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# 2 The past: from asylum to community care?

Figure 2 The Hospital of Bethlem (Bedlam) in Moorfields, London (1747)

The history of mental health services in the United Kingdom is significant not only in terms of those who were identified as having a mental health problem and what treatment they received, but also where that treatment was delivered. The location of such services is perhaps particularly symbolic in mental health as it raises a fundamental question about the place of people in society who are seen as having serious mental health problems.

In this next activity, you will read about mental health in terms of place; looking at asylums and community care.

## Activity 6 A brief history

Allow around 1 hour

#### Task A

Read the first part of this short article written by an OU academic. As you do make notes on the different phases of care.

## Reading C

> The provision of mental health care and treatment, particularly in the UK, can be divided into three historical phases – the pre-asylum era; the asylum era; and the post-asylum or community care era.

> The pre-asylum era

> Before the eighteenth century, there was very little specific provision for people who experienced mental health problems. People who experienced mental distress lived in the community without any care or support, other than in workhouses or other places designed for paupers. The Vagrancy Act 1774 distinguished between lunatics and paupers for the first time. This led to the development of some private madhouses for people who could afford to pay or were supported by their parish. Conditions and standards of care in these institutions were very poor (Jones, 1972). During the same period, hospitals for people experiencing mental health problems began to develop, partly in response to public concerns about the welfare of people who were thought to be in need of such care.

> The asylum era

> By the end of the eighteenth century, the asylum era had begun. The County Asylums Act 1808, and subsequently the Lunacy Act 1845 and the Lunacy (Scotland) Act 1857, required each county to build an asylum. The rationale for this was that this would provide better care for people with mental health problems than the ad hoc and unregulated provision of madhouses and workhouses. The asylum era (in which care was provided in large mental hospitals, often located in rural areas with their own water supplies, farms, laundries and factories) lasted until the end of the twentieth century. This effectively isolated asylum inmates from their local community and psychiatrists from colleagues in other medical specialties (Killaspy, 2006).

> Grounds for admission to the asylums, which was nearly always compulsory, clearly indicated the connection between diagnosis of mental health problems and the social context in which they took place. People were admitted to large asylums during the nineteenth century for either physical or moral causes, such as intemperance (such as excessive consumption of alcohol) or prostitution or bad conduct and domestic troubles (e.g. Devon County Mental Hospital, 2015). Making a distinction between physical and moral causes had the effect of attributing a degree of personal responsibility to a person’s mental health problems as well as contributing to the stigma attached to mental disorders. However, patients were not expected or even allowed to take responsibility for their treatment, with compulsory admission to asylums the accepted norm.

> The gates of these institutions – and of all others like them – marked the boundary between the outside world of the ‘sane’ and the inside world of the ‘mad’ (Gittens, 1998). Although the institution could be a haven, a place of safety and security for some people – literally an asylum – for many others the gates of the local mental hospital were best avoided. This point is made by Gittens: ‘In Western culture over the past two hundred years one of the most feared gates, along with that of the workhouse, has been that of the asylum, the loony bin, the nuthouse’ (p. 29). Two early institutions are nearly always cited as important landmarks in the unfolding history of mental health services. They are Bethlem Hospital in London and The Retreat in York. Bethlem came first. In its earliest manifestation, it was in use as a hospital for lunatics (from around 1377 until into the seventeenth century).

> Bethlem (or Bedlam as it became known in the eighteenth century) was famous for its practice of allowing large numbers of casual visitors to view the lunatics as a spectacle of popular entertainment. Conditions improved slightly when the hospital was moved to a new site in 1815, but nevertheless remained harsh – essentially providing containment rather than care. The Retreat was founded in York by the Society of Friends in 1792. It was the brainchild of William Tuke, a Quaker tea merchant. This was, from the outset, a humanitarian setting – far away from the spirit of Bethlem that allowed naked and manacled people to be viewed by the public as part of an entertaining day out. The Retreat strove for an atmosphere of benevolence, comfort and sympathy, appointing staff who shared this approach. However, we do not know much about how lunatics in the eighteenth century who were kept in custody were actually treated such as how they were diagnosed and treated by the staff (Eccles, 2013).

> In the nineteenth century, people with mental problems may have been sent to workhouses or asylums if they could not be cared for in the community such as by family members. The Vagrancy Act of 1824 meant that people could be classified as a vagrant varied widely based on the interpretation of on-the-ground constables. The Vagrancy Act 1824 defined a vagrant as “someone who deceived the public to solicit alms [e.g. money, food or charity], deserted accepted societal norms and did not conform to contemporary labour practices (they were workshy)” (Yates, 2021, p. 303). For example, there was a tendency to consider women who were wandering (for example, unemployed or with no fixed abode) to be prostitutes or abandoned wives. In any case, women choosing to leave their family sphere were considered “dangerous in their own right” (Yates, 2021, p. 206) and could be deemed a vagrant on these grounds and sent to workhouses or asylums. This highlights ways in which social factors, such as societal norms and or an individual’s discriminatory attitudes, could play into whether someone was considered mad or dangerous regardless of an individual’s biology or psychopathology.

