On the changing role and ideology of British Asylums since the ’60s
The 1980s and 1990s saw the release of between 100,000 and 150,000 mental hospital inpatients onto the streets of the UK. This policy was born years earlier, in a 1961 address of the National Association for Mental Health by then Health Minister Enoch Powell. Powell’s speech, typically radical and unsentimental, called for the closure of the entire psychiatric hospital system and the destruction of all asylum buildings. He described those temples of reaction:
“There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day.”
Powell, intent on making a mark in a post he’d been offered largely to be rid of him, was fully aware of the entrenched resistance to any reform of the health service. His fear that the buildings themselves would offer opposition to his planned modernisation of the health service seems dramatic, but even now what architecture is left of the county asylum system holds a weird power over the people who live around their remains.
Still clinging on in parts of the country, these ruins are built in a style that leaves one unsure whether they were designed to be intimidating, or whether their features just became intimidating with use. Today aside from a very few exceptions derelict or redeveloped, in the early 1960s these were still enormous institutions with heavy staffing requirements, highly paid clinical directors and considerable purpose-built infrastructure. More and more, they were seen as a Victorian embarrassment by the modernising conservative government.
In the same year Powell spoke, Michel Foucault, then largely unknown and still proudly sporting a receding peak of hair, published his first major work A History of Madness, examining the changing fates of madmen since the renaissance and the development of the industrial asylum system. One strand of this work compares the pre-renaissance system of living with the mad, managed by vagrancy laws or temporary detention in religious and municipal buildings, and the disappeared madmen of post-enlightenment and industrial Europe. The rational age wanted to confine lunatics but also make a display of unreason as its enemy; hence the infamous practice of Bedlam tours, with equivalents found in every European country. His own era, in what he considered a regression, wanted to hide these potential embarrassments and ideally get rid of them with a cure.
England was relatively quick to implement Powell’s recommendations: A year after his speech, one of the first points was introduced, with on-site psychiatric wings being added to some general hospitals. From 1962 each of the regional boards responsible for the county asylums had to produce a five-year strategy for their closure. Initially, the asylum population continued to be stable, still well over 100,000 in the early 1970s, a decade that saw a slew of abuse scandals and patient deaths.
Eventually, it was the Thatcher government who implemented Powell’s recommendations, under steadily more syrupy titles until the now-current ‘care in the community’ emerged in 1990. Though implementation was not immediate, the end result of the policy was dramatic, leaving vast expanses of ruins in villages like Hellingley in Sussex and above all at Epsom, where nearly 10,000 patients were once held in five hospitals, served by a dedicated railway. Many of the ruined complexes were only redeveloped in the mid-2010s, and a few isolated examples still exist.
Rapid changes in the provision of mental health services, followed by large spikes in street crime, homelessness and drug use, both fuelled and reflected a general trend in British ideology from institutional moral enforcement to monitoring by overlapping services that existed in the ‘community’. This change would be a slower process in France, where the ordered asylum with its focus on moral hygiene and constructive activity appeared to Foucault an enclosed miniature of the Gaullist nation, one that had morphed over time to reflect its values.
Jumping back a few hundred years, Foucault detects a hardening on the question of the insane after 1700, with a total separation between reason and unreason and a formal solution to the question becoming more and more urgent. The old religious models, borrowing the language of possession but also the idea of the roaming band of lunatics, waned in favour of a medicalised and moralising system. Instead of strange clowns to entertain pilgrims, the mad became the sufferers of a new leprosy, requiring colonies away from decent people.
Before then, no real separation was made between the mad and the various other categories of undesirables found in hospitals. Though moral contagion still existed, even if not in such extreme forms as the dancing outbreaks of medieval Europe, the mad now had a reassuring role as sworn enemies of reason. This grew from the belief they had at least in some cases chosen their position, and so worked as a flattering mirror to the ordered and rational society they abdicated from.
The conditions of the pre-industrial asylums, at least according to Foucault, were grim. A constant stream of visitors (nearly 100,000 a year in Paris) would be shown through caged-off rooms where a mixture of prostitutes, the dissolute or deranged, and sometimes their children were left largely to their own devices. Though moral nonconformism was enough to confirm madness, there was no real attempt to force any change in beliefs or attitudes among the confined. Throughout the eighteenth century experiments with cures became popular; these were based on physiological theories and involved sudden shocks with cold water, rapid spinning around a centrifuge, or other mechanical devices.
