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Deinstitutionalization and After

What went right and what went wrong with the closure of psychiatric asylums?

This past week at the University of Strathclyde, we hosted a conference called: 'Deinstitutionalization and After: Post-War Psychiatry in Global Perspective. Invited were not only historians, but also psychiatrists, community workers, medical anthropologists and service users from the UK, North America, Sweden, Germany, France, Australia, and a good number of other places. As far as we could tell, it was the first conference of its type, tackling one of the thorniest issues in the history of mental health.

Most of the battles fought amongst historians about the history of mental health, and psychiatry in particular, have been about psychiatric asylyms: whether they were humane or not; whose needs they really served; and how mad were those locked behind their walls. During the 1960s, a number of illustrious (some might say infamous) thinkers, ranging from the French philosopher Michel Foucault and the Canadian sociologist Erving Goffman to psychiatrists R.D. Laing and Thomas Szasz railed against the asylum, claiming that it was a stigmatizing agent of social control that caused as much madness as it cured. The views of such anti-psychiatrists (a generalizing term, but broadly applicable), were, in turn, attacked, not least by historians who argued that they were not supported by historical evidence.

As with most historical debates, both sides of the debate had a point or two. Not all psychiatric asylums were created equal - some were inhumane, others weren't - and while some patients desperately wanted freedom, others sought the solace and refuge such institutions provided (compare Geoffrey Reaume's Remembrance of Patients Past and Diana Gittens' Madness in its Place for two contrasting views). Regardless of who won the debate, however, by the 1970s most of the asylums in western countries were beginning to be shut down, not particularly because of anti-psychiatry, but rather because of budgetary pressures and the promise of liberating medications.

As our conference demonstrated, the ideal of care in the community rarely, if ever, became a reality. Many communities didn't want ex-asylum residents and many jurisdictions failed to put in the resources in place to make community mental health care a reality. One of our panels, representing a research group out of UCLA, stated that, in California, the families of schizophrenia sufferers were left to provide 24-hour care for patients 'freed' from the asylum. Similar stories emerged in other countries. While a patient-led mental health association in Vancouver provided a bottom-up, egalitarian approach to community mental health during the 1970s, bureaucratic interference transformed it into yet another top-down, disenfranchaising service. For many patients, deinstitutionalization resulted in either homelessness and destitution or transinstitutionalization - a life in the prison system.

Despite the fairly gloomy picture, we were all fairly buoyant by the end of the conference, having learned a great deal and met up with many like-minded individuals. Although it is often tricky to gather 'lessons' from history, two messages emerged that were hard to ignore. First, at the root of mental health policy is social policy, in other words, the poorer you are, the less likely you will cope well with mental illness and the less efficacious your treatment will be. So, even if mental illness isn't 'caused' by poverty (although it might certainly be a factor), social circumstances have an enormous impact on the outcomes of those who suffer from it.

Second, and this eloquent point was made by one of the elder statesmen of the conference, there should be an absolute right in all societies to be mad. I interpreted this to mean not only that if one succumbs to mental illness, society should provide appropriate and sufficient care and welfare - whether it be in institutions or in the community - but also that society should be more accepting of people who are mad, those who are just a little less normal than the rest of us.