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### Discussion

You have read a brief history of mental health services and how they were provided in phases of care primarily based around the institution of the asylum. It is interesting to note how attitudes change over time to reflect societal norms. This is an important point to remember when studying this course, as society does change as do people’s attitudes with it.

#### Task B Moving to community-based care

Now read the second part of the article and make notes.

## Reading C (continued)

> The community care era

> The growth in the asylum population (peaking at over 150,000 in 1954) that resulted from a largely one-way, compulsory admission process led to a renewed focus on community-based care for people with mental health problems deemed ‘curable’. In particular, the Mental Treatment Act 1930 made it possible for people to be admitted to asylums on a voluntary basis and encouraged the growth of outpatient departments. The subsequent development of a National Health Service in 1948, the introduction of new anti-psychotic drugs and a changing social and political climate during the 1950s also led to a move away from asylum-based mental health care.

> An open-door movement developed with the aim of unlocking the doors and literally opening up the institutions. It was partly triggered by the Second World War experiences of dealing with traumatised refugees and armed forces personnel. The closure of the large psychiatric hospitals was an unusual example of sustained political pressure effecting major change in mental health care. Enoch Powell’s famous ‘water towers’ speech when he was Minister for Health in 1961 started the process, although the closure programme took the best part of 30 years. Powell summed up challenges involved in closing down these institutions, not only in taking down these massive buildings but changing our minds about how vulnerable people should be housed and looked after. Interestingly, Enoch Powell did not even envision using the old asylum buildings, declaring that they should serve no future use for health and social care the majority of these old asylums:

> ‘First there is the actual physical solidity of the buildings themselves: the very idea of these monuments derelict or demolished arouses an instinctive resistance in the mind. At least, we find ourselves thinking, "Can't we use them for something else if they cannot be retained for the mentally ill ?" "Why not at least put the subnormals into them? "Wouldn't this one make a splendid geriatric unit, or that one a convalescent home." "What a pity to waste all this accommodation!" Well, let me here declare that if we err, it is our duty to err on the side of ruthlessness. For the great majority of these establishments there is no appropriate future use, and I for my own part will resist any attempt to foist another use upon them unless it can be proved to me in each case that, such, or almost such, a budding would have had to be erected in that, or some similar, place to serve the other purpose, if the mental hospital had never existed’ (Powell, 1961).

> Care outside hospitals was to be the main direction of government mental health policy from the 1950s onwards and it was also recommended that patients must not be retained in hospital when they had reached a stage at which they could go home. The Mental Health Act 1959 emphasised the need for care outside hospital by making it a requirement for local authorities to provide facilities for after care. In addition to these political and policy factors, academic research by Goffman (1961) and Wing and Brown (1970) on the institutionalisation of psychiatric patients, poor standards of care and the poor quality of life inside asylums added to pressures to close the large institutions of the asylum era. However, the decisive shift to care in the community and the closure of the large mental hospitals did not gather momentum until the 1980s.

> For people with mental health problems, the community may not actually provide the care that was needed. For the others in the community, initial concerns for the welfare of people who had spent many years living in the asylums began to change to anxieties about them and the risks they might pose. This was triggered by a number of high profile cases in the early 1990s where community patients committed violent acts, sometimes including murders, after losing contact with mental health services. The subsequent development of the Care Programme Approach (CPA), where an identified professional coordinates a person’s community care package, together with the use of early intervention, crisis resolution and assertive outreach teams, sought to address the challenges of monitoring people with mental health care needs living in the community and ensuring continuity of care. The development of specialised housing for people with enduring mental ill health, provided by voluntary organisations, housing associations and local authorities, has also been a significant part of community care provision. The promotion of independence through supported living enables a large proportion of people with mental health problems to stay out of hospital.

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### Discussion

The information that has been provided in this activity has described mental health services in England and Wales according to place, namely that which happened prior to, during and after the asylum era. This process has been replicated in many other countries, see for example Italy and the United States whereby mental health care has reflected societal norms.

Having started this course by considering language use, you were then asked to think about how this impacts on how mental health is understood. You have also been introduced to one historical perspective on mental health care provision. However, mental health means more than simple perspectives and approaches.

The next section will therefore enable you to think about what these perspectives and approaches might. But first, you will think about strategies for dealing with emotive content. The next section ends with an opportunity for you to think about study where you may have other responsibilities.

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OpenLearn - Mental health in society
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