Closing Asylums for the Mentally Ill: Social Consequences

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Closing Asylums for the Mentally Ill: Social Consequences

Anthony J O'Brien
Centre for Mental Health Research, Policy and Service Development, University of Auckland; Liaison Psychiatry, Auckland Healthcare Services Ltd, Auckland, New Zealand

As part of its colonial inheritance Australia, like other Commonwealth countries, inherited a system of mental health care steeped in the asylum as the locus of care, and a view of people with mental illness as different and other, to be excluded from the mainstream of society. Like other Western countries, Australia has been through a process of dismantling the asylum network, and rethinking the social position of people with mental illness. These processes share the label, 'deinstitutionalization', but it is far form clear what the meaning of that term is beyond a simple definition of asylum closure. In this special edition of Health Sociology Review, Guest Editor Pauline Savy has brought together a range of views on asylum closure, and its consequences for mental health policy and mental health care. Broadly sociological in focus, this publication contains contributions from sociologists, nurses, and other academics. The papers examine deinstitutionalization in Australia, with one contribution from New Zealand. There is an emphasis on the experience in Victoria, which provides a number of useful lessons on implementation of mental health reform. The papers do not present a unitary view: deinstitutionalization is held to be a qualified success, or a failure, depending on the lens of analysis and the perspective brought to bear by the individual contributors. Together, this adds up to a thought-provoking review of the single most significant mental health reform in mental health policy in the 20th century.

Editor Pauline Savy backgrounds the issues in her introductory summary. She laments the lack of sociological interest in deinstitutionalization. That might come as an interesting observation to those immersed in the area given the many excellent sociological critiques of psychiatry and institutions from the time of Goffman, continued by sociologists such as Scull and Rose. But it seems that Savy's interest is in the microprocesses of deinstitutionalization: the impact of large-scale reform on people with mental illness and members of the clinical teams charged with providing care. Savy's summary of three recent Australian studies reminds us that theory and policy are not ends in themselves. They have as their focus people in the context of their daily lives. Perhaps for that reason the closing contribution to this issue is a narrative inquiry into the experiences of individuals following lengthy periods of institutional care.

In the first paper, Richmond and Savy begin optimistically, concluding that on the whole, changes in mental health in Australia have been positive. Without saying that the job is done (there are still 20 stand-alone hospitals in Australia), there have been increases in numbers of staff, and a shift in professional discourse to tolerance and citizenship. Sociological analysis is frequently critical of mental health staff and service provision, so it is refreshing to see that from a broad perspective there have been definite improvements. From 'out of sight out of mind' to 'in sight in mind' may not be enough, but as Richmond and Savy state, 'That's a start'. In the next contribution Mike Hazelton takes an international perspective, comparing deinstitutionalization in Australia, Brazil, Italy, and the UK. Hazelton agrees with Savy that sociology has not engaged with the later reforms of deinstitutionalization. His analysis notes that much of the focus of deinstitutionalization in Australia has been on service improvement, and that there is now a need to focus on citizenship, and to develop indicators by which this can be evaluated. Hazelton identifies a challenge for mental health posed by the possible segregation of people with mental illness who pose a risk from those who do not. Were this to happen (and trends in the use of mental health legislation and growth in forensic services indicate that it is happening) then some of the gains of deinstitutionalization would be lost.

Julie Henderson uses discourse analysis to examine key policy documents, in particular to discover the construction of informal care in the post-institutional context. Her conclusion is that informal carers (families, friends) have been placed under a moral compulsion to care in response to withdrawal of the state. This implicates families in self-government, and individuals as objects of social control by the devolved authority of the state. Valerie Gerrand's paper, like that of Richmond and Savy, is positive about the process of deinstitutionalization in Victoria, arguing that many of the problems usually associated with deinstitutionalization were avoided by overlapping funding and sound planning. The process was not always smooth, but the result was that new services were developed in advance of closure of the institutions, and a policy of total closure of large institutions freed up funds for the new services. Gerrand comments that the relocation side of deinstitutionalization is easier to achieve than a change in service philosophy, a reminder that institutional practices are not dependent on their physical environment. This point is taken up in the following paper by Janice Chesters. If the story so far has been one of guarded optimism, Chesters is somewhat less upbeat. She sees the new community services as being fragmented parts of the old hospitals, relocated and underpinned by the old institutional model of care. This notion has been argued by Rogers and Pilgrim (2001) in respect of mental health policy in Britain. Following Chesters' argument one might conclude, after Baudrillard, that deinstitutionalization did not take place. Chesters reviews the history of reform in Victoria, noting that the redefinition of mental health services is a theme in that history. She draws on the case of one region, Gippsland, and the case of Cornelia Rau, detained as an illegal immigrant without access to mental health care, to support her case that deinstitutionalization is an unrealized desire. Chesters also notes the re-establishment of the specialist hospital in forensic guise, and calls for the establishment of more specialist hospitals. Where others see discontinuities, Chesters sees continuity, and her paper is a timely reminder that reform is all too easily seen as linear and progressive. This history of mental health reform suggests otherwise.

The final Australian paper takes up the issue of risk as a dominant discourse within mental health services. Anne-Marie Sawyer draws on personal clinical experience and Rose's conceptualization of risk to develop a sociological case study of crisis assessment and treatment teams. Crisis teams are a key component of post-institutional care, acting as both the first response to mental health crises, and a filter for access to inpatient care. Sawyer suggests that a therapeutic response has been replaced with the management of risk. This will be a familiar story to crisis assessment and treatment team clinicians. Sawyer does not attempt to prescribe a solution to this issue, but she does pose important questions about what approach will best avoid the pitfalls of either institutionalization or deinstitutionalization.

The paper by Clare Hocking, Jane Phare, and Jan Wilson uses narrative inquiry to study the experiences of eight people discharged from New Zealand hospitals. They show a group of people with limited social contact, leading lives that are impoverished by any standard of reasonable social involvement. Although the eight participants told different types of stories, this paper fits nicely with Hazelton's earlier discussion of citizenship. The lack of citizenship that was previously contained within institutional walls is now lived in private accommodation by people with little power and limited resources to make improvements in their lives.

This special issue of Health Sociology Review places some important issues before mental health professionals. For clinicians whose full-time job is to provide services to mental health consumers, this publication provides an analysis of those services, and some directions for service development. It also signals that realization of the ideals of deinstitutionalization is not simply about mental health services; there is a need for a broader response to respond to the issues of citizenship. Deinstitutionalization is clearly not over. Future work of this nature could include some analysis of aboriginal mental health issues, and further analysis of the issues raised by Chesters of the reinvention of the asylum as the forensic hospital. This latter development harks back to an association between mental illness and criminality and dangerousness, both of which provided justification for creation of the 19th century asylums. There is also a need to extend analysis to cover primary health care, and to consider that sector's engagement with mental health issues.

Daphne Habibis's Epilogue brings the focus of this publication back to the discipline of sociology, suggesting that sociology has the freedom to move beyond disciplinary boundaries to combine the insights of other disciplines. If Pauline Savy's admonishment to sociology to be more responsive in this area is accepted, the discipline clearly has work to do. If the current publication is an example of what is on offer, future work will provide valuable material for nurses and other clinicians, for policy advocacy, and for further reform.

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