2 The past: from asylum to community 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.