginality and dependency are likely to detract from whatever efforts they do make. Worse still, chronic psychotics exhibit persistent dependency, and it is unlikely that even the best programs of treatment will produce "recoveries" on any very large scale.

The idea that we bear a collective moral responsibility to provide for the unfortunate—indeed, that one of the marks of a civilized society is its determination to provide as of right certain minimum standards of living for all its citizens—has never secured widespread acceptance in the United States. Ideologically, this is a society dominated by the myth of the benevolent "invisible hand" of the marketplace and by a correspondingly amoral individualism. Moreover, in the last decade and a half, this ideology, always congenial to the privileged, has enjoyed a striking resurgence on the other side of the Atlantic. There is little place

(and less sympathy) within such a worldview for those who are excluded from the race for material well-being by chronic disabilities and handicaps—whether physical or mental disease, or the more diffuse but cumulatively devastating penalties accruing to those belonging to racial minorities or living in dire poverty.

The punitive sentiments directed against those who must feed from the public trough extend only too easily to embrace those who suffer from the most severe forms of psychiatric misery. Those who seek to protect the long-term mental patient from the opprobrium visited on the welfare recipient may do so by arguing that the patient is both dependent and sick . But I fear this approach has only a limited chance of success. After all, despite two centuries of propaganda, the public still resists the straightforward equation of mental and physical illness. Moreover, the long-term mental patient in most instances will not get better and often fails to collaborate with his or her therapist to seek recovery. Such blatant violations of the norms governing access to the sick role in our societies^[109] make it unlikely that chronic schizophrenics will be extended the courtesies and exemptions accorded to the conventionally sick. Instead, even those incapacitated by psychiatric disability all too often find themselves the targets of those who would abolish social programs because they consider any social dependency immoral.

Symptomatic of the status of the chronically mentally ill as the ultimate outsiders is the retreat even of organized psychiatry from any attempt to deal with their problems. Ironically, it was by capturing control in the nineteenth century of the new state-run establishments for the seriously mad that psychiatry both established itself as a profession and ensured medical hegemony in the treatment of mental disorder. But in the long run, this core patient population became a liability rather than an asset. It was, after all, overwhelmingly drawn from the lower classes; it bore the additional stigma of being composed of wards of the state; and psychiatrists discovered that, notwithstanding the extravagant claims of the founders of their enterprise, it was largely beyond the reach of their therapeutic armamentarium. The development, from the late nineteenth century onwards, of a bifurcated profession, saw the creation of a group of higher-status practitioners who increasingly concentrated on an office practice offering a more treatable, more affluent clientele.^[110]

But even this expansion of the psychiatric territory only mitigated the

socially contaminating effects of overly close association with an impoverished, clinically hopeless clientele. Hence, perhaps, the alacrity with which the majority of the profession has handed over the task of coping with the chronically psychotic to the operators of nursing homes, boarding houses, and welfare hotels. Psychiatric involvement with such unrewarding cases can now be reduced to the occasional prescription of psychoactive drugs to be dispensed by others, thus providing a bare semblance of "medical" attention. And with these miracles of modern psychopharmacology to hand, our contemporary madhouse keepers possess a restraint with which to subdue their charges, less blatant than the chains and straitjackets employed by their counterparts two centuries ago, and, in consequence, all the more desirable.

Some fifteen years ago, George Brown and his colleagues claimed that "the acid test of a community service lies in whether it can meet the needs of the seriously handicapped persons who used, in the old days, to become long-stay mental hospital inmates."^[111] By even the most generous interpretation of subsequent events, British and American policies have failed to meet that test. Nor should this occasion much surprise. Many of "the most basic needs of the mentally disabled—above all, the needs for housing, for occupation, and for community—are not satisfied by the market system of resource allocation which operates under capitalism."^[112] Nor is it realistic to suppose they will be. In this most profound sense, then, Peter Sedgwick is surely correct when he concludes that "the crisis of mental health provision . . . is simply the crisis of the normal social order in relation to any of its members who lack the wage based ticket of entry into its palace of commodities."^[113]