Success in these cases was limited to one or two isolated examples, but the next generation were more evangelical about the prospects for new humane treatments, none more so than the working cure. The introduction of this moral cure, reaching its greatest heights in Victorian Britain, was viewed as a great advance over the cruelty of the 18th century. The county asylum system gradually appeared from 1808 and by the end of the century an immense network, modelled consciously on and often built on the site of medieval manorial estates, was in operation. Patients, many of whom were there on temporary respite, worked in agricultural labour or artisanal industries that were just then disappearing from life outside. Unlike the chaos of old Bedlam, there was no prospect of the insane choosing how to structure their own time, and discipline was enforced tightly.
Foucault views the end of the circus-like cruelty of the 18th century asylum, embodied in France by the work of Phillipe Pinel, as a worsening and not improvement of conditions. Brutalisation by a man with a club is less personally destructive than moral coercion. The inclusion of sexual deviants in the ‘insane’ population – described in detail by Foucault with prostitutes and the venereally diseased held in the same cells as common or garden lunatics – continues, with updated taboos, to this day.
Particularly after the development of psychoanalysis and various shock treatments, including the artificial induction of diabetic coma, the back-to-the-land era of the hospital gave way to one marked by a greater and greater insistence on patient compliance with various cures. Many British hospitals were taken over by the military during both World Wars, leaving a lasting legacy in their organisation, and all saw their population peak in the decades immediately following 1945.
Looking at the system of his era, Foucault saw the mental hospital as an artificial family and microcosm of post-war Europe, where the subjective moral judgements of the psychiatrist carried the weight of law and regimented activity offered salvation through work. His review of history unveiled a grand confinement that had continued uninterrupted from the medieval era to his day.
Writing before the explosion of interest in anti-psychiatry, the management from home of psychotic patients, and the resurgence of liberalism in Western Europe, it is interesting to see whether his theory still holds for the period 1961 to now. After the age of reason, industrial paternalism and the growth of institutional medical power, a new age was instituted that claimed to protect the ‘rights’ of the patient to autonomy, while simultaneously expanding the possibilities for coercion and blurring the distinction between the medical and prison systems.
Powell and Foucault were very different men, but both in a sense liberals who chafed at the centralising ideology of the early 1960s. Foucault saw each step in the development of the asylum system as an increase in moralistic control – even if it was outwardly more humane. Advocates of deinstitutionalisation claim they are the exception, some even citing Foucault as their inspiration.
In Britain today, while Powell’s intervention undoubtedly spurred the destruction of the English system, the primary cause was technological. After the development of chlorpromazine in 1950 a large portion of patients could be treated outside of a hospital setting. Initially the marketing of such drugs focused on their potential in controlling outbursts within hospitals, but soon the drugs were considered to manage symptoms so effectively that patients could lead a ‘normal’ life.
These drugs have been so successful that today a vast majority of psychotic individuals are managed by their GPs, with varying degrees of success. The Blair government denounced care in the community as a failed policy, and oversaw a minor growth of secure forensic settings (for patients convicted of crimes), but without changing the overall direction and continuing the policy of closing down large institutions. The moral purpose of the asylum reappears in the 2000s with a vengeance, when unpopular crimes – especially terrorism or sexual offences – became increasingly portrayed as something ‘only a madman would do’.
One patient currently in a Sussex low secure facility has served an effective 40-year sentence for a 5-year rape charge; without approval from the Home Office, which is seldom forthcoming for sexual offences, rapists may be held indefinitely. Another common ploy is for a sex offender coming to the end of their prison sentence to be screened for schizophrenic symptoms – when they express their (correct) feelings that other prisoners hate them and ‘there’s something wrong with my food’, they are marked as paranoid and assigned to a medium or low-secure hospital for assessment, a process that lasts a minimum of six months and often results in a longer confinement.
Critically, and unlike a prison sentence that cannot be extended beyond the maximum term, the conditions of release then include public safety and the risk of reoffending. In effect, unless the criminal is both intelligent enough to understand exactly how to perform, and willing to humiliate himself to do it, he will never be released.
Moral ambitions now even stretch beyond the hospital walls: One of the stated aims for the government’s Mental Health Strategy 2010 (a bumper year for bad legislation) includes the provision that ‘discrimination and stigma will decrease’. Reducing discrimination in practice means giving patients more ‘choice’ over their own treatment, namely by sleeping and eating more, taking more benzodiazepines and codeine, and sitting up in their rooms until three or four in the morning.
Suicide by biscuit – where a patient with multiple prevented suicide attempts adopts a bizarre and gluttonous diet to shorten his life – is more and more common, and costs balloon with the waistlines of patients. Pornography is quietly but officially distributed to Broadmoor inmates by staff, forming part of their ‘care plan’. Lower down the security scale, the provision for reducing stigma is met by allowing patients out unsupervised for hours at a time, during which they often take drugs or get drunk before returning late, sometimes by taxi, to their accommodation.
This state of affairs is lambasted ineffectively by nursing staff, who normally come from African and Asian countries that still follow some variant of the older system. Despite this, the goal of self-reliance in order to be ready to return to ‘the community’ is applied universally, even to patients with no real prospect of release. With benefit payments, unlike in prisons, continuing during secure hospital stays, patients with zero living costs are left with considerable sums to spend on sweets, cakes and chocolate. The morbidly obese soon develop fungal blooms in their skin folds, caused by the same pathogen as thrush, which have a distinctive odour and recur incessantly. The cost of forensic confinement ranges from £200,000 to £350,000 per patient per year, depending on the security level.
True believers would say it’s better for people to make their own choices – even if those choices are constantly monitored and scored on formal assessments. Although the old system of mandatory activity led to a physically healthier population and one under less personal scrutiny, its reputation continues to appall. That many people exaggerate the horrors of the Victorian asylum system is well-documented; between the 1820s and the birth of medical cures like insulin shock therapy, the idea of the work cure and of respite created an ordered, isolated, but essentially benign environment that allowed men like the orientalist artist Richard Dadd to live and work in peace.
For Foucault this doesn’t matter – the principle of liberty is more important than wellbeing. Some psychiatrists may feel they have enacted these principles with care in the community; certainly this was the feeling of the administrators and civil servants who crafted it. But the closure of asylum buildings has not increased patient liberty.
Release is subject to recall at any time and flocks of public employees are asked to report on the status of the patient, meaning missed meetings with social workers or medical staff are considered grounds for a new round of assessment and imprisonment. The only criticisms of this system come from those social services themselves, and always with the unsubtle message that they require more money to meet patient needs.
Additionally, the introduction of antipsychotic drugs, sometimes administered by force via subcutaneous depot, introduces an entirely new level of corrective discipline. In order to maintain the outward illusion of liberty by keeping someone ‘outside’ and unchained, the body’s chemistry must be altered by a crude blunderbuss that has a clear causal link to heart failure. The most popular antipsychotics now see tens of millions of daily doses prescribed per year in England, with the majority going to outpatients dealing with their GP. It is now extremely difficult for patients who are not children and have not committed a crime to be treated in an inpatient setting.
It is however true that most nostalgia for the old system is attached, as Powell predicted, to irrelevancies like grand old buildings, uniforms and indoor smoking. Against the nostalgists, and in face of the obvious failure of applying consumer choice to psychiatric hospitals, the asylum’s detractors fall back on prejudice about the bad old days. Even patients at Broadmoor would sometimes say how glad they were that they weren’t there when ‘things were really bad’, and they were allowed to have jobs, paint or spend all day outside without fear of random assault.
While immediate clinical staff are normally aware of the realities of the modern system, occasional visitors tend to be highly ideological or have special interests. Sometimes these are high profile – as in the case of Sir Jimmy Saville, who was called in as a fixer after a 1988 mistreatment scandal, and then proceeded to personally choose the next clinical director, who remained in his position until 1997, all while allowing a campaign of abuse to continue inside the hospital.
Today, the humanitarian ideology is most fiercely guarded by the chaplain, who keeps a poster of Ruth Baider Ginsburg outside the door of his office, and runs a non-denominational service full of platitudes about how Christianity means respecting other religions and looking forward sweetly to being ‘stepped down’ to sheltered accommodation in Hastings.
The asylum, patronising in much the same way as that other 18th century invention, the children’s novel, is less a reflection of outside society than an idealised vision of how it sees itself. The mostly soot-stained and revolting 19th century built manorial estates in lost wooded corners, where patients were made to garden and practice painting; likewise extensive efforts were made in the later 20th century to return patients to their ‘communities’ – at exactly the point most of them descended into mass drug abuse or disappeared entirely. Today’s patients are given a taste of what their freedom outside will look like; constant monitoring for moral transgressions, easy access to drugs, and a forced, shallow socialisation.
Inside, the principle of keeping inpatient numbers down means selection for individuals with poor social skills, little hope of reintegration, and who are less able to express themselves verbally, often to the point of being subnormal. This drags down the average level of the hospital. Reading medical notes from the pre-antipsychotic era is like entering into a different world, where intelligent people suffered from bizarre symptoms they were able to express clearly, throughout their madness.
Patients in secure hospitals are now divided between personality disorders (an invented category used to imprison people as moral lepers, viewed as incurable), and mental illness, which is largely continuous with schizophrenia. Delusional beliefs are weighed against the arbitrary ideological assumptions of psychiatrists.
This is not new: Foucault cites Daquin’s Philosophie de la Folie, claiming “a man is not mad because he imagines himself made of glass… but if he believes this makes him fragile,” a principle that doesn’t translate well to a score sheet of psychotic symptoms. Daquin’s point may be wrong – someone who feels as if he is made of glass isn’t committing a secondary fault of reason, he is responding to a stimulus most people do not have – but today this nuance of reason versus unreason is replaced by another ‘symptom’ contributing to a patient’s risk score. These quantified score sheets are great for enforcing accountability and sending to tribunals, but are crudely reductive and have the side effect of making normal interaction impossible.
In the climate of suspicion this creates between sectioned patients and staff, it is common practice to mark people down as ‘hiding their symptoms’, for example, if someone speaks to themselves at night, but denies hearing voices. A warning like this can seriously delay any prospect of release. The sectioned patient who hopes to get out will have to play a fine balancing act between openly admitting enough is wrong with them to see an ‘improvement’, and saying anything that will be marked as a red flag on their report, prolonging their stay. Various subclinical programs are carried out, with quiet note-taking going on in the background, to encourage this. Recently the most popular of these is ‘mindfulness’.
One of the weirdest practices found in hospitals today, attendance for mindfulness classes is on paper optional, but is quite essential for anyone wanting to get out soon. Like Hatha yoga’s conversion to a stretching game in the twentieth century, mindfulness is a desacralized spiritual exercise that arrived in Britain through various western Buddhist organisations.
If you don’t already know, mindfulness involves becoming ‘aware of your surroundings’ and attempting to separate from the press and flow of thoughts and desires for a certain portion of the day. A practice more woefully unsuited to people on medication that causes extreme sedation is hard to imagine, but its exotic flavour and fantastic research findings on symptom reduction have catapulted it to the top rank of non-drug treatments.
In fairness, mindfulness is relatively popular with patients, although most sessions quickly degenerate as older patients fall asleep, leading to extremely violent snoring, met with a mixture of amusement and anger by the other participants. Here as elsewhere, the toleration of eccentric behaviour, one of the main characteristics of the asylum in the later 19th and early 20th century, is increasingly restricted to better prepare patients for their release. On that release, psychiatrists and social workers will carefully monitor the patient, including asking family to report on unusual behaviour – which can include things like praying, or staying up late – checking to make sure medical compliance continues outside of the hospital setting.
This, then, is what ‘community’ means; to be constantly monitored by a system of social disapproval. The hospital remains there to remind anyone who forgets their moral duties, and is now stripped of any paternalistic ideology about being healthy. Powell’s great liberation of the psychiatric process from the building itself has instead made a ghostly hospital that follows the madman around outside.
If your idea of a fun weekend is the same as Foucault’s; congratulations, you now have a ‘personality disorder’ – a concept once rubbished in Soviet medical textbooks as a Western ploy to imprison dissidents – and will be liable to rolling periods of imprisonment, unless you are able to gain exemption via membership of some protected class.
Though prisons and asylums appear at first unsuited or even opposed to left-liberal ideology, they historically are both a result of these beliefs and one of the great testing grounds of their success. The myth of a distant past of inhumanity followed by an enlightened but difficult struggle for improvement, one that will continue indefinitely, was there at their founding and continues in the imagination today. The normally unsaid state metaphysick is also clearer in a hospital setting; religious expression is encouraged provided it is linked to your ‘community’, but total atheism in all but morals is required – “you would lock up Jesus were he alive today” is a common truism thrown at psychiatrists.
Nostalgia for early 1960s paternalism, though in some ways an understandable reflex, is as barren an ideology in the psychiatric system as in the liberal world at large. The orderly, hierarchical structure of nurses and doctors living in dormitories and on-site cottages has been replaced with a visa mill and staff who frequently cannot understand patients (or each other) at all. Elsewhere too, the conditions for re-establishing grand institutions are gone: The collapse in deference to psychiatrists means they now effectively hide from their wards, seeing patients for perhaps fifteen minutes each fortnight.
The impossibility of rebuilding the old structure is either not noticed or not cared about by the nostalgists, whose attachment to the old system is based on twee sentimentality, admittedly true claims about ugly hospital architecture replacing Victorian buildings, and a continuing compliance with the new system, where they remain working even as they complain, and wish for a way back to how things used to